Communication skills teaching – Can one size fit all?
Julie Rowlands
Dr Nikki Pease
It is now widely recognised that good communication is
essential for the delivery of high quality care but this was not
always the case…
Time of Hippocrates – Communication was of prime
importance to doctors
Medicine advanced, focus changed to learning new
skills, new techniques and treatments.
Communication remained integral to good medicine but
doctors were not trained to communicate
Between 1920s and 1960s there
was recognition of the
importance of taking a history
and various clinical approaches
taught.
1960s onwards – attempts to analyse interview content
• Interactional analysis of interviews – Korsch (1968)
• RIAS – Roter interactional analysis scheme – Roter (1977)
• MIPS – Medical interaction process system - Ford et al (2000)
Lipkin and Putnam (1979) set up an interest group to identify how to equip
doctors with the necessary skills and attitudes to communicate effectively:
Publication of a curriculum for effective medical interviewing in 1984 (General
medicine).
1984 – current day. Several main players in CS research and teaching. Further
evidence generated in cancer and palliative care
Core communication skills 3 day course in England for Cancer MDT members
‘Connected’ by NCAT – future unknown.
1980s onwards - evidence suggests that teaching can
improve communication skills but…
• How should we teach
for best effect?
• What evidence exists
already?
The evidence provides many common themes with all
models based on similar components
Learner
centered
Small
groups
Patient
centered
interviewing
Facilitated
Role play
Personal
awareness
Credible
trainer
s
Face
to face
Immediate
constructive
feedback
Short
course
1 ½ , 2, 3
days
Traine
d
actors
How robust is the evidence for a short intensive
course?
• 1 ½ day courses demonstrated improvement in skills
(Fallowfield 1998).
• 2 – 5 day intensive courses increase skills further (Fallowfield
et al 2001, 2003).
• Longer, less intensive courses demonstrated no additional
improvements (Ravasi et al 1993, and 2002).
• A recent consensus meeting of European experts (Steifel et al
2009) reported no conclusive results for the optimal length of
course.
Important!
This is research evidence for greatest skills improvement.
What were the students’
starting points?
Previous training (2001)?
What is our aim in teaching
– some improvement?
- achievement of a set level?
- improve the student to the
best they can achieve?
MSc/Postgraduate Diploma in Palliative medicine/care
The history
• Teaching communication skills since 1989
• Students are assessed in order to gain credits towards MSc.
• Developed a ‘toolkit’ that can be used in any situation
regardless of profession, culture or clinical setting.
The research
• Evidence was collected by scoring students along the 2 year
timeline of our postgraduate diploma.
So how do we teach communication skills for the MSc?
A Blended Learning Approach
Teaching blocks yr 1 and yr 2
• Face to face lecture – theory: ‘Cardiff communication
skills 6 point toolkit ‘.
• Facilitated role-play with and without professional
actors
Electronic resources
• Reading material, Podcasts and videos
The Cardiff Communication Skills 6 point Toolkit
1.
2.
3.
4.
Comfort
Language
Question style
Listening/Use of
silence
5. Reflection
6. Summarising
What questions did we want our research to answer?
• Did communication skills improve?
• Were improved skills maintained over time? (12 month
follow up assessment)
• Were skills improved further with a second session of
training? (16 month follow up assessment from initial
training)
• Were students’ self assessments reliable? (comparison
of self assessment to tutor assessment)
Method and data collection
• Data collected for 2 cohorts to allow comparison of results:
Cohort 1: 2008 – 2010
Cohort 2: 2009 – 2011
• Triangulated approach to analysing data:
Self assessment and facilitator rated competence of
‘consultations’ at 6 points across 2 years
Collection of data
Cohort 1- N= 46 – 34 doctors, 12 nurses
Cohort 2- N = 43 - 34 doctors, 9 nurses
• Assessment at RTB against 6 ‘tools’ by
students and tutors
• Assessment of DVD against 15 key
performance indicators
• Comparison of student/tutor scores
Data collection timeline
Cohort 1
Sept 2008
Jan/Feb 2009
Sept 2009
Feb/Mar 2010
Jan/Feb 2010
Sept 2010
Feb/Mar 2011
Cohort 2
Sept 2009
Findings for Cohort 1.
Were communication skills improved by training?
Yes
Student self-scoring at RTB against ‘tools’.
• 72% of the cohort scored themselves > 70% post
training compared to 48% of cohort pre training.
Tutor scoring post training for comparison
• 87% of the cohort were scored >70% post training.
Did students feel their skills were maintained over time?
Post RTB year 1 score compared with pre RTB year 2 score
• Students felt that their skill level had reduced over time
to their original score or lower.
• This is inconsistent with published evidence of follow up
questionnaires which raises questions………………
Why did they score themselves lower?
• Because they felt their skills had deteriorated?
• Because they had more insight into their skills after
practicing and having further written feedback?
• Because they understood the assessment system
better?
• Because they completed the self-assessment
immediately pre-training and wanted to ensure they
could demonstrate improvement?
Were skills improved further with a second session of training?
YES
Cohort 1 data. N=46 - Self and tutor ratings at RTB
40
35
30
25
20
15
10
5
0
> 80%
70 - 79%
60-69%
50-59%
40-49%
<40%
Pre
RTB
yr 1
Self Tutor
post post
RTB RTB
Pre
RTB
yr 2
Self Tutor
Post post
RTB RTB
yr 2
Did students feel that their skills/confidence had improved by the
end of the course?
Student self assessment of 2nd DVD:
YES
• Students scoring 70% and above increased from 22% (n=7) in
year 1 to 60% (n=19) in year 2
At the end of the 2 years of teaching most students were
communicating at a very good or excellent level
• Over 90% of Students were scored at 60% and over both by
self assessment and by tutors
*The Number of students with full data across both years is 32
Are students self-assessments from teaching sessions
reliable?
• Both students and tutors felt that their competencies had
improved overall but there was some difference of opinion in
which areas the students had improved most.
Where were the greatest improvements perceived?
The students perceived their
greatest improvement in
Questioning and Listening
• The tutors perceived
greatest improvement in
the students’ Reflecting and
Summarising
Did the findings for Cohort 2 support those for Cohort 1?
Partly but not fully:
All students perceived their competence levels to be higher
following training.
Most students reverted to the original scores after a year
(self assessed)
However..
Students did not perceive their competence levels to be
improved further after a 2nd session of training.
Tutors did not perceive that students improved further
between year 1 and 2.
Can this be explained?
• There were differences in the pre-course skills of the
students (self assessed): The second cohort had less
high scorers
• The amount of improvement in skills was different:
- In high scorers the change was small but quick
- In lower scorers change was incremental over a
longer time
What evidence can we use to guide future teaching/assessment?
• ALL students and tutors felt teaching had improved skills
• Students may need different lengths of teaching programmes
• Assessments should be included as self-assessment scores are
unreliable
• Certificates of competence are more meaningful than
certificates of attendance
The Take Home Message?
Why design ‘standard’ length
communication skills courses
regardless of prior skills and try to
make everyone fit?
One size does NOT fit all!
• Identifying
high/mediocre/low
scorers may be the key.
• An assessment method
that can be used after 1
day of training could do
this.
Our Training proposal – progression by traffic light system
• 1 day of training which
benefits all = cost
effective
• Some students will
need more training to
reach desired level
• Students can be ‘traffic
lighted’ at the end of
day one and the most
appropriate route and
follow up offered.
Training for all: Theory + toolkit, facilitated role-play,
assessment and allocated ‘Green’, ‘Amber’ or ‘Red’.
Day 1 assessment outcome
• Green: Student exits with
certificate of competence,
returns within 5 years for
update
Training for all: Theory +toolkit, facilitated role-play,
assessment and allocated ‘Green’, ‘Amber’ or ‘Red’.
Day 1 assessment outcome
Amber and Red: Stays for
a 2nd day and receives
further training, role-play
and reassessment.
Day 2. Further facilitated role-play, assessment and allocated
‘Green’, ‘Amber’ or ‘Red’.
Day 2 assessment outcome
• Green: Student exits with
certificate of competence,
returns within 5 years for
update
Day 2. Further facilitated role-play, assessment and allocated
‘Green’, ‘Amber’ or ‘Red’.
Day 2 assessment outcome
• Amber: Given further
advice/pointers advised to
practice using the toolkit
and returns for training
within 2 years.
Day 2. Further facilitated role-play, assessment and allocated
‘Green’, ‘Amber’ or ‘Red’.
Day 2 assessment outcome
Red:
Given further advice/pointers.
Advised to practice using the toolkit.
Given guidance on how to reflect on
practice.
Wherever possible partnered up with
local colleague or team to
mentor/support.
Returns for training in 1 year.
The Future of communication skills teaching for HCPs What do you think?