Support Care Cancer (2004) 12:692–700

DOI 10.1007/s00520-004-0666-6 REVIEW ARTICLE

Marjolein Gysels
Alison Richardson
Communication training
Irene J. Higginson for health professionals who care
for patients with cancer:
a systematic review of effectiveness

Received: 3 March 2004
Accepted: 8 June 2004
Published online: 16 July 2004

Springer-Verlag 2004
M. Gysels · I. J. Higginson
Department of Palliative Care and Policy,
King’s College,
London, UK
A. Richardson
The Florence Nightingale
School of Nursing and Midwifery,
King’s College,
London, UK
M. Gysels ())
Weston Education Centre,
Cutcombe Road, London, SE5 9RJ, UK
e-mail: marjolein.gysels@kcl.ac.uk
Tel.: +44-20-78485629
Fax: +44-20-78485517
Abstract Background: Effective
communication is increasingly re-
cognised as a core clinical skill.
However, there is evidence that
health and social care professionals
still lack basic communication skills.
Purpose: To assess the effectiveness
of different communication skills
training courses for health profes-
sionals in cancer care. Methods: We
searched six computerised databases
and augmented this with a follow-up
of references and grey (unpublished)
literature. We included all studies
evaluating communication training
and assessed methodological quality
according to the standard grading
system of the Clinical Outcomes
Group. Data on author, year, setting,
objectives, study design and results
were extracted and compared in tab-
ular format. Results: A total of 47
studies potentially assessing commu-
nication training in the area of cancer
care were identified. Sixteen papers
were included describing 13 inter-
ventions. Four were randomised
controlled trials (RCTs) (grade I),
with samples ranging from 72 to 233
subjects. The others were all grade
III. Eleven interventions trained
health professionals, two trained
medical students. The outcomes
measured included communication
skills as assessed on audio or video,
professionals’ self-report and patient
assessment. All the interventions
demonstrated modest improvements
(effect sizes ranged 0.15–2) and one
found deterioration in the outcomes
measured. Conclusion: Communica-
tion training improves basic commu-
nication skills. Positive attitudes and
beliefs are needed to maintain skills
over time in clinical practice and to
effectively handle emotional situa-
tions.
Keywords Communication training ·
Health professionals · Cancer care ·
Systematic review · Effectiveness

Introduction physiologic status and pain control. Effective communi-

Effective physician-patient communication is a central
clinical skill [4, 24]. This is especially so in cancer care
where successful interaction between health carers and
patients is essential, where the diagnosis is distressing and
treatment choices are complex. In a systematic review,
Stewart et al. [26] found that in 16 out of 21 studies, more
‘effective’ history taking and communication (usually
involving open rather than closed questions, empathy,
etc.) led to better symptom resolution, functional and
cation can also have an effect on recall of previously
received information, satisfaction and adherence to rec-
ommended treatments [3].
Achieving good communication in clinical practice is
problematic. Doctors and nurses still have widely varying
skills [28]. Shortcomings are due to a number of factors:
the medical education of health professionals with an
emphasis on diagnosis and treatment of physical dys-
function, fear of being confronted with unpredictable
emotional outbursts, health professionals’ assumptions

about what the patient thinks is most distressing, their
own attitudes toward death and dying and their involve-
ment in a job with high demands and long hours, which
can lead to stress. Failings in communication also can
have negative consequences for staff. Inappropriate de-
tachment [11, 12, 16, 20, 25] is a major source of stress
for doctors and nurses, making them especially suscepti-
ble to burnout [21] and further reducing the quality of
care for patients.
Thus, in recent years, there has been a greater em-
phasis on communication skills training [5, 6, 27].
However, questions remain as to whether this is effective,
and if so, what form of training is most effective and cost
effective. As part of a review for the National Institute of
Clinical Excellence on Models of Effective Supportive
and Palliative Care (MESP), we conducted a systematic
review to determine whether communication skills train-
ing was effective in improving communication for pa-
tients and families.
Methods
Identification of the literature
Relevant studies for meeting the inclusion criteria were identified
by searching:
– Computerised databases: MEDLINE (1966 to March 2003),
EMBASE (1980 to March 2003), CINAHL (1982 to March
2003), CDSR (2003, Issue 2), the Cochrane Effective Practice
and Organisation of Care Group (EPOC) specialised register,
and the Cochrane Central Register of Controlled Trials (CEN-
TRAL, 2003, Issue 2).
– The reference lists of identified studies were searched for fur-
ther relevant studies.
– An expert panel advised on recently published articles or on-
going research as part of their function for the NICE Guidance
for supportive and palliative care for those affected by cancer.
Inclusion criteria
Studies that evaluated interventions providing communication
skills training programmes for either undergraduate medical or
Table 1 Grading system for individual studies
Grade I
(RCT)
Grade II
Prospective study with a comparison group (non-randomised
controlled trial, good observational study) or retrospective study
with controls effectively for confounding variables
Grade III
693
nursing students or health professionals with experience in caring
for cancer patients were included. Interventions focusing on basic
skills as well as on attitudes with the aim of improving commu-
nication were considered. The types of studies included were ran-
domised or quasi-randomised controlled trials (RCTs), controlled
before-and-after studies (CBAs), interrupted time series and ob-
servational studies (ITS).
Data extraction and analysis
A standardised data extraction form recorded the characteristics of
the intervention, participants, factors that contributed to the
methodological quality of the individual studies and main out-
comes. Studies were graded using a standard system, as used by the
Clinical Outcomes Group [19] (Table 1). From this, data were
extracted into detailed tables, including author, year, setting, ob-
jectives, population, study design, outcome measures and main
results in terms of improvement, deterioration and no difference.
The main results were compared in a meta-synthesis contrasting the
results of higher-grade studies and those using different types of
interventions. Although outcomes were too heterogeneous to permit
formal meta-analysis, we calculated effect sizes (ES) so that these
could be contrasted, using the formula
mean difference
standard deviation
where mean difference is the change or difference in mean outcome
value associated with the intervention, and standard deviation is the
weighted average standard deviation of the intervention and control
groups. For binary outcomes (proportions) the effect size was de-
fined [13] as the
difference in proportions
p
ðproportion 0 yes0 Þ
ðproportion 0 no0 Þ
In some studies, results were not given in a format to allow this
calculation, but odds ratios (OR) or relative rates (RR) were given.
For effect sizes, a score of 0 indicates no difference between inter-
vention and control, for RR and OR. This is indicated by a score of 1.
Results
Nature of the evidence
Thirteen studies (Table 2) out of 47 met the inclusion
criteria. Reasons for exclusion were: non-evaluation
IA–calculation of sample size and accurate, standard definition
of outcome variables
IB–accurate and standard definition of outcome variables
IC–neither of the above
IIA–calculation of sample size and accurate, standard definition
of outcome variables and adjustment for the effects of important
confounding variables
IIB–one or more of the above
IIIA–comparison group, calculation of sample size and accurate,
standard definition of outcome variables
IIIB–two or more of the above
IIIC–none of these
694

Table 2 Studies that met inclusioin criteria

Study Objectives Design Participants Subjects, Results
method of
recording
Fallowfield Attitudes, RCT Senior Real, video Improvements:
et al. 2002 knowledge, oncologists
skills (n=160).
Focused questions, focused and open questions,
expressions of empathy, appropriate responses
to patients cues
Ia No significant differences:
United Use of leading questions, summarising information,
Kingdom interrupting, checking understanding
Fallowfield Follow-up at Twelve months later:
et al 2003 [9] 12 months
Maintenance of all but one of the skills plus two
new key behaviours: an increase of summarising
information and a decrease in interrupting patients
Jenkins and Attitudes Subgroup Improvements:
Fallowfield of above
2002 [14] (n=93)
Empathy
Open questions
Appropriate responses to cues
Psychosocial probing
Physicians’ self-rating: support findings measured
by Medical Interaction Process System
(improvements in skills)
Klein 1999 Interview RCT Undergraduate Real, video Improvements:
[15] skills medical students
Attitudes (n=233) Participants consider the ability to listen and trust
in doctor-physician relationship essential
Ia (n=54 in 5th Two years later:
year)
United Participants find the ability to communicate with
Kingdom patients important, and think that clinical decisions
should reflect patients wishes
Razavi et al. Attitudes RCT Experienced Simulated, Improvements:
1993 [22] (self-concept) oncology nurses video
(n=72)
Occupational Control of the interview
stress
Communication No differences:
skills
Ia Form, function, content, structure, use of cues,
psychological depth of interview, blocking behaviours
Belgium Also no differences in summarising information,
interrupting, checking understanding
Razavi et al. General RCT Experienced Simulated plus Improvements:
2002 [23] communication oncology nurses real, video
skills
Ia Empathy (n=115) An increased use of emotional words by health
professionals right after the training and 3 months
later compared to the controls in clinical interviews
The same trend was noticeable in simulated interviews
Belgium The emotional words registry remains stable over
time in clinical interviews and is enlarged in
simulated interviews
This facilitates patient emotion words expressions
especially 3 months after training
Anderson Bad news Single group Medical students Students Improvements:
1982 [1] pre-test assessed by
post-test answers to
design questionnaire
IIIc (n=145) divided 38% of the students had a change in opinion
into 12 seminars towards one of three questions:
Hong Kong Whether to tell the patient he has cancer,
is going to die, and who is responsible to tell
 695

Table 2 (continued)
Study Objectives Design Participants Subjects, Results
method of
recording
Baile et Bad news Single group Postgraduate Physicians Improvements:
al1999 [2] pre-post-test oncologists fulfill the role
design of simulated
patients
Problem solving (n=17) Breaking bad news: confidence improved
(e.g. requests for for 18 of 21communication outcome items
futile treatment)
IIIc Managing difficult patient situations:
11 of 45 items
United States Satisfaction
Fallowfield Attitudes, Pre-post Senior Simulated, Improvements:
et al 1998 [7] knowledge, comparison physicians video
skills. (plus
follow-up)
(n=178) Confidence ratings for key communication areas
IIIb Three months post-course:
United Positive shifts in attitude toward patients’
Kingdom psychosocial needs, more patient centred
The courses were highly rated
Faulkner et al Bad news (skills, Single Doctors plus Simulated, Improvements:
1995 [10] knowledge, group post nurses (mixed) video.
attitudes) test design.
(n=441) The physicians used a warning shot
IIIc They questioned feelings but immediately
blocked response. They gave information in stages
United Other findings:
Kingdom Only two asked screening questions
Major area of difficulty comes after giving information
Exploring patients’ feelings is a necessary part
of giving information
Heaven and Assessment Single group Hospice nurses Real plus Improvements:
Maguire1996 skills pre-post test (trained/ simulated
[12] design (plus untrained)
follow up)
(n=44) Audio-taped Skills post test, continue, and significant follow-up:
interview
Proportion of open questions
IIIc Number of behaviours with a psychological focus
and the level of clear expression used with patients
United Other findings:
Kingdom Levels of blocking increased
Little improvement in identifying patients
main concern
At 9 months: back to pre-intervention levels
Maguire and Interviewing, as- Single group Doctors plus Health Improvements:
Faulkner sessment, coun- pre-post-test nurses professional
1988 [17] selling design bringing up a
problem from
his practice
experience
IIIc (n=20) Audio-taped Confidence in assessing and counselling. Skills
of effective interaction
United Other findings: Few encourage patient
Kingdom to clearly express their feelings
Maguire et al Interviewing Single group Doctors, nurses, Simulated Improvements:
1996 [18] skills pre-posttest social workers,
design. (plus clinical
follow-up) psychologists,
chaplains
IIIc (n=212) Audio-taped Use of open, directive questions,
questions with a psychological focus, clarification
of psychological aspects
696

Table 2 (continued)
Study Objectives Design Participants Subjects, Results
method of
recording
United 169 (80%) No increase in:
Kingdom follow-up
Educated guesses, empathic statements, significant
reduction of the use of questions with a physical focus,
clarification of physical aspects and premature advice
No reduction in the giving of advice or the use
of leading questions
Six months after: Questions and clarification still
significantly better. Although some decline compared
to post-No change in: Educated guesses or empathy.
Compared to pretest: inhibitory behaviours still used
but increasing towards preworkshop level.score
Wilkinson et Integrated, Single group Nurses Real. Improvements:
al 1998 [29] experiential pre-test,
mid-test,
post-test
design
Assessment Follow-up (n=110) Audio-taped In 6 of the 9 areas measured
skills of 1998
study
IIIb Attitudes (n=33) (2.5 years Most pronounced changes were found in introduction,
later) patients’ awareness of their diagnosis or prognosis,
history of present illness, psychological assessment
United Knowledge Improvement pre to mid: 79%. Mid to post: 70%
Kingdom
Wilkinson et Awareness Pre to post: 90%
al 1999 [30] No significant deterioration or improvement in 8 of the
9 areas
Significant improvement in psychological assessment
Wilkinson et Integrated, Single group (n=308) Real Improvements:
al. 2002 [31] experiential pre-test
post-test
design
United Assessment Audio All nine areas of the assessment (p<0.001)
Kingdom skills, attitude,
knowledge,
awareness

studies, training programmes that made use of other
methods than face-to-face teaching (e.g. distance learn-
ing, computer-assisted instruction) and interventions not
directly training the health professionals whose commu-
nication skills were to be improved (e.g. teaching teach-
ers). Four were grade Ia randomised controlled trials [8,
15, 22, 23]. Of these, two were from the United Kingdom
[8, 15], and two from Belgium [22, 23]. The other studies
reviewed were all grade III (six IIIc and three IIIb). Seven
were carried out in the United Kingdom [12, 7, 10, 17, 18,
29, 31], one in Hong Kong [1] and one in the United
States [2].
Types of interventions
Training objectives were directed towards improving the
medical interview in three studies [15, 17, 18], assessment
of psychological distress among patients in five studies
[12, 17, 18, 29, 31], imparting distressing information in
three studies [10, 1, 2], counselling in one study [17],
problem solving in one study [2] and assessment of pa-
tients’ needs for information in one study [8]. Fallow-
field’s studies [8, 7, 9] were more comprehensive and
combined knowledge, awareness and general skills.
Razavi et al. [22] focused on a variety of skills as a
component of a more encompassing psychological train-
ing programme. A similar broad approach was taken in a
later study [23] to improve communication skills in
general and empathy in particular. A number of studies
targeted attitudes, knowledge and awareness as part of
their interventions [8, 15, 22, 7, 10, 29], and it was the
central focus of the Jenkins and Fallowfield study [14].
Eleven studies targeted practising health professionals,
and two targeted undergraduate students during their
training in medicine [15, 1]. The grade I randomised
controlled trials had a large number of subjects ranging
from 72 to 233. Faulkner et al. [10], Maguire et al. [18],
Fallowfield et al. [7] and Wilkinson et al. [29, 31] also
included many participants (441, 212, 178, 110 and 308

respectively), whilst remaining studies worked with
smaller groups. The communication training programmes
demonstrated very high response rates and negligible drop
out only Heaven and Maguire [12] reported 50% attrition.
Of the studies assigned grade III without randomisa-
tion or a control group, six were conducted with a single
group pre-test/post-test design [12, 7, 17, 18, 31, 2]. One
study also applied mid-test assessment [29] while one
study only applied a post-test design [10]. Anderson [1]
assessed students’ solutions to problems before training,
and these were compared after the course.
Effectiveness
All interventions demonstrated significant improvements,
and only one found deteriorations in the outcomes mea-
sured: Heaven et al. [12] found an increase in the levels of
blocking occurred after the intervention.
Combined communication skills
All four RCTs measured different outcomes. Following an
earlier pilot study [7], the most recent and most sophisti-
cated RCT [8] found that after a 3-day training course,
participants changed significantly in the use of more fo-
cused questions (RR=1.34), more focused and open
questions (RR=1.27), expressions of empathy (RR=1.69),
appropriate responses to patients’ cues (RR=1.38) and
fewer leading questions (RR=0.76) compared with indi-
viduals randomly selected to receive no course. There
were, however, no significant improvements for sum-
marising information, interrupting, and checking under-
standing. These skills were also tested in a written feed-
back condition, but no significant differences were found.
Razavi [22] measured similar skills such as sum-
marising, interrupting the patient and checking under-
standing, but no changes were observed in these or in
other areas relating to the form, function, content, struc-
ture, use of cues, psychological depth of the interview or
blocking behaviours. The only significant change detect-
ed was that the intervention group of nurses were more in
control of the interview than the controls. ES could not be
calculated.
The more recent RCT by Razavi et al. [23], which
focused on empathy, found an increased use of emotional
words by trained health professionals (ES=0.45), which
facilitated cancer patient emotional word expressions
compared to untrained health professionals, especially 3
months after training (ES=1.70).
697
Bad news
Studies with the objective of enhancing skills in giving
distressing information were generally reported as having
positive outcomes. These were all grade IIIc studies of
which only Faulkner et al. [10] used an instrument to
evaluate the training, whereas the other studies relied on
self-report assessments. After training, Faulkner et al. [10]
reported the use of a warning shot (91%), information-
giving in stages (85%), and the questioning of the pa-
tient’s feelings (57%), although the patient’s response was
immediately blocked. However, the lack of information
about prior behaviour means that the changes in behav-
iour cannot be determined. The authors came to the
conclusion that the exploration of patients’ feelings is a
necessary part of giving information. Anderson [1] com-
pared a post-evaluation questionnaire with solutions to
problems provided by the participants prior to training
and found that 38% had a change of opinion towards the
responsibility for giving distressing information (insuffi-
cient data to calculate ES). Baile et al. [2] reported that
for the part of the training where they focused on breaking
bad news, confidence improved in 18 of 21 communica-
tion outcome items, with the most significant score for
assessing the patient’s ability to discuss bad news
(p<0.001, insufficient data to calculate ES). The three
items not reaching significance were detecting verbal
cues, encouraging family presence and detecting patient
anger. The other part of the training, which focused on
managing difficult patient situations, showed improve-
ment in 11 of the 45 communication outcome issues, with
the most significant for dealing with a patient who has
been lied to (p=0.003).
Assessment skills
Interventions with the primary objective of improving
assessment skills also achieved positive outcomes.
Heaven and Maguire [12] found an improvement of as-
sessment skills from pre- to post-test, which had become
significant by follow-up. Staff increased the median
number of open questions from 4 to 8–10, and increased
median psychologically focused behaviour from 7 to 10.
Maguire and Faulkner’s report [17], which described the
effect of training through self-report in terms of confi-
dence in assessment and counselling, and at follow-up in
terms of the extent to which the participants were able to
apply what they had learned, found that their skills of
effective interaction had improved, although few en-
couraged the patient to clearly express their feelings.
Maguire et al. [18] showed significant increases in the use
of open, directive questions, questions with a psycho-
logical focus and clarification of psychological aspects,
which was maintained 6 months after the intervention,
although some decline was observed compared to the
698
post-score. There was no increase in educated guesses or
emphatic statements, nor did this change at follow-up. A
significant reduction in questions with a physical focus,
clarification of physical aspects and premature advice was
found. But there was no reduction in the giving of advice
or the use of leading questions. At follow-up, these in-
hibitory behaviours were still used. The more effective
the course attendees became in eliciting feelings, the more
worried they became of exploring patients’ feelings fur-
ther. Jenkins and Fallowfield [14] showed an increase in
effective communication skills in the areas of the ex-
pression of empathy (p=0.2), open questions (p=001),
appropriate responses to cues (p=.005) and psychological
probing (p=.041). Wilkinson’s study [29] reported sig-
nificant improvements in six of the nine areas measured.
The most pronounced areas of improvement in commu-
nicative skills were the introduction (ES=1.42), patients’
awareness of their diagnosis or prognosis (ES=1.04),
history of present illness (ES=0.82) and psychological
assessment (ES=0.77). These gains were maintained at 9
months. The total mean post-training score was 16.3
(range 8–23). A follow-up of a subset of nurses at 2.5
years post-training showed that these gains were main-
tained (ES ranged 0.63–2.0). In Wilkinson’s later study
[31], all of the nine areas measured improved after
training. A statistically significant post-training change in
overall scores was observed, with mean scores rising by
just under six points from 10.44 pre-intervention to 16.34
post-intervention (ES=1.61).
The use of skills in clinical practice
Three studies in particular examined the effects of train-
ing on clinical practice. Heaven and Maguire [12] ad-
dressed objective skill levels but found that the inter-
vention failed to change clinical practice. The results
showed a small improvement in eliciting patients’ con-
cerns (ES=0.15, detection of patients most important
concerns increased from 52 to 59%). Jenkins and Fal-
lowfield [14] reported on Fallowfield’s communication
skills training intervention [18] containing behavioural,
cognitive and affective components to find that this not
only increased potentially beneficial and more effective
interviewing styles but also led to alter health profes-
sionals’ attitudes and beliefs, thus increasing the likeli-
hood that such skills would be used in the clinical setting.
A self-assessment questionnaire highlighted changes in
practice: significantly more of the physicians who at-
tended a course reported greater awareness of their style
of questioning (ES=0.73) and felt that they discussed
more psychosocial issues with patients (ES=0.53). Wil-
kinson’s integrative training program [29] achieved sig-
nificant improvements in the breadth and depth of cov-
erage as well as in the psychological aspects of patient
assessment (see above).
Attitudes and beliefs
Studies that targeted attitude as part of their intervention
showed positive results. Razavi et al. [22] found a sig-
nificant training effect on attitudes (ES could not be
calculated), although these were no longer evident after a
2-months period. With the participation of cancer pa-
tients, in training, Klein’s study [15] accomplished ben-
eficial and enduring effects on the attitudes and interview
performance of medical undergraduates. Faulkner et al.
[10] found positive results in the provision of distressing
information, but due to the poor methodological quality of
the study, it is unclear whether the attention to attitude
contributed to these results. Challenging attitudes and
beliefs of participants in Wilkinson et al. [29] led to in-
creased confidence and efficacy in communication, with
90% of the nurses showing quantifiable evidence of im-
provement.
Discussion
In this paper, we have reviewed 16 papers that evaluated
training programmes to improve communication for
health professionals who care for cancer patients. Given
the wide variety of objectives, participants, designs, out-
come measures and results used in the studies included in
this review, a quantitative meta-analysis was impossible.
Still, these studies raise some interesting issues. Most
importantly, the results confirm that health professionals
can be trained to communicate more effectively with
patients who have cancer. Available effect sizes ranged
from 0.15 to 2, with all but one greater than 0.5. For an
effect size of 0.5, the average score in the intervention
group was 0.5 standard deviations above the control or
comparison group. This is larger than the effect size of
palliative care teams [13].
The four RCTs providing level Ia evidence ensure the
replicability of the interventions applied, the level IIIc
studies with a less rigourous design offer a broader picture
and allow for comparison among training programmes.
Studies that focused on attitudes raised broader questions
about the conditions that are necessary to improve com-
munication. Jenkins and Fallowfield [14] first tested
participants as to whether they held beliefs that might
clash with the promoted behaviours. The newly acquired
skills would otherwise not last for very long or they would
be rejected right away. Greater awareness goes together
with the recognition of not knowing how to practically
apply new knowledge. This is one of the most important
obstacles to the effectiveness of the communication
training programmes. A clear example is Heaven and
Maguire’s study [12]. They concluded that, despite an
improvement in the nurses’ skills, there was no noticeable
development in their ability to identify their patients’
concerns. They surmised that basic skills training is not
 699

sufficient to have an effect on nurses’ ability to elicit
patients’ concerns, and they suggested incorporating be-
havioural elements into training programmes.
Other training programmes with a sole focus on skills
showed similar patterns: significant improvements in the
skills taught during the courses but little effect on their
application in practice [10, 17, 18, 2]. Evidence that in-
terventions that take into account attitudes and beliefs
produce better results comes from Wilkinson et al. [29,
31], Fallowfield et al. [8], Jenkins and Fallowfield [14]
and Klein [15]. Wilkinson’s studies applied an integrated
approach providing communication skills courses as part
of a broader training programme on cancer and palliative
care, addressing areas such as death and dying and raising
self-awareness. They showed that this approach signifi-
cantly improved nurses’ confidence in tackling the es-
sential areas of care.
Behaviour change has proved to be the most prob-
lematic in emotionally charged situations. In Wilkinson et
al. [29, 30], the training had most effect on emotionally
laden areas for which the integrated approach was re-
sponsible. Similarly, communication training embedded
in a workshop with the aim of developing understanding
of psycho-social dimensions related to cancer diagnosis
and progression by Razavi et al. [23] reached positive
results.
Only six of the studies incorporated a long-term fol-
low-up phase to the intervention [12, 8, 15, 23, 18, 30].
The long-term assessments at 12 months in Fallowfield’s
trial [9] demonstrated the maintenance of all but one of
the skills shown at 3 months and two new key behaviours
not apparent before (an increase of summarising infor-
mation and a significant decrease in interruption of pa-
tients). The effects in Razavi’s study [23] were main-
tained at 3 months. Klein [15] reported that a positive
effect of the course could still be found 2 years after the
intervention. Wilkinson et al. [30] reported that the level
of skills the nurses obtained was maintained at 2.5 years.
Heaven and Maguire [12] found only a small improve-
ment in the application of skills in clinical practice and at
9 months this had returned to pre-intervention levels.
Maguire et al. [18] observed a decline in skills to pre-
workshop level at 6 months follow-up. An important issue
for further investigation is, therefore, the maintenance of
the effectiveness of the programmes over time. Where the
attrition of skills occurs, the utility of regularly repeated
consolidation sessions should be investigated.
Another review focuses in more detail on the training
methods and the assessment procedures used in these
communication training programmes (Gysels et al., un-
published data). Insights gained could help health care
providers involved in the planning and implementation of
interventions to develop optimally functioning training
courses and find the right combination of components to
achieve the best results.
Acknowledgements This work was undertaken by King’s College
London, which received funding from the National Institute of
Clinical Excellence (NICE). The views expressed in this publica-
tion are those of the authors and not necessarily those of the In-
stitute. We thank Lesley Fallowfield for helpful comments on an
earlier draft of this paper.

References
1. Anderson JL (1982) Evaluation of a
practical approach to teaching about
communication with terminal cancer
patients. Medl Educ 16:202–207
2. Baile W, Kudelha AP, Beale EA,
Glober GA, Myers EG, Greisinger AJ et
al (1999) Communication skills training
in oncology. Description and prelimi-
nary outcomes of workshops on break-
ing bad news and managing patient re-
actions to illness. Cancer 86:887–897
3. Bartlett EE, Grayson M, Barker R,
Levine DM, Golden A, Libber S (1996)
The effects of physician communication
skills on patient satisfaction, recall and
adherence. J Chron Disease 37:765–772
4. Cassell EJ (1978) The Healer’s Art:
A New Approach to the Doctor-Patient
Relationship. Penguin Books,
Harmondsworth
5. Department of Health (2000) The NHS
Cancer Plan. London
6. Fallowfield L, Baum M, Maguire G
(1986) The effects of breast conserva-
tion on the psychological morbidity
associated with the diagnosis and
treatment of early breast cancer. BMJ
293:1331–1134
7. Fallowfield L, Lipkin M, Hall A (1998)
Teaching senior oncologists communi-
cation skills: results from phase i of a
comprehensive longitudinal program in
the United Kingdom. J Clin Oncol
16:1961–1968
8. Fallowfield L, Jenkins V, Farewell V,
Saul J, Duffy A, Eves R (2002) Efficacy
of a cancer research UK communication
skills training model for oncologists: a
randomised controlled trial. Lancet
359:650–656
9. Fallowfield L, Jenkins V, Farewell V,
Solis-Trapala I (2003) Enduring impact
of communication skills training: 12
month follow-up results of a random-
ised trial. Br J Cancer 89:1445–1449
10. Faulkner A, Argent J, Jones A,
O’Keeffe C (1995) Improving the skills
of doctors in giving distressing infor-
mation. Medl Educ 29:303–307
11. Ford S, Fallowfield L, Lewis S (1996)
Doctor-patient interactions in oncology.
Soc Sci Med 42:1511–1519
12. Heaven C, Maguire (1996) Training
hospice nurses to elicit patient con-
cerns. J Advanced Nursing23:280–296
13. Higginson I, Finlay I, Goodwin D,
Hood K, Edwards A, Cook A et al.
(2003) Is there evidence that palliative
care teams alter end-of-life experience
of patients and their caregivers. J Pain
Sympt Man 25:150–68
14. Jenkins V, Fallowfield L (2002)
Can communication skills training alter
physicians’ beliefs and behavior in
clinics? J Clin Oncol 20:765–769
700
15. Klein S (1999) The effects of the par-
ticipation of patients with cancer in
teaching communication skills to med-
ical undergraduates: a randomised study
with follow-up after 2 years. Eur J
Cancer 35:1448–1456
16. Ley P (1982) Satisfaction, compliance,
and communication. Br Clinl Psychol
21:241–245
17. Maguire P, Faulkner A (1988) Improve
the counselling skills of doctors and
nurses in cancer care. BMJ 297:847–
849
18. Maguire P, Booth K, Elliott C, Jones B
(1996) Helping health professionals in-
volved in cancer care acquire key in-
terviewing skills—the impact of work-
shops. Eur JCancer 32A:1486–1489
19. Mann, T (1996) Clinical guidelines:
using clinical guidelines to improve
patient care within the NHS.
NHS Executive
20. Mishler EG (1984) The discourse of
medicine: dialectics of medical inter-
views. Ablex, Norwood
21. Ramirez AJ, Graham J, Richards MA,
Cull A, Gregory WM (1996) Mental
health of hospital consultants: the ef-
fects of stress and satisfaction at work.
Lancet 347:724–728
22. Razavi D, Delvaux N, Marchal S,
Bredart A, Farvaques C, Paesmans M
(1993) The effects of a 24-h psycho-
logical training program on attitudes,
communication skills and occupational
stress in oncology: a randomised study.
Eur J Cancer 29A:1858–1863
23. Razavi D, Delvaux N, Marchal S,
Durieux J-F, Farvacques L, Dubus L et
al. (2002) Does training increase the use
of more emotionally laden words by
nurses when talking with cancer pa-
tients? A randomised study. Br J Cancer
87:1–17
24. Simpson M, Buckman R, Stewart M
(1991) Doctor-patient communication:
the Toronto Consensus Statement.
BMJ 303:1385–1387
25. Spiro H (1992) What is empathy and
can it be taught? Ann Intern Med
116:843–846
26. Stewart MA (1996) Effective physi-
cian-patient communication and health
outcomes: a review. Can Med Assoc J
152:1423–1433
27. Walker LG (1996) Communication
skills: when, not if, to teach. Eur J
Cancer 32A:1457–1459
28. Wilkinson S (1991) Factors which in-
fluence how nurses communicate with
cancer patients. J Adv Nur 16:677–688
29. Wilkinson S, Roberts A, Aldridge J
(1998) Nurse-patient communication in
palliative care: an evaluation of a
communication skills programme.
Pall Med 12:13–22
30. Wilkinson S, Bailey K, Aldridge J,
Roberts A (1999) A longitudinal eval-
uation of a communication skills pro-
gramme. Pall Med 13:341–348
31. Wilkinson S, Gambles M, Roberts A
(2002) The essence of cancer care: the
impact of training on nurses’ ability to
communicate effectively. J Adv Nurs
40:731–738