Research Report

Exploring staff attitudes to undertaking

advanced communication skills training

Professor Sheila Payne

Dr Mary Turner

and

Dr Terri O’Brien

International Observatory on End of Life Care

Division of Health Research
Lancaster University

December 2009
Contents
Page

List of tables 3

Executive summary 4

1. Introduction 5

2. Literature review 5

3. Methods 10
3.1 Study design 10
3.2 Sample 10
3.3 Recruitment 11
3.4 Design of data collection tools 12
3.5 Data analysis 13
3.6 Ethical considerations 13

4. Findings 13
4.1 The sample 13
4.2 Communication skills training 16
4.3 Attitudes to communication skills training 17
4.4 Additional comments 20

5. Discussion 24
5.1 Key findings 24
5.2 Limitations of the study 25
5.3 Implications for practice 26
5.4 Recommendations 27

References 28

Appendices 31 – 37
Appendix A: Interview Schedule 31
Appendix B: Questionnaire 33

2
List of tables
Page

Table 1: Sampling strategy for Phase 1 12

Table 2: Characteristics of interview respondents 12

Table 3: Comparison of study responders and non-responders 14

Table 4: Staff qualifications in cancer or palliative care 15

Table 5: Multidisciplinary teams 16

Table 6: Doctors’ and nurses’ self-ratings of communication skills 17

Table 7: Staff attitudes to communication skills training 17

Table 8: Differences between doctors’ and nurses’ attitudes to communication skills 19

training

Table 9: Staff views on the ‘Connected’ course 19

Table 10: Staff views about undertaking communication skills training 20

Table 11: Attitudes towards communication skills training: themes and illustrations 20

Table 12: Experiences of the ‘Connected’ course: themes and illustrations 21

Table 13: Positive, negative and neutral comments by professional group 22

Table 14: Positive, negative and neutral comments in relation to course completion 23

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Executive summary

This report describes a study that was commissioned by Lancashire and South Cumbria
Cancer Services Network to explore staff attitudes to undertaking advanced communication
skills training. The study was conducted by the International Observatory on End of Life Care
at Lancaster University.

Methods
The research took place in two phases. In Phase 1 a questionnaire was developed through
semi-structured interviews with cancer and palliative care staff. In Phase 2 the
questionnaire was distributed to 200 doctors, nurses and allied health professionals who
were members of cancer and palliative care multidisciplinary teams in Lancashire and South
Cumbria; 109 completed questionnaires were returned (54.5% response rate).

Key findings
The key findings from the research can be summarised as follows:
• Nurses self-rated their communication skills higher than doctors; there was no
difference between staff who had completed the ‘Connected’ course and those who had
not.
• Overall, doctors were more resistant to communication skills training than nurses: they
felt more strongly that good communication was not essential to the job, that
experienced cancer and palliative care staff should already be skilled communicators
and should not require additional training, and that communication skills do not need to
be taught as they are learned ‘on the job’.
• Nurses were much more in favour of mandatory communication skills training than
doctors.
• Doctors expressed greater preference for communication skills training to be provided
for separate professional groups.
• Nurses felt better supported by their managers if they had to deal with a distressed
patient or relative.
• More doctors wanted further information about the necessity of communication skills
training prior to undertaking the course.
• Staff who had not undertaken the course felt that more could be done to advertise it.

Recommendations
The report makes the following recommendations:
• Marketing of the ‘Connected’ course could be improved to make it more appealing to
those members of staff who are required to complete it.
• An assessment of skills prior to the course would enable individual training needs to be
identified.
• Further consideration needs to be given to course design and length.
• Course facilitation needs be of a consistently high quality.
• Further research is required to assess both the effectiveness of communication skills
training and the training needs of different staff groups.

4
 Exploring staff attitudes to undertaking advanced
communication skills training

1. Introduction
It is widely acknowledged that levels of communication skill amongst health care
professionals vary greatly and can sometimes be described as poor. A report by the Health
Care Commission (2007) is just one of many reports which highlight the large number of
complaints that relate either directly or indirectly to poor communication. In both the NHS
Cancer Plan (Department of Health 2000) and the NICE Guidance for Supportive and
Palliative Care (NICE 2004), communication skills are identified as essential for health care
professionals engaged in delivering cancer or palliative care. This is echoed in the NHS
Knowledge and Skills Framework (Department of Health 2004), which identifies
communication skills as a core competency for all staff working within the NHS. Most
recently, the End of Life Care Strategy (Department of Health 2008) also identified the need
for organisations to provide communication skills training for staff to enable them to meet
the challenges of caring for those approaching end of life. Cancer Peer Review (National
Cancer Action Team 2004) sets out the requirement for those health care professionals who
are members of a multidisciplinary team to attend a recognised accredited communication
skills course.

Lancashire and South Cumbria Cancer Services Network (‘the Cancer Network’) has made a
commitment to provide ‘Connected’, the national communication skills training recognised
to meet the requirements of Cancer Peer Review. This is a three-day experiential workshop
consisting of a didactic overview of the evidence base, presentation and demonstration of
communication skills and an opportunity to practise key skills through the medium of role-
play. The Cancer Network commissioned researchers from the International Observatory on
End of Life Care at Lancaster University to conduct a study focused on members of staff who
are required to complete this training.

Aims
This study had two key aims:
• To explore the attitudes of staff to undertaking the ‘Connected’ communications
skills training programme; and
• To provide the Cancer Network and other organisations with information that will
help them to develop effective ways of recruiting staff on to the training courses.

2. Literature review
This section of the report examines the development of communication skills training for
healthcare professionals in general, and then reviews the evidence in the field of cancer
care. It draws on the literature to describe the policy arena regarding communication skills
training and specifically in cancer care. The purpose is to explain why communication skills
training is important, to examine what barriers and facilitators exist to the uptake of
advanced communication skills training for cancer care professionals (which is now
5
mandatory), and finally to consider what benefits advanced communication skills training
may have in the long term in improving patient care.

Communication skills of health professionals

In the past two decades there has been an increasing focus on the importance of effective
communication in healthcare, and on the ability of health professionals to be competent in
communicating with patients and relatives in their professional practice. Two primary
reasons may explain this phenomenon. Firstly, since the introduction of consumerism in the
National Health Service (NHS) in the 1980s, patients have been recast as ‘clients’ with
attendant rights and responsibilities (Thompson 2007). These rights include an entitlement
to be listened to, and treated with respect and dignity by health professionals, and these
intentions are reiterated in the recent Department of Health NHS Constitution (Department
of Health 2009). Secondly, the dominance of the paternalistic approach to patients in the
traditional medical model has been challenged by an accompanying shift in ideology, from
the passive patient to active participant, which paralleled the introduction of internal
market reforms in health care. Such circumstances have also created opportunities for
attempts to implement more patient centred models of care (Connelly et al 2009).

These social and political developments have led to the emergence of some powerful social
discourses in relation to the positioning of patients, whom health professionals are now
encouraged to regard as clients or customers, partners in care, and as active participants in
the decision making processes in their care. This intention to promote a more inclusive
attitude to patient care is evident in the following policy statement by the Department of
Health:

In the twentieth century NHS patients were assumed to be passive recipients of

care. In the twenty first century NHS patients will be active partners of care.
(Department of Health 2001, p.23)

Predominantly in the medical model, communication skills were taken for granted as an
innate ability, or something that could be learned on the job, and therefore not considered
as a suitable subject that should be taught as part of the healthcare curriculum (Fadlon et al
2004; Dickson et al 1997). However this view has altered over time as the amount of
evidence citing poor communication by health professionals (as a major cause of patient or
client dissatisfaction and complaint) has grown. The majority of patient complaints to
disciplinary bodies relate to the breakdown of communications between patients and
doctors (British Medical Association Board of Medical Education 2004). A recent
Ombudsman report cited communication as a major cause of complaints about healthcare
professionals (Pincock 2004). Similarly, there is evidence of communication failings by
nurses; despite or perhaps because of the rhetoric of individualised care and patient
participation it appears that many nurses continue to lack empathy during patient
interactions. According to Wilkinson (1991) nurses tend to use a variety of blocking tactics
to prevent patients from telling them their problems, therefore keeping patient interactions
and assessments at a superficial level, and paying insufficient attention to patients’
psychological needs. Wilkinson (1999) also found that nurses tend to focus on physical
problems at the expense of psychological aspects of care, suggesting that care is planned

6
with little assumption of need. Research has also found that poor communication skills
contribute to stress and burnout of health professionals (Wilkinson et al 2008).

Barriers to effective communication include the following factors: the emphasis on

biomedical aspects of medical education such as diagnosis and treatment of physical
dysfunction at the expense of psychological and social care; fear of emotional outbursts
from patients by health professionals; health professionals’ assumptions about what is most
distressing to patients; and burn out by health professionals from a culture of long working
hours (Gysels et al 2004).

Maguire and Pitceathly (2002) also suggest that poor or no communication skills training on
medical courses leads some doctors to cling to the medical model and adopt an appearance
of being cool and detached, which they associate with being a professional. Instead of
adopting a patient centred model of negotiation and allowing patients to participate, some
clinicians demonstrate blocking techniques as a way of controlling the conversation. These
are behaviours that include giving advice and reassurance before the patient has had an
opportunity to express their main concerns, and other behaviours such as dismissing
distress as merely a normal reaction, being overly cheerful and restricting the conversation
to only discussing physical aspects of illness, and avoiding any acknowledgement or
exploration of feelings. It is behaviours such as these that advanced communication skills
training programmes are designed to change.

Policy drivers for communication skills training in cancer care

There are a number of important policy developments in cancer and end of life care that
have led to the development of communication skills training and advanced communication
skills training for cancer clinicians, including doctors and specialist nurses. The Calman Hine
Report (Department of Health 1995) set out the relatively poor state of cancer treatment in
the UK compared with other European countries. This was followed by the Cancer Plan
(Department of Health 2000) which led to the setting up of cancer networks, and made a
commitment that advanced communication skills training would be a mandatory part of
health professionals’ personal development plans. Additionally, the National Institution for
Clinical Excellence (NICE) (2004) focused on face-to-face communication in its manual
‘Improving Supportive and Palliative Care for Adults with Cancer’, and reinforced the
commitment that ‘accredited training should be available for all health and social care
professionals who work with patients and carers’ (p.58). The Cancer Reform Strategy
(Department of Health 2007) built on commitments made in the Cancer Plan (Department
of Health 2000), and recommended the three-day advanced communication skills training
course as the training of choice for cancer specialists.

The ‘Connected’ course

The ‘Connected’ advanced communication skills training course is a three-day workshop
that is sometimes residential depending on local resources in different parts of the UK. It
combines elements from three previous variants of advanced communication skills training
courses for health professionals, pioneered by Peter Maguire, Suzie Wilkinson and Lesley
Fallowfield. Such courses, including the ‘Connected’ course, usually employ a learner-
centred approach based on that pioneered by Lipkin and colleagues (1995). ‘Learner
centred’ courses ensure that professionals identify their own learning goals, and the course

7
content is focussed on learners working on their perceived difficulties in relation to
communication with patients and relatives. Therefore courses comprise three distinctive
components: provision of a cognitive element, i.e. an explanation of the evidence base for
communication skills; a behavioural element, such as the rehearsal and practice of the
newly acquired skills via role play; and an affective component that enables professionals to
explore their feelings evoked by difficult communication interactions with patients/relatives
in the professional role (Fallowfield and Jenkins 2004).

Advanced communication skills training aims primarily to change behaviour, and it appears
to be assumed that negative attitudes to undertaking communication skills training will also
be changed through acquiring new communication skills. The techniques used to teach
communication courses comprise a didactic (instructive) element, in the form of a
presentation or lecture on the evidence base of the need for effective communication in
patient/relative interactions, and role play with the use of actors simulating patients or the
participants simulating the roles of patients, relatives and professionals. Scenarios are often
based on real difficulties experienced by the health professionals in their professional roles,
and in courses for cancer care professionals mainly concentrate on giving bad news to
patients or relatives. The interactions are video recorded and stopped at regular intervals to
allow for feedback from the facilitators, course participants and actors if used. Model
behaviours and speech utterances can then be tried out by the professional in role, in a
controlled safe environment. Instruction on accepted forms of behaviour and constructive
feedback is given to the participants by those observing the videoed scenarios.

Effectiveness of communication skills training

Research in the field of psychology and oncology has been concerned to observe if and how
communication skills training programmes are evaluated by course organisers and also to
evaluate whether the course interventions enhance communication skills. A systematic
review by Kruijver (2000) critically reviewed 14 nursing communications studies between
1979 and 1998, eight of which involved professionals in cancer care. Kruijver found that
overall these studies showed little or no effect on communication skills or behaviour in
practice. However there is other evidence to suggest that communication skills can be
taught with positive results (Fallowfield et al 1990, 2001; Maguire 1990; Faulkner 1992 and
Wilkinson 1999). Several studies also claim that communications skills can be maintained
over time (Heaven et al 1996; Wilkinson 1999). As a consequence of such evidence
communication skills training has emerged as an important core topic in health care
professional training (Department of Health 2007).

A problem with many of the studies, which do evaluate effects on participants of course
programmes, is that most rely heavily on subjective self-reported confidence ratings, taken
pre- or post-course attendance from participants. The ratings are often restricted to
evaluating acceptability of the course to participants, rather than the interventions per se
(Fallowfield and Jenkins 2004). A systematic review by Moore et al (2004) demonstrates
how difficult it is to find studies that combine various methods of measurement and meet
the gold standard of a randomised control trial (RCT) for what counts as rigorous research
(Department of Health 2008). Out of 2,822 studies found on medical databases, only 3
studies met Moore et al’s (2004) stringent criteria; these studies were Fallowfield et al
(2002), which involved 160 oncology doctors and 2407 patients in video consultations;

8
Razavi et al (1993), which involved training 72 nurses from hospitals in Belgium and France;
and Razavi et al (2002), which involved 110 oncology nurses from 33 hospitals in Belgium.
The findings from the three studies included in this systematic review did offer some
evidence that communication skills training can lead to observable improved behaviours.
However, the researchers suggested that this may be due to the enthusiasm and skill of the
facilitators and/or participants. Moore et al (2004) concluded that more research is needed
to ascertain the long-term effects of compulsory training.

In relation to the techniques used on advanced communication skills training courses, much
is made in the policy literature about the benefits of using role play and videotaping
(Department of Health, 2007, 2008). Much of the oncology and psychology literature tends
not to discuss negative effects of these two principal methods, either when used separately
or in combination. However a few commentators do allude to the disadvantages of role
play. Cooke (1987 cited by Dickson et al 1997) points out that some participants find role
play too artificial to really engage with. Others have difficulty sustaining a role, and ‘dry up’
causing the individual much discomfort and embarrassment. Conversely others have
difficulty disengaging from a role, or may be disabled by a painful personal memory. Some
may suffer badly from the exposure, and may prefer a more anonymous form of learning.
Role play may degenerate into caricatures and stereotyping, with participants ‘hamming it
up’. Much depends on the ability of the facilitators to control the learning environment.
Anecdotal evidence suggests that course facilitators can frequently recall individuals who
struggled with role play. Now that advanced communication skills training course is
mandatory, the question of more participants being openly hostile during training sessions
is a possible concern, and there may be an increased likelihood of individuals attempting to
sabotage the course.

There is also a question about whether a course should include the whole range of
communication skills training or whether a ‘pick and mix’ approach would be preferable.
Again, as with the lack of critical evaluation of role play in the literature, little attention is
paid to this issue. Kruijver et al (2000) observed that the content of most communication
skills training is standardised for all participants, but they point out that individuals may
start from different skills bases and may differ in their educational needs. They suggest that
boredom or disengagement from some elements of the course may lead to a reduction of
effectiveness of communication.

Conclusions
This literature review has attempted to locate the developments in advanced
communication skills training in cancer care, in health and in the wider policy arena. It is
clear that the need for health professionals to demonstrate efficacy in communication skills
is likely to intensify in future years. The current Labour government has invested significant
resources and attention to the importance of communication in the context of healthcare,
which has been firmly on the policy agenda in recent years. Even if a Conservative
government is elected in the near future, there is little sign that the rhetoric of patient-
centred care would change, despite the threat of cost constraints in an economic recession
and constant health restructuring, which may impede attempts at best practice.

9
‘Connected’ has been established as the current model of advanced communication skills
training course since October 2008, and in this sense it is still in its infancy; in addition it has
yet to be fully evaluated in research terms. It is hoped that by conducting this study into
attitudes to communication skills training in general by cancer care health professionals,
and to the barriers and facilitators of advanced communication skills training in particular,
we may be in a position to provide Cancer Network organisations with information to
enable them to develop effective ways of recruiting staff onto future ‘Connected’ courses,
and also contribute to this growing field of research.

3. Methods

3.1 Study design

This study used mixed methods of data collection and analysis, and was conducted in two
phases:
• Phase 1 consisted of qualitative semi-structured interviews with a small number of
healthcare professionals to inform the development of the questionnaire;
• Phase 2 consisted of a postal questionnaire survey which was sent to a larger sample
of healthcare professionals.

3.2 Sample

All participants in this study were healthcare professionals who at the time of the research
were members of cancer or palliative care multidisciplinary teams in one of the four acute
NHS Trusts in Lancashire and South Cumbria (Blackpool, Fylde and Wyre Hospitals NHS
Foundation Trust, East Lancashire Hospitals NHS Trust, Lancashire Teaching Hospitals NHS
Foundation Trust and University Hospitals of Morecambe Bay NHS Trust). These four Trusts
were selected because cancer and palliative care multidisciplinary teams are based in these
locations. As members of these teams, all healthcare professionals are required to
undertake advanced communication skills training.

Two groups of participants were sought for both the interviews and the questionnaire phase
of the study:

• Group A: A sample of professionals who had already undertaken the ‘Connected’

advanced communication skills course. This group was chosen to elicit satisfaction
with the course and the extent to which it was perceived to have relevance for
practice.
• Group B: A sample of professionals required to undertake the ‘Connected’ advance
communication skills course but who had not already done so. This group was
selected to determine expectations and perceived barriers to uptake of the course.

10
The following inclusion and exclusion criteria were set for the study:

Inclusion criteria:
• Doctors, nurses and allied health professionals mandated to undertake advanced
communication skills training;
• Members of cancer and/or palliative care multidisciplinary teams.

Exclusion criteria
• Healthcare professionals not working in cancer and/or palliative care teams;
• Staff not required to undertake advanced communication skills training;

3.3 Recruitment

Lancashire and South Cumbria Cancer Services Network provided the research team with
names and contact details of cancer and palliative care professionals eligible to undertake
the ‘Connected’ course and who therefore met the criteria for inclusion in the study. This
information was provided in the form of two lists, one of Group A staff and the other of
Group B staff.

Phase 1: Interviews
The researchers aimed to recruit 10 respondents to the interview phase of the study, and
sent out 20 invitation packs in anticipation that not everyone would reply. Each invitation
pack consisted of an invitation letter, information sheet about the study, reply slip, consent
form and prepaid return envelope. Ten of the potential respondents were in Group A and
the other 10 in Group B; five were invited from each of the four Trusts. Respondents were
able to choose whether they preferred to be interviewed face-to-face or on the telephone.
In order to try and increase the response rate a researcher made telephone calls to
potential respondents to alert them to the study and tell them that they would shortly
receive an invitation to participate.

Phase 2: Questionnaires
A cohort of 120 healthcare professionals was initially invited to complete the questionnaire.
Each person was sent a pack containing an invitation letter, an information sheet, a
questionnaire and a prepaid return envelope; each questionnaire had a unique reference
number to enable tracking. As with the interviews, both Group A and Group B staff were
invited to participate in the study. Two weeks after distributing the questionnaires, the
response rate was somewhat disappointing, so a second cohort of 80 staff was invited to
participate in the study. Reminder packs (consisting of a covering letter, another copy of the
questionnaire and a pre-paid return envelope) were then sent to every potential
respondent in both cohorts from whom a reply had not been received two weeks after the
initial pack had been sent. Table 1 shows the sampling strategy used in Phase 2 of this study.

11
Table 1: Sampling strategy for Phase 2
Cohort 1 Cohort 2 Total
Group A Group B Group A Group B
Trust A 15 15 10 10 50
Trust B 15 15 10 10 50
Trust C 15 15 10 10 50
Trust D 15 15 10 10 50
Total 60 60 40 40 200

3.4 Design of data collection tools

Interview schedule
The interview schedule was designed through a series of discussions between the
researchers and experts in the field of communication skills training. Its purpose was to elicit
a range of views and attitudes about communication skills training in general and the
‘Connected’ course more specifically, and the barriers and facilitation factors in the uptake
of the course. The purpose of the interviews was to inform the development of the
questionnaire. The interviews were semi-structured, to allow the researcher to focus on and
probe areas of particular interest raised by the respondents. The interview schedule is
shown in Appendix A.

Five responses were received from the 20 invitations that were distributed to take part in an
interview. Four respondents were interviewed on the telephone, and one requested a face-
to-face interview. Four respondents had completed a ‘Connected’ course and one had not.
The characteristics of the interview respondents are shown in Table 2.

Table 2: Characteristics of the interview respondents

Respondent Occupational Gender Age Workplace Completed
group ‘Connected’?
1 Nurse Male 41 Trust D Yes
2 Nurse Female 47 Trust A No
3 Nurse Female 49 Trust B Yes
4 Nurse Female 51 Trust C Yes
5 Doctor Male 59 Trust A Yes

The interviews lasted between 22 and 49 minutes (average 36 minutes), and elicited a range
of themes that contributed to the development of the questionnaire. All interview
respondents were broadly in favour of communication skills training.

Questionnaire
The questionnaire was designed by the research team in collaboration with the Cancer
Network. An initial ‘brainstorming’ of ideas was undertaken during a preliminary meeting
between a researcher and a member of staff from the Cancer Network at the start of the
study. Data from the interviews were then used in conjunction with evidence from the
literature to develop these initial ideas and construct a draft questionnaire. The final

12
questionnaire (see Appendix B) consisted of 41 items focused on experience, feelings and
attitudes towards communication skills training. Some demographic information was also
sought, and respondents were given an opportunity to make any additional comments.

Because of the extremely tight timescale for this project, and unforeseen delays in gaining
approval for the questionnaire from both the NHS Research Ethics Service and Research and
Development Departments in each of the four Trusts (see below), it was not possible to pilot
the questionnaire prior to distribution (please see Section 5.3 of this report for further
discussion of this issue).

3.5 Data analysis

All data from the questionnaires were entered into the computer software package PASW
Statistics 17.0 (formerly known as SPSS, the Statistical Package for Social Scientists).
Numerical data were analysed for frequencies and some cross-tabulations were performed
using Pearson Chi-Squared and Fisher’s Exact Tests. Open ended data were subjected to a
thematic analysis by grouping conceptually similar topics. Illustrative quotations have been
selected to demonstrate the diversity of views expressed.

3.6 Ethical considerations

Ethical approval for the study was sought from the NHS Research Ethics Service. A full
application was made and initial approval gained on 14 July 2009. However, a second
application, known as a ‘substantial amendment’, had to be made because the
questionnaire was developed within the study. Approval of the final version of the
questionnaire was granted on 21 September 2009.

In addition to gaining ethical approval, the researchers also applied to the Research and
Development (R&D) Departments in each of the four Trusts for research governance
approval; this was required before Trust employees could be included in the study.
Permission was gained from each R&D Manager at the start of the study and again following
the substantial amendment.

4. Findings

4.1 The sample

Two hundred questionnaires were distributed. Two packs were returned unopened, and
another was reported by a secretary to be undeliverable. Further enquiries revealed that in
all three cases the intended recipients were no longer in post; they therefore could not
respond so are excluded from the total. In addition, one further questionnaire was returned

13
not completed, together with a covering letter stating that the intended recipient had
neither undertaken a course nor was on a waiting list to do so. This constitutes a response,
even though a completed questionnaire was not returned. One hundred and nine
questionnaires out of 197 were completed and returned to the research team, giving a 55%
response rate.

Representativeness of the study sample

The sample of questionnaire respondents was compared to those who did not respond in
order to determine how representative the responders were of the whole sample. Limited
information was available on the non-responders; however, it was possible to consider
employing organisation, professional group and gender across the whole sample. Table 3
shows these factors in relation to the two groups.

Table 3: Comparison of study responders and non-responders*

Responders Non-responders Total

Organisation
Trust A 29 21 50
Trust B 23 26 49
Trust C 30 17 47
Trust D 27 23 50
Total 109 87 196

Professional group
Doctors 53 54 107
Nurses 50 26 76
AHPs 6 6 12
Profession not known 0 1 1
Total 109 87 196

Gender
Male 46 34 80
Female 63 30 93
Gender not known 0 23 23
Total 109 87 196

* The respondent who returned the questionnaire without completing it and the three who
never received the questionnaire are not included in this table.

Cross-tabulations showed no statistically significant differences between responders and

non-responders in terms of employing organisation and professional group, demonstrating
that those who responded were representative of the whole sample in these two respects.
However, because the gender of a quarter of non-responders was not known, it was not
possible to conduct valid statistical tests on the gender data.

14
Characteristics of the study sample
Forty-six (42.2%) of the 109 respondents who returned a completed questionnaire were
male and 63 (57.8%) were female. The average age of 105 respondents who provided this
information was 44.1 (range 27 – 63). Respondents were mainly doctors (48.6%) or nurses
(45.9%), but there were also six allied health professionals (AHPs) who took part in the study
(three dieticians, two speech and language therapists and one physiotherapist). In terms of
ethnicity, 88 respondents (80.7%) were white, one black African (0.9%), five Indian (4.6%),
five Pakistani or Bangladeshi (4.6%), four ‘other’s (3.6%) and six (5.5%) who did not
complete this question.

Qualifications and experience

Fifty-three respondents (48.6%) had additional qualifications in cancer or palliative care; 56
(51.4%) did not. However, there were marked differences between the professional groups,
with many more nurses than doctors having additional qualifications, as shown in Table 4.

Table 4: Staff qualifications in cancer or palliative care

45
40
35
30
25 Doctors
20 Nurses
15 AHPs
10
5
0
Specialist qualifications No specialist qualifications

The respondents had between one and 39 years of experience working with cancer patients,
and over a third (37.6%) had 20 years or more; the median length of time was 16 years.

Multidisciplinary teams
Eighty-one respondents (74.3%) belonged to only one disease-specific MDT; however, 16
(14.7%) were involved in more than one disease. These respondents included oncologists,
pathologists and radiologists; 11 of them belonged to two MDTs, three belonged to 3 teams,
and two respondents were members of four MDTs. Of the remaining 12 respondents
(11.0%), seven did not specify which team they belonged to and five stated that they did not
belong to any MDT. Table 5 shows the MDTs the respondents were members of.

15
Table 5: Multidisciplinary teams
Team Number *
Breast 27
Colorectal 20
Lung 19
Upper gastro-intestinal 10
Urology 10
Haematology 8
Head and Neck 8
Gynaecology 7
Palliative care 4
Dermatology 3
Hepatobiliary/pancreatic 1
Neurology 1
Testis 1
Thyroid 1
Total 120

* Totals more than the 97 respondents who answered this question because it includes those
who were members of more than one MDT.

In addition to different disease-specific MDTs, seven respondents (6.4%) reported being

members of MDTs in different locations: for example, nurses attending palliative care MDTs
in both hospital and hospice; some staff being part of both local and Cancer Network MDTs;
and cardiothoracic surgeons attending lung MDTs in two different hospital Trusts.

4.2 Communication skills training

The ‘Connected’ course

Seventy respondents (64.2%) stated that they had heard about the ‘Connected’ course; 38
(34.9%) had not (one did not complete this question). Twenty-five respondents had heard
about the course from their line manager; the others through a variety of means including
the Cancer Network, emails and the intranet.

Forty-three respondents (39.4%) reported that they had completed the ‘Connected’ course;
three (2.8%) had a confirmed place on a forthcoming course, and 7 (6.4%) were on a waiting
list. Fifty respondents (45.9%) had completed a previous Advanced Communication Skills
training course (Maguire, Fallowfield or Wilkinson variants) and 18 (16.5%) had completed
other communication skills training. Seven respondents (6.4%) expressed a preference for
the ‘Connected’ course to be residential, 42 (38.5%) non-residential, and 48 (44.0%) had no
preference; 12 (11.0%) did not complete this question.

Other communication skills training

Respondents who had completed communication skills training other than the ‘Connected’
course were asked to rate their most recent experience. Most of the 57 respondents to this
question reported very positive experiences. Twenty-one (36.8%) stated that their most

16
recent experience of communication skills training was excellent, 20 (35.1%) very good and
12 (21.1%) good. Only four (7.0%) reported their experience as fair, and none as poor.

Self-rating of communication skills

Respondents were asked to rate their communication skills as excellent, very good, good,
fair or poor. Fifty-six respondents (51.4%) rated their skills as excellent or very good, 50
(45.9%) as good or fair, and none as poor; three (2.8%) did not respond. Cross-tabulations
showed no significant difference between staff who had completed the ‘Connected’ course
and those who had not; however, there was a significant difference between nurses and
doctors (p<.05), with nurses rating their skills more highly than doctors (see Table 6).

Table 6: Doctors’ and nurses’ self-ratings of communication skills

35

30

25

20
Doctors
15
Nurses
10

0
Excellent or very good Good or fair

4.3 Attitudes to communication skills training

Respondents were asked to rate their agreement with 11 statements about communication
skills training. Table 7 shows the views of all respondents in relation to these 11 statements.

Table 7: Staff attitudes to communication skills training (n = 109)

Statement Agree / Disagree / Don’t
strongly strongly know / not
agree disagree completed
n (%) n (%) n (%)
Communication skills training should be mandatory for 91 (83.5) 14 (12.8) 4 (3.6)
cancer and palliative care professionals

Communication skills training should be available for all 104 (95.4) 3 (2.8) 2 (1.8)
health care professionals

Good communication with patients and relatives is not 13 (11.9) 94 (86.2) 2 (1.8)
essential to my job

17
Experienced cancer and palliative care staff should already 19 (17.4) 80 (73.4) 10 (9.2)
be skilled communicators and should not need additional
training
Communication skills do not need to be taught as they are 8 (7.3) 93 (85.3) 8 (7.4)
learned ‘on the job’

Healthcare professionals should attend communication 9 (8.3) 87 (79.9) 13 (12.0)

skills training in separate groups – e.g. nurses / doctors /
others
More could be done to advertise the ‘Connected’ 68 (62.4) 11 (10.1) 30 (27.6)
communication skills course

I think that my communication skills could be improved 82 (75.2) 12 (11.0) 15 (13.8)

with training

I am supported at work by my line manager if I have to 39 (35.8) 56 (51.4) 14 (12.9)

deal with a distressed patient or relative

My colleagues support me at work if I have to deal with a 89 (81.7) 12 (11.0) 8 (7.4)

distressed patient or relative

I am supported at work in clinical supervision if I have to 35 (32.1) 51 (46.7) 23 (21.1)

deal with a distressed patient or relative

Cross-tabulations of these data were then performed to determine whether there were any
significant differences between the attitudes of different groups of staff. To begin with,
results for staff members who had completed the ‘Connected’ course were compared with
results for those who had not. There was no significant difference between these two
groups of staff for 10 of the statements. However, for the statement “More could be done
to advertise the ‘Connected’ communication skills course” there was a significant difference
(p<.05) between the two groups, with staff who had not undertaken the course agreeing
more strongly with the statement.

Cross-tabulations were also undertaken to look for differences between the attitudes of
different professional groups. As only six AHPs took part in the study it was not possible to
draw any conclusions about this group. However, there were statistically significant
differences between doctors’ and nurses’ attitudes to six of the 11 statements, shown in
Table 8. Nurses felt much more strongly than doctors that communication skills training
should be mandatory for cancer and palliative care professionals. Doctors agreed more
strongly that good communication with patients and relatives was not essential to the job,
that experienced cancer and palliative care staff should already be skilled communicators
and not require additional training, and that communication skills do not need to be taught
as they are learned ‘on the job’. More doctors favoured attending communication skills
training in separate professional groups, and nurses felt better supported by their managers
if they had to deal with a distressed patient or relative. For the remaining five statements
there was no significant difference between doctors’ and nurses’ attitudes.

18
Table 8: Differences between doctors’ and nurses’ attitudes to communication skills training

Statement Number Nurses Doctors P value

Agree Disagree Agree Disagree
Communication skills training 99 49 1 36 13 <.001**
should be mandatory for cancer
and palliative care professionals
Good communication with 101 3 47 10 41 <.05*
patients and relatives is not
essential to my job
Experienced cancer and palliative 93 1 46 18 28 <.001
care staff should already be skilled
communicators and should not
need additional training
Communication skills do not need 95 1 49 7 38 <.05
to be taught as they are learned
‘on the job’
Healthcare professionals should 91 1 47 7 36 <.05
attend communication skills
training in separate groups – e.g.
nurses / doctors / others
I am supported at work by my line 89 24 25 10 30 <.05
manager if I have to deal with a
distressed patient or relative

* A result of <.05 indicates a significant difference between the two groups. The probability that this
result is attributable to chance is less than 5%.
** A result of <.001 indicates a highly significant difference between the two groups. The probability
that this result is attributable to chance is less than 0.1%.

The ‘Connected’ course

Staff who had completed the ‘Connected’ course were asked to rate their agreement with
seven statements about the training. Table 9 shows these findings.

Table 9: Staff views on the ‘Connected’ course (n = 43)

Statement Agree / Disagree / Don’t
strongly strongly know / not
agree disagree completed
n (%) n (%) n (%)
The ‘Connected’ course provided the right level of training 33 (76.7) 9 (21.0) 1 (2.3)
for me
I feel happier about communication skills training having 33 (76.7) 7 (16.3) 3 (7.0)
undertaken the course
I did not enjoy working in small groups on the course 6 (14.0) 37 (86.0) 0 (0.0)

I would have liked more information about the necessity 13 (30.2) 29 (67.5) 1 (2.3)
of communication skills training prior to the course

19
I feel less anxious now about role play having undertaken 25 (58.1) 14 (32.6) 4 (9.3)
the course
Specific feedback about my communication skills on the 38 (88.3) 3 (7.0) 2 (4.7)
course was helpful
A refresher course on communication skills would be 31 (72.1) 7 (16.3) 5 (11.6)
helpful

Only one of these statements, “I would have liked more information about the necessity of
communication skills training prior to the course”, showed any significant difference
between nurses and doctors (p<.05), with stronger agreement amongst the doctors.

Staff who had not completed the ‘Connected’ course

Similarly, staff who had not completed the ‘Connected’ course were asked to rate their
agreement with three statements concerning their feelings about undertaking the course;
these findings are shown in Table 10. Cross-tabulations of these data showed no significant
differences between doctors and nurses.

Table 10: Staff views about undertaking communication skills training (n = 66)
Statement Agree / Disagree / Don’t
strongly strongly know / not
agree disagree completed
n (%) n (%) n (%)
I feel anxious about undertaking communication skills 10 (15.2) 45 (68.2) 11 (16.6)
training
I have no concerns about role play in communication skills 41 (62.1) 17 (25.8) 8 (12.1)
training
I feel happy about working in small groups when 55 (83.3) 3 (4.6) 8 (12.1)
undertaking communication skills training

4.4. Additional comments

Forty-three respondents (39.4%) made additional comments at the end of the

questionnaire. Analysis of these data revealed a variety of themes related to experiences,
attitudes and feelings about undertaking communication skills training. These themes were
grouped into two categories, ‘Attitudes towards communication skills training’ and
‘Experiences of the ‘Connected’ course‘, which are shown with illustrative data extracts in
Table 11 and Table 12 respectively.

Table 11: Attitudes towards communication skills training: themes and illustrations
Importance of training

“Communication skills training should be integral to professional training at all levels.” [Doctor, Trust
2]

Relevance of good communication

“I am a radiologist and I do not ‘speak’ to patients as I report scans of patients mostly; I am not

20
involved in breaking bad news.” [Doctor, Trust 3].

“I do not generally communicate with patients whilst reporting their CT scans.” [Doctor, Trust 3]

Mandatory training

“I object strongly to being told I have to go on this course. I did a course with Maguire about 20 years
ago. I’m an experienced clinician and consider myself a good communicator.” [Doctor, Trust 3]

Learning on the job

“I do feel that some degree of communication is learnt ‘on the job’, but unless trained you can just go
on getting it wrong.” [Nurse, Trust 2]

Different levels of training

“I think it’s important that staff should have basic and enhanced communication skills training before
embarking on advanced communication skills training, the problem often being that if this is not
addressed then ACS is wasted almost.” [Nurse, Trust 2]

Changing attitudes

“Prior to attending the course I thought I had good communication skills; however, on attending the
course I realised there were definite areas for improvement.” [Nurse, Trust 3]

“Very doubtful about the course initially, but the convenors were excellent, enthusiastic and
knowledgeable. In the end I was converted totally. Very positive about the course and the skills I was
taught. Thank you.” [Doctor, Trust 1]

Table 12: Experiences of the ‘Connected’ course: themes and illustrations

Experiences of the course

“I really enjoyed the communication course […] It gave me confidence in the way I communicate and
ideas on how to handle difficult situations as well.” [Nurse, Trust 2]

“The only real benefit I derived from the course was confirmation that what I was already doing was
about right.” [Doctor, Trust 3]

Role play

“We all helped and supported each other during the role play and learnt a lot from each other’s
‘situations’ during the role play that can be used within our practice.” [AHP, Trust 3]

“Although role play causes increased anxiety it is a great learning tool.” [Nurse, Trust 4]

Mixed professional groups

“The first day was very daunting as there was myself and one other nurse, and 8 consultants – most
of whom didn’t want to be there. I think it would have been better to have mixed up the professions
more.” [Nurse, Trust 3]

21
“I think mixed professional courses are a good idea, especially as we are working in MDTs.” [AHP,
Trust 3]

Quality of facilitation

“I was more experienced and better trained in communication than the course facilitators, who were
very new to the field.” [Doctor, Trust 1]

Length of course

“This course was far too long. Half a day would have been adequate.” [Doctor, Trust 4]

Positive and negative comments

As can be seen from the table above, there were wide-ranging views and some very strong
opinions expressed in the comments section of the questionnaire. Sixteen nurses and three
AHPs used the opportunity to make comments; however, most of the comments (24 out of
43) were from doctors, indicating stronger views amongst this group of professionals. As
part of the analysis, the researchers classified each comment as mainly positive, mainly
negative or neutral. Table 13 shows the numbers of positive, negative and neutral
comments made by each group of professionals.

Table 13: Positive, negative and neutral comments by professional group

16

14

12

10
Positive comments
8
Negative comments
6 Neutral comments

0
Doctors Nurses AHPs

These findings echo those of the data presented earlier which indicated that doctors are
more sceptical about the value of communication skills training than their colleagues from
other professions and are more resistant to mandatory training. A key obstacle identified by

22
several respondents was time: one doctor from Trust 4 who had not yet undertaken the
‘Connected’ course commented that “the current communication course over three days is
too long and I cannot commit to this”; another from the same Trust said: “I am not
convinced that it is necessary to take three full days to impart necessary training to
experienced senior clinicians in hard-pressed posts”. There was also a view that certain
medical specialists, such as radiologists, should not have to undertake this training because
they have little patient contact.

The range of views about the ‘Connected’ course can perhaps be summed up by two
doctors, one from Trust 1 who commented “Very useful and excellent course” and the other
from Trust 2 who felt it had been “a bit of a waste of time”. One respondent suggested that
the ‘Connected’ course should carry an examination or test at the end:

If you want people to ‘improve’ their communication skills presumably there needs to be
some form of assessment with a before and after result. I might be an awful
communicator and be completely unaware; I might be so bad that I don’t pick up on all
the negative responses and cues that I get. You don’t have to pass or fail the course –
simply turn up. For the people who have avoided attending so far – and I know a few –
this is their attitude. If you want them to take it seriously I think that there needs to be
the prospect of failure to push them into making an effort. [Doctor, T3]

It is also worth noting that a greater proportion of negative comments were received
from people who had not yet undertaken the course compared with those who had
(see Table 14). These data indicate that once people have completed the course they
feel more positive about it.

Table 14: Positive, negative and neutral comments in relation to course completion

14

12

10

8
Positive comments
6 Negative comments
Neutral comments
4

0
Not completed 'Connected' Completed 'Connected' (n = 23)
(n = 20)

23
5. Discussion

5.1 Key findings

A number of key findings emerged from this research, which merit further consideration.
Perhaps the most significant findings concern the differences between doctors’ and nurses’
attitudes towards communication skills training. The study clearly demonstrates that
doctors involved in cancer and palliative care are more resistant than their nurse colleagues
to undertaking communication skills training, and it is important to consider the possible
reasons for this.

To begin with, some doctors feel that communication skills training is of little relevance to
them. It is likely that amongst this group are radiologists and pathologists, who may have
little patient contact and are unlikely to be the person delivering bad news to patients and
their relatives. By contrast, most of the nurses who took part in the study were clinical nurse
specialists, with a specific role to provide information and support to patients and families;
their need for good communication skills is much more apparent. It is perhaps not surprising
therefore that nurses were much more strongly in favour of mandatory communication
skills training than doctors.

The issue of time (highlighted in Section 4:4 above) is another probable reason for doctors’
negative attitudes towards communication skills training. Several doctors felt that the
‘Connected’ course was too long, and they were reluctant to take three days out of clinical
practice, especially in view of the pressure they were under to see as many patients as
possible and meet required targets. However, there did seem to be particular resistance to
this specific training, raising questions about whether the same doctors would have been as
reluctant to take time out of clinical duties to undertake other forms of training.

It is also possible that some doctors are already highly skilled communicators and therefore
arguably do not need to undertake this course; some sort of refresher course may suit such
individuals better. However, another possible reason for some doctors’ resistance is fear of
exposing poor skills in front of colleagues. Most of the study respondents had been qualified
for many years and were in senior clinical positions; it is likely that such individuals would be
assumed to be expert communicators. However, some may feel very insecure about their
communication abilities, and may find it highly embarrassing for other people to scrutinise
their performance. The doctors’ preference for doctor-only courses which has emerged
from our study would seem to strengthen this contention. There has been some debate in
the literature about the best way to train doctors, and one approach suggested is to train
doctors not only separately from other professionals but in groups according to seniority;
for example, consultants only. Fallowfield’s work supports this view, highlighting the
difficulties doctors have in handling their own emotions (Fallowfield and Jenkins 2004).

It is important to consider the likely impact of negative attitudes to communication skills

training. Our study data show that other course participants were aware at times of
colleagues’ resistance; having openly hostile course participants is likely to diminish the

24
quality of everyone’s experience, as well as put the course facilitators under extreme
pressure.

However, as the more negative perceptions were expressed by respondents who had not
yet undertaken the course, these findings indicate that there is scope for better marketing
in order to promote a more positive view of the training. One particularly interesting finding
was that over a third of respondents reported never having heard of ‘Connected’; most of
these were on a waiting list held by the Cancer Network to undertake the course, whilst
some had already completed it without realising that what they had done was the
‘Connected’ course. It seems likely that raised awareness about the course and its value
would lead to more compliance and less hostility, which can only be of benefit to all
concerned.

Another important issue is the ‘one size fits all’ approach currently being taken nationally to
advanced communication skills training. The findings of this study indicate that course
participants had widely differing levels of existing knowledge, skills and experience in the
field of communication. Several respondents commented that there should be assessment
of individual ability and needs so that staff can undertake the most appropriate training;
some cancer and palliative care staff appear to be benefitting from undertaking advanced
training, whilst others may require more basic skills. Tailoring courses more appropriately to
individuals may generate more positive perceptions about communication skills training.

Finally, there is a lack of objective evidence that the ‘Connected’ course makes any
difference to an individual’s communication skills. Some of the comments made by
respondents in this study indicate that some members of staff are enthusiastic about the
training, and feel that undertaking the course has enabled them to improve their skills for
the benefit of patients. However, it is not known whether or not their skills did indeed
improve, whether any improvement was sustained, or whether improvements were
experienced by all members of staff.

5.2 Limitations of the study

There are a number of limitations to this study that should be acknowledged. First, it was
conducted within only one Cancer Network in the North West of England, and the findings
therefore cannot be generalised to the rest of the country. The research also relied on self-
reporting from the participants, and so we cannot comment on actual communication skills.

The study used a cross-sectional design, and our data suggest that attitudes prior to
attending the course are more negative; however, the two groups of respondents (Group A
and Group B) are independent, and therefore longitudinal pre- and post-course data are
needed to assess whether attitudes change after completing the course. Our study also
lacks follow-up data, although positive post-course comments indicate that insight into skills
is enhanced on return to clinical situations.

The final limitation was time; the research was conducted over a period of only nine
months, a very short time-scale for a two-phase study of this complexity. In addition, the

25
requirements of the NHS Research Ethics Committee and the Research and Development
(R&D) Departments in the four Trusts proved to be time-consuming and laborious, leaving
less time for data collection and analysis. Nevertheless, a large amount of data was
collected and the study was completed on schedule.

5.3 Methodological issues

Two significant methodological issues were encountered during this research study, which
are briefly discussed here.

Questionnaire distribution
There were initial difficulties in obtaining the necessary information from the Cancer
Network to enable the researchers to distribute the questionnaire to the right people. The
research team was provided with names, job titles and employing organisations for
potential study respondents, but some addresses were incomplete and no departments
were included in the address information. In addition, in error the first cohort of
questionnaires was sent out without individuals’ job titles, and it is thought that a significant
proportion of them did not reach the intended recipient, which probably accounts for the
relatively poor initial response rate. A second cohort of potential respondents then had to
be identified and questionnaire packs were sent to a further 80 individuals. In order to
improve the response rate, potential respondents in both cohorts were sent a reminder and
a second copy of the questionnaire if they had not already responded; this added to the
workload of the research team, and meant that there was less time than originally planned
for data analysis.

Piloting the questionnaire

A great deal of time was spent complying with the requirements of Research Ethics and R&D
Committees, and it was therefore not possible to pilot the questionnaire before distributing
it. Instead, an expert advisory group consisting of key staff from the Cancer Network and
colleagues of the researchers were asked to complete the questionnaire and/or provide
feedback. This was considered to be very helpful in refining and improving the tool;
however, it did not constitute a formal pilot study. For this reason a number of issues arose
with the returned questionnaires. For example, certain sections of the questionnaire were
to be completed by Group A staff and other sections by Group B staff; despite this being
made explicit on the questionnaire, a number of respondents misread the instructions and
completed both sections. In addition, one question could have been interpreted as two
questions in one; careful piloting would probably have picked this up as a potential problem.

However, the whole study can be viewed as a pilot for a larger national study, and it would
now be possible to make refinements to the tool which would make it relatively robust.
Instead of one questionnaire, two could be used – one for Group A staff and the other for
Group B staff – which would avoid some of the confusion caused by having both groups
complete the same questionnaire and follow complex instructions.

26
5.4 Recommendations

The report concludes with recommendations for both the ‘Connected’ course and further
research.

Recommendations for the ’Connected’ course

• Marketing of the ‘Connected’ course could be improved to make it more appealing to
those members of staff who are required to complete it. This could include the
dissemination of information prior to the course (perhaps with testimonials from
previous course attendees) to raise awareness about its rationale and value.
• An assessment of skills on an individual basis (e.g. by questionnaire or audio recorded
patient interview) prior to the course would enable training needs to be identified.
Different levels of training could then be provided and tailored appropriately to
individuals.
• Further consideration needs to be given to course design and length; the possibility of
delivering the ‘Connected’ course in smaller segments should be explored.
• Course facilitation needs be of a consistently high quality, with the more experienced
and confident facilitators leading the highest level of training; less experienced
facilitators could gain experience by facilitating lower level courses.

Recommendations for further research

Further research is recommended before wider roll-out of the ‘Connected’ course, to
provide evidence of the effectiveness of communication skills training. Such research may
help to convince reluctant members of staff of the value and necessity of the course.
Possibilities for further research include:
• A national study, based on this questionnaire, to gauge the views of a larger number of
staff about mandatory advanced communication skills training. Such a study would seek
to explore differences between the attitudes and needs of not only different
professional groups but also different specialists, for example radiologists, surgeons and
pathologists.
• A randomised controlled trial to assess the impact of different levels of training.
Healthcare professionals could be randomised to undertake, for example, a half-day
introductory level course, a 2-day mid-level course or the 3 day ‘Connected’ course. Each
participant’s communication skills would be assessed both before and after the course
to assess improvements.
• A comparative study to evaluate differences in outcomes of communication skills
training courses of different durations; for example, an intensive one-day course
compared to the standard three day ‘Connected’ format.

27
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30
Appendix A: Interview schedule

Questions about you

Are you male or female?
How old are you?
How would you describe your ethnicity?

Questions about your job

Which acute trust do you work in?
What is your job title?
To which professional group do you belong?
When did you qualify (Date of first qualification)
Do you have any other professional qualifications?
Which multidisciplinary team (MDT) do you attend?
How long have you been working with cancer patients – specifically in this speciality/as a
member of this MDT?

Questions about your communication ability

Do you feel that you are a good communicator with patients at work?
Can you tell me about two strengths you feel you have when communicating with patients?
Can you tell me about two weaknesses you feel you had recently when communicating in a
difficult situation with patients?

Questions about communication training generally (Both groups)

Have you previously had any training in communication skills?
Have you done a course or are you waiting to do one?
Have you previously heard about advanced communication skills training?
What do you think is the purpose of advanced communication skills training?
Do you think that advanced communication skills training should be mandatory for cancer
professionals?
How do you feel about mandatory communication skills training?
Do you think that clinical professionals should receive training as separate groups –
doctor/nurse – or mixed?
Does the mix of the group affect your willingness to undertake the course?
If advanced communication skills training was not a requirement of your role how would
you feel about attending?
How do you feel about undergoing communication skills training?
How do you feel about doing role play/group work?
Do you have any other feelings/views about undertaking this training?
How important is communication generally within your role?
How important do you think communication is when linked to the treatment of cancer
patients?

Questions for participants who have done a course

When did you do a course?
How did you hear about the course?
How many people were on the course and did you know any of them?

31
Did you feel anxious about doing the course before you attended?
Was there anything you liked about the course?
Were there things you thought were not relevant to you or that you disliked about the
course?
Is there anything you would change about the course?
Are there any improvements you would like to see being made to future courses?
Do you feel that anything has changed in your attitudes or behaviour with patients from
attending the communication course?

Questions for participants who have not done a course but are waiting to go on one
How did you hear about the course?
How do you feel about doing the course?
Do you feel anxious about doing the course?

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Appendix B: Questionnaire

Exploring Staff Attitudes to Undertaking Advanced

Communication Skills Training

Thank you for taking the time to complete this questionnaire. By completing and returning
it, you are giving your consent for the information you provide to be used in the study. The
questionnaire is in 5 parts and should take approximately 15 minutes to complete. Please
answer the questions as directed and return the completed questionnaire in the prepaid
envelope provided.

Section 1: Questions about your job and experience

1. Which organisation are you employed by?

University Hospitals of Morecambe Bay NHS Trust

Lancashire Teaching Hospitals NHS Foundation Trust

East Lancashire Hospitals NHS Trust

Blackpool, Fylde and Wyre Hospitals NHS Foundation Trust

2. Please state your job title

…………………………………………………………………………………………………………………………………………………

3. To which professional group do you belong?

Medical Doctor Nursing Other

If other please specify

…………………………………………………………………………………………………………………………………………………

4. When did you qualify? (Date of first professional qualification)

…………………………………………………………………………………………………………………………………………………

5. Do you have a specific qualification related to cancer or palliative care?

(If so, please state name and date of qualification below)

…………………………………………………………………………………………………………………………………………………

6. How long have you been working with cancer patients?

…………………………………………………………………………………………………………………………………………………

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7. Of which multidisciplinary team (MDT) are you a member?

…………………………………………………………………………………………………………………………………………………

8. How long have you been a member of this MDT?

…………………………………………………………………………………………………………………………………………………

Section 2: Questions about communication skills training

9. Have you heard about the ‘Connected’ Advanced Communications Skills Training Course?

Yes No

If you answered yes to question 9, how did you hear about it?

My line manager Other

If other, please specify: .......................................………………………………………………………..

Please tick one box for each of the following statements:

Yes No
10. I have completed a ‘Connected’ course

11. I have a confirmed place on a forthcoming ‘Connected’ course

12. I am currently on a waiting list for a date to undertake a ‘Connected’ course

13. I have completed a previous Advanced Communication Skills training course

(Maguire, Wilkinson or Fallowfield variants)
14. I have completed other communication skills training course(s)
(If yes, please specify below)

…………………………………………………………………………………………………………………

15. Do you have a preference for the ‘Connected’ course to be:

Residential Non-residential No preference

Please complete Question 16 only if you have undertaken a communication skills training course
other than the ‘Connected’ course.

16. My most recent experience of communication skills training was: (please tick one box only)

Excellent Very good Good Fair Poor

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Please complete Question 17 regardless of whether or not you have undertaken any
communication skills training.

17. I would currently rate my communication skills as:

Excellent Very good Good Fair Poor

For each of the following statements please tick one box that most accurately reflects your
agreement with the statement:
Strongly Agree Disagree Strongly Don’t
Agree Disagree know
18. Communication skills training should be
mandatory for cancer and palliative care
professionals

19. Communication skills training should be available

for all health care professionals

20. Good communication with patients and relatives

is not essential to my job

21. Experienced cancer and palliative care staff

should already be skilled communicators and
should not need additional training

22. Communication skills do not need to be taught,

as they are learned ‘on the job’

23. Health care professionals should attend

communication skills training in separate groups
– e.g. nurses / doctors / others

24. More could be done to advertise the ‘Connected’

communications skills course

25. I think that my communication skills could be

improved with training

26. I am supported at work by my line manager

if I have to deal with a distressed patient or
relative

27. My colleagues support me at work if I have to

deal with a distressed patient or relative

28. I am supported at work in clinical supervision if I

have to deal with a distressed patient or relative

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Section 3: Questions about the ‘Connected’ course
If you have completed a ‘Connected’ course, please answer Questions 29 – 35 in Section 3A.
If you have not completed a ‘Connected’ course, please answer Questions 36 – 38 in Section 3B.

Section 3A
For each of the following statements please tick one box that most accurately reflects your
agreement with the statement:
Strongly Agree Disagree Strongly Don’t
Agree Disagree know
29. The ‘Connected’ course provided the right level of
training for me

30. I feel happier about communication skills training

having undertaken the course

31. I did not enjoy working in small groups on the

course

32. I would have liked more information about the

necessity of communication skills training prior to
the course

33. I feel less anxious now about role play having

undertaken the course

34. Specific feedback about my communication skills

on the course was helpful

35. A refresher course on communication skills would

be helpful

Section 3B
For each of the following statements please tick one box that most accurately reflects your
agreement with the statement:
Strongly Agree Disagree Strongly Don’t
Agree Disagree know
36. I feel anxious about undertaking communication
skills training

37. I have no concerns about role play in

communication skills training

38. I feel happy about working in small groups when

undertaking communication skills training

36
Section 4: Questions about you

39. Are you male? or female?

40. How old are you?

41. How would you describe your ethnicity? (Please tick one box)

White
Black African
Black Caribbean
Chinese
Indian
Pakistani / Bangladeshi
Other

If other, please specify

………………………………………………………………………………………………………………………………………………………...

Section 5: Comments
We would be grateful for anything else you would like to tell us; please use the space below and
continue on the back of the page if necessary.

………………………………………………………………………………………………………………………………………………………...

………………………………………………………………………………………………………………………………………………………...

………………………………………………………………………………………………………………………………………………………...

………………………………………………………………………………………………………………………………………………………...

………………………………………………………………………………………………………………………………………………………...

………………………………………………………………………………………………………………………………………………………...

Thank you very much for your help in completing this questionnaire. Please now return your
completed questionnaire by (insert date) in the pre-paid envelope to:

Dr Terri O’Brien
Research Associate
International Observatory on End of Life Care
Division of Health Research
Lancaster University
Lancaster
LA1 4YT

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