Journal of Cancer Education 2007 Rosenzweig_Development of Communication Skills Workshop for...

7/27/2019 Journal of Cancer Education 2007 Rosenzweig_Development of Communication Skills Workshop for Oncology Adv

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Development of Communication Skills Workshopfor Oncology Advanced Practice Nursing Students

Communication SkillsWorksho pfor Advanced Practice Nursing Students

MARGARET ROSENZWEIG, PHD, CRNP, AOCN,MAURICE CLIFTON MD, MSED, ROBERT ARNOLD, MD

AbstractBackground. Communication skills have not traditionally been included in nursing cur-

riculum. The best educational method to improve health care providers practice in communica-tion skills is first, introduction of content, followed by continuous skills assessment and mentored

feedback. Methods. A communication skills workshop using standardized patients (SPs) wasplanned for oncology nurse practitioner students. A 6-step development plan was used to design,

implement, and evaluate the curriculum. Three patient cases using SPs were developed to repre-sent a specific communication skill. SP teaching methodology is relatively new to nursing curricu-lum. Results. Four methods of evaluation revealed a high level of satisfaction with the course, a

high level of communications skills demonstrated during the course, and student need to havemore communication content throughout their curriculum. Confidence in communication skills

increased following the workshop. Conclusions. This methodology has widespread application toother areas of cancer nursing including nurses with less oncology experience and practicing nurses

on the oncology units. In addition, there is application throughout nursing curriculum for under-graduate and graduate programs. The content should be presented earlier in the curriculum and

then reinforced throughout the remaining courses with clinical follow-up.J Cancer Educ. 2007;22:149-153.

ommunication between health care providers andpatients facing life-threatening illness is challeng-

ing for both patients and clinicians.1-5 Poor com-munication in cancer care often results in treatment

discussions that are often overly optimistic and focused on

medical/technical issues and treatment timing rather thanquality of life or emotional issues.6-7 Patient and family

requests for information are often indirect and subtle.8,9

Oncology nurses overall feel a lack of confidence in the

area of communication,10 particularly about how to talk topatients and families about end-of-life care.11,12 Commu-

nication skills are necessary for all areas of advanced prac-tice nursing, particularly for nurse practitioners, but havebeen poorly addressed in nursing education in both under-

graduate and graduate education.13 The communicationskills preparation that is critical for advanced practice

nurses in todays clinical cancer environment requires

didactic content, presentation of specific skill sets, andopportunities within the curriculum for integration of

material, practice of new skill sets, and evaluative feed-back. These critical communication educational elements

are virtually nonexistent in nursing education. Practicingnurse practitioners report inadequacies in their end-of-life

care skills, often citing the communication skills for

breaking bad news and end-of-life discussions as majoreducational deficits.14,15

Communication skills for the cancer care setting can besuccessfully implemented into the curriculum with proper

foresight and planning based on clear, realistic goals,although it is challenging. Preparing curriculum requires

the presentation of didactic content, demonstration ofskills, and the opportunity for evaluative feedback for each

specific skill.16 Content and program evaluation are criti-

cally important for ongoing quality improvement. The goalof this article is to outline the development of a communi-

cation workshop for students in an oncology advanced

nursing practice program and to analyze the workshop feed-back to provide a template for the development of this crit-ically important educational content area.

MATERIALS AND METHODS

Workshop PreparationGoals and Objectives

A communication skills workshop was planned for 4nurse practitioner and 2 clinical nurse specialist students

specializing in cancer care. The specialty program is a

Received from University of Pittsburgh School of Nursing (MR, MC);

and University of Pittsburgh School of Medicine (RA).

Supported by the University Of Pittsburgh School Of Nursing, Deans

Instructional Strategies Initiative Teaching Award, 2004.

Address correspondence and reprint requests to: Margaret Rosenzweig,

PhD, CRNP, AOCN, Assistant ProfessorResearch, Director, Oncology

Nurse Practitioner Program, University of Pittsburgh School of Nursing,

Room 329-A, Victoria Building, Pittsburgh, PA 15261; phone: (412) 383-

8839; fax: (412) 383-7229; e-mail: .

C


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150 ROSENZWEIG et al. Communication Skills Workshop for Advanced Practice Nursing Students

component of a larger Acute Care Nurse Practitioner Pro-gram from a large urban university. The students were in

their last 1 to 2 semesters of their course work with inte-grated clinical experiences. Communication content had

not been included in this program of study. Interviewing

skills for the elicitation of patient information werereviewed in the standard nurse practitioner physical assess-ment course, but there was no specific communication

content. The overarching goal for the communicationworkshop was to improve communication skills for the

cancer care setting.The workshop was formulated over several months. The

nurse educator developed 3 common scenarios of difficultcommunication within the cancer care setting incorporat-

ing clinical experience and a review of the literature todetermine the cancer communication needs that are spe-cific to nursing.17 Communication skills particularly impor-

tant for nursing at all levels are (1) asking before telling and(2) overall empathic communication.18 In addition, con-

veying news of disease progression or speaking about theoption of forgoing further antitumor therapies are appropri-

ate and necessary skills for advanced practice nurses in can-cer. The cases were chosen based on clear-cut objectives.These objectives were then developed into a patient case,

which allowed the demonstration of specific communica-tion skills. Each of these skills required a brief didactic lec-

ture. SPs are valuable in teaching communications skillsbecause they can provide a realistic patient encounter and

provide instant student feedback.19 The decision to inte-

grate SPs helped to formulate the cases and delineate thedesired skill set. The University of Pittsburgh School of

Medicine has a successful history of integrating SPs intocurriculum throughout medical education. Their expertise

regarding content development, logistics, and organization

was critically important to workshop development.

Workshop PreparationEducational Strategies

Each communication scenario was developed into anSP case. Detailed written instructions were given to the

SPs describing the clinical aspects of each case as well asinstructions on how to portray the patient. Each case

included content outlining the current symptoms of thepatient, the past medical history, social and family history,

and the impact of the disease on the patient. SPs wererecruited from among a well-experienced pool and trainedusing common protocols for case portrayal, assessment,

and feedback. For each scenario, specific communicationskills appropriate for the case were identified from the lit-

erature. These skills were then developed into a 4-to-6item, case-specific checklist that the SPs used to provide

both verbal and written feedback. The checklist wasworded such that they provided the content of the feed-

back that the SPs would provide to the students. Eachitem was phrased in a positive and a negative manner thatenabled the SPs to provide scripted feedback that was spe-

cifically designed for each case. For example, for the case

involving breaking bad news, the positive checklist

items are prefaced with What went well about the inter-view and included you set the stage through positioning

and eye contact, and you established what I knew aboutthe illness. The negative items are prefaced with What

would have improved the interview? The items are thesame as the positive items except they are worded If you.

For example, the student is told the interview would have

improved If you set the stage through positioning and eyecontact, for all of the items specific to that communica-tion skill.

The first scenario focused on empathetic communica-tion and served as the basis for all further interactions.The scenario represented an opportunity for empathetic

communication with a patient with early-stage, resectedcolon cancer with an excellent prognosis who was

requesting frequent tumor markers, computed tomogra-phy scans, and reassurance that he was cured. Empa-

thetic communication incorporates active listeningusing I statements and the ability to be responsive to

suffering.22 The acronym NURSE is taught to represent

name, understand, respect, support, and explore asessential components of empathetic communication.This content was presented in manuscript form the week

before the workshop and in lecture format the day of theworkshop.

The second scenario built on the first case and allowed amore in-depth exploration of the various options forpatients with a life-limiting illness. The case involved a

patient with malignant melanoma with newly diagnosedbrain metastasis and worsening pulmonary metastasis who

was beginning to openly question the futility of furthertherapy. This scenario allowed an exploration of positive

and negative aspects of a decision regarding an experimen-

tal protocol in an open, client-centered environment.Skills required for these scenarios were active listening, anassessment of patient openness to an exploration of options,and difficult decision making.21 A manuscript outlining

this concept was presented and discussed the week prior tothe workshop.

The third scenario focused on breaking bad news. Thispatient scenario was a patient with long-standing prostate

cancer who had a rise in prostate specific antigen and posi-tive bone scan. The didactic session was used to present awell-known, 6-step method (SPIKES) for giving bad news.

The acronym delineates Setting up the interview, assessingPerception of the illness, obtaining the patients Invitation

to give bad news, giving bad news with Knowledge andinformation, and Strategizing and summarizing for further

care.22

ImplementationThe Workshop

Institutional review board permission for evaluation of

educational strategies was obtained. The first sessioninvolved an overview of the content for the 3 sessions

presented by the chief physician of the Palliative Care


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Journal of Cancer Education 2007, Volume 22, Number 3 151

Team at the University of Pittsburgh Medical Center.The didactic session included a written posting of the

skills and acronyms to be used throughout the day as wellas an opportunity for partner interviewing and warm-up

exercises.

The students then began the patient interviews. Theworkshop sessions were conducted in 4 conference roomswithin the School of Nursing, each with a video camera. A

brief summary of the patient was posted on the door. Stu-dents had 17 minutes for the encounter, after which the SP

scored the checklist and provided 3 minutes of scriptedfeedback. Feedback started with the checklist items (com-

munication skills) that were successfully demonstrated andthen provided constructive feedback using the items that

were not demonstrated. After each encounter, the studentsspent 20 minutes writing a progress note to document thecommunication issue discussed and to provide some time

for self-reflection.During the lunch hour, the faculty obtained the video-

tapes from each conference room and prepared for the feed-back session. The videotapes were reviewed to find examples

for reinforcement or edification of content such as open-ended questions, examples of empathetic communication, or

effective use of silence. Conversely, simulated patient feed-back to the individual students and content that was poten-tially embarrassing for the students was edited.

In the afternoon, the rules for group feedback wereestablished. The afternoon session started as a brief

review of the 3 cases and the key communication skillsfor each case. There was a brief opportunity for the stu-

dents to comment on the teaching methodology andtheir particular likes and challenges with the process.

The videotapes were appraised, with opportunities forthe reviewed student to comment first on their strengths

and areas for improvement. The group followed with cri-tique. Faculty added few comments, instead challengingthe individual and group to think about possible rephras-

ing of questions or missed opportunities for empatheticfeedback.

Workshop EvaluationEvaluation and Feedback

There were 4 areas that were evaluatedthe postworkshop evaluative survey, the simulated patient feed-

back to the students, the videotapes of the actual com-munication scenarios, and the students comments on

open-ended questions. The 4 methods of formative eval-uation were chosen based on previous well-documented

experience with this evaluative methodology.23 No for-mal student grading was performed. The evaluations

measured communication and interpersonal skills usingthe standardized patients rating with anchored state-

ments of the desired communication skills for that sce-nario, faculty feedback based on viewed videotape, and

students self-evaluation. In addition the students evalu-ated the overall workshop and components of the teach-

ing methodology through Likert scale and open-ended

question methodology. (1-7, ranging from not very helpfulto very helpful).

RESULTS

Postevaluative Likert Scale

A postevaluative survey was composed of a 6-item Likert

scale evaluation with scores ranging from 1, not very help-ful to 7, very helpful. The first 3 questions assessed the

helpfulness in learning communication skills through lec-ture, standardized patient encounters, and feedback

sessions. The 3 educational components received the maxi-mum score (7) from all respondents. The differencebetween the questions How would you rate your overall

ability to communicate in difficult situations? before andafter the workshop was determined to be key evaluative

data. The mean response from the scale for communicationability prior to the workshop was 5.0 preworkshop, and it

was 6.2 post workshop.Written comments included common themes such as

previous difficulties with communication, the need for rein-forcement of skills, and the need for placement of contentearlier in the semester. Multiple uses for standardized

patients within the nurse practitioner curriculum were pro-posed. See Table 1.

Second, feedback from the standardized patient was ana-lyzed. The standardized patients completed the checklist of

what went well about the interview? and then whatcould have improved the interview? while giving feedback

to the students. The items are the same in both categories.See Table 2. The breaking bad news and empathetic explo-ration of treatment options had 7 items, and empathetic

communication had 5 items. The students did very well

with feedback in the breaking bad news and moderatelywell with empathetic communication. The third scenariorequiring empathetic exploration of treatment options had

the weakest demonstration of skills. Last, the review of vid-eotape was tedious but beneficial. Without faculty prompt,

the students were able to critique and identify areas for self-improvement.

DISCUSSION

Communication skills must be incorporating into nurs-

ing curriculum.28 This workshop was designed in responseto an educational need to teach specific communication skills

for difficult conversations commonly encountered in the can-cer care setting. The students demonstrated a relatively high

level of communication competence during the workshops.Future workshops will incorporate the communicationworkshops earlier in the curriculum to follow the students

in clinical situations to measure true practice change.Other aspects of the program went well. The evaluative

process worked well. The standardized patients providedexcellent feedback. The videotaping was helpful, but better

editing would have shortened and enlivened the process.


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152 ROSENZWEIG et al. Communication Skills Workshop for Advanced Practice Nursing Students

The larger issue is the incorporation of this content into

routine nursing curriculum. One problem with the integra-tion of communication skills training into advanced prac-

tice nursing curriculum is the amount of communicationexpertise among clinical faculty.24 Feedback regarding com-

munication techniques or presumed communication effec-tiveness will need to be taught to clinical nursing facultybefore there can be wide-scale critique of student perfor-

mance. Communication skills training for faculty is beingoffered through End of Life Nursing Education Curriculum,

a train the trainer program for nursing faculty at the grad-uate and undergraduate level.25 The dissemination of this

information to all nursing schools has a potentially pro-found impact on facultys ability to train students in diffi-cult communication and other end-of-life skills.

Another place where communications skills could betaught is oncology-nursing units. Nurses in cancer care need

help in all communication skills, particularly end-of-life andadvanced directives discussions.26,27 Health care institu-

tions that have implemented this type of training have real-ized the incorporation of communication skills into

training retreats reduces turnover and increases satisfaction

in nursing units.33

The development of this workshop has been a valuable

exercise. The students were experienced oncology nurses,each with 10 to 15 years of clinical oncology experience.

They had perceived strong communication skills butneeded to have focused and specific examples of ways toimprove communication in the cancer clinical setting.

There are ongoing attempts to finalize and incorporatecommunication skills workshops into the advanced nursing

practice curriculum. The workshops are developed to meetthe needs of acute care nurses, particularly within the criti-

cal care units. This didactic and skills content will be incor-porated earlier in the curriculum so that ongoing

evaluation and reinforcement can be provided in later clin-ical courses. The videotaped critique would benefit frommore time for editing to use this evaluative tool more effi-

ciently in reinforcement of the communication content.Last, the feasibility and acceptability of this teaching meth-

odology needs to be evaluated on a larger scale with a morediverse student cohort.

TABLE 1. Themed Qualitative Responses with Examples

Open Ended Theme Examples of Comments

1. Previous difficulty with communication At times I do not feel comfortable and I can apply the structured content

presented today.

Moderately comfortable but some words are hard to find.

I have done this several times before and its always hard. Slightly better now.

I have a better understanding of how to approach things now. Before this, I

would just go with my gut which sometimes worked and sometimes didnt.2. Need for reinforcement of newly taught skills Would like to consistently reinforce these techniques through self learning,

clinical practice, and independent workshops.

I would like to have more practice with patients.

The phrases are uncomfortable.

3. Need for content placement earlier in the

nurse practitioner curriculum

Earlier placement in the semester would be better.

Have this earlier in the semester.

This should be in the beginning of the curriculum.

TABLE 2. Feedback from Simulated Patients: Example of Breaking Bad News Evaluation

What went well about the interview? What could have improved the interview?

1. You set the stage through positioning and eye contact 1. If you set the stage to be more conducive to counseling and

communication

2. You established what I knew about the illness 2. If you established what I already knew about my cancer before sharing

the news of the scan

3. You established my main concerns 3. If you helped to establish my main concerns

4. You determined how much I wanted to participate in

decision making

4. If you determined my level of wanting to participate in decision making.

5. You geared the discussion to my level of

understanding

5. If you facilitated communication by using appropriate vocabulary

6. You discussed the next plan of care and left me with

some hope

6. If you left me with hope and an established plan of care.


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Journal of Cancer Education 2007, Volume 22, Number 3 153

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