HJCE

Development of Communication Skills Workshop for Oncology Advanced Practice Nursing Students
MARGARET ROSENZWEIG, PHD, CRNP, AOCN, MAURICE CLIFTON MD, MSED, ROBERT ARNOLD, MD

Communication Skills Workshop for Advanced Practice Nursing Students

AbstractBackground. Communication skills have not traditionally been included in nursing curriculum. The best educational method to improve health care providers practice in communication skills is first, introduction of content, followed by continuous skills assessment and mentored feedback. Methods. A communication skills workshop using standardized patients (SPs) was planned 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 represent a specific communication skill. SP teaching methodology is relatively new to nursing curriculum. 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 have more communication content throughout their curriculum. Confidence in communication skills increased following the workshop. Conclusions. This methodology has widespread application to other 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 undergraduate 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 and patients facing life-threatening illness is challenging for both patients and clinicians.1-5 Poor communication in cancer care often results in treatment discussions that are often overly optimistic and focused on medical/technical issues and treatment timing rather than quality 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 to patients and families about end-of-life care.11,12 Communication skills are necessary for all areas of advanced practice nursing, particularly for nurse practitioners, but have been poorly addressed in nursing education in both undergraduate and graduate education.13 The communication skills preparation that is critical for advanced practice nurses in todays clinical cancer environment requires didactic content, presentation of specific skill sets, and opportunities within the curriculum for integration of
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) 3838839; fax: (412) 383-7229; e-mail: <mros@pitt.edu>.

material, practice of new skill sets, and evaluative feedback. These critical communication educational elements are virtually nonexistent in nursing education. Practicing nurse 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 major educational deficits.14,15 Communication skills for the cancer care setting can be successfully 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 of skills, and the opportunity for evaluative feedback for each specific skill.16 Content and program evaluation are critically important for ongoing quality improvement. The goal of this article is to outline the development of a communication workshop for students in an oncology advanced nursing practice program and to analyze the workshop feedback to provide a template for the development of this critically important educational content area.

MATERIALS AND METHODS

Workshop PreparationGoals and Objectives A communication skills workshop was planned for 4 nurse practitioner and 2 clinical nurse specialist students specializing in cancer care. The specialty program is a
149

component of a larger Acute Care Nurse Practitioner Program from a large urban university. The students were in their last 1 to 2 semesters of their course work with integrated clinical experiences. Communication content had not been included in this program of study. Interviewing skills for the elicitation of patient information were reviewed in the standard nurse practitioner physical assessment course, but there was no specific communication content. The overarching goal for the communication workshop 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 difficult communication within the cancer care setting incorporating clinical experience and a review of the literature to determine the cancer communication needs that are specific to nursing.17 Communication skills particularly important for nursing at all levels are (1) asking before telling and (2) overall empathic communication.18 In addition, conveying news of disease progression or speaking about the option of forgoing further antitumor therapies are appropriate and necessary skills for advanced practice nurses in cancer. The cases were chosen based on clear-cut objectives. These objectives were then developed into a patient case, which allowed the demonstration of specific communication skills. Each of these skills required a brief didactic lecture. SPs are valuable in teaching communications skills because they can provide a realistic patient encounter and provide instant student feedback.19 The decision to integrate SPs helped to formulate the cases and delineate the desired skill set. The University of Pittsburgh School of Medicine has a successful history of integrating SPs into curriculum 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 an SP case. Detailed written instructions were given to the SPs describing the clinical aspects of each case as well as instructions on how to portray the patient. Each case included content outlining the current symptoms of the patient, the past medical history, social and family history, and the impact of the disease on the patient. SPs were recruited from among a well-experienced pool and trained using common protocols for case portrayal, assessment, and feedback. For each scenario, specific communication skills appropriate for the case were identified from the literature. These skills were then developed into a 4-to-6 item, case-specific checklist that the SPs used to provide both verbal and written feedback. The checklist was worded such that they provided the content of the feedback that the SPs would provide to the students. Each item was phrased in a positive and a negative manner that enabled the SPs to provide scripted feedback that was specifically designed for each case. For example, for the case
150

involving breaking bad news, the positive checklist items are prefaced with What went well about the interview and included you set the stage through positioning and eye contact, and you established what I knew about the illness. The negative items are prefaced with What would have improved the interview? The items are the same 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 eye contact, for all of the items specific to that communication skill. The first scenario focused on empathetic communication and served as the basis for all further interactions. The scenario represented an opportunity for empathetic communication with a patient with early-stage, resected colon cancer with an excellent prognosis who was requesting frequent tumor markers, computed tomography scans, and reassurance that he was cured. Empathetic communication incorporates active listening using I statements and the ability to be responsive to suffering.22 The acronym NURSE is taught to represent name, understand, respect, support, and explore as essential components of empathetic communication. This content was presented in manuscript form the week before the workshop and in lecture format the day of the workshop. The second scenario built on the first case and allowed a more in-depth exploration of the various options for patients with a life-limiting illness. The case involved a patient with malignant melanoma with newly diagnosed brain metastasis and worsening pulmonary metastasis who was beginning to openly question the futility of further therapy. This scenario allowed an exploration of positive and negative aspects of a decision regarding an experimental protocol in an open, client-centered environment. Skills required for these scenarios were active listening, an assessment 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 to the workshop. The third scenario focused on breaking bad news. This patient scenario was a patient with long-standing prostate cancer who had a rise in prostate specific antigen and positive bone scan. The didactic session was used to present a well-known, 6-step method (SPIKES) for giving bad news. The acronym delineates Setting up the interview, assessing Perception of the illness, obtaining the patients Invitation to give bad news, giving bad news with Knowledge and information, and Strategizing and summarizing for further care.22 ImplementationThe Workshop Institutional review board permission for evaluation of educational strategies was obtained. The first session involved an overview of the content for the 3 sessions presented by the chief physician of the Palliative Care

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

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 well as an opportunity for partner interviewing and warm-up exercises. The students then began the patient interviews. The workshop sessions were conducted in 4 conference rooms within the School of Nursing, each with a video camera. A brief summary of the patient was posted on the door. Students had 17 minutes for the encounter, after which the SP scored the checklist and provided 3 minutes of scripted feedback. Feedback started with the checklist items (communication skills) that were successfully demonstrated and then provided constructive feedback using the items that were not demonstrated. After each encounter, the students spent 20 minutes writing a progress note to document the communication issue discussed and to provide some time for self-reflection. During the lunch hour, the faculty obtained the videotapes from each conference room and prepared for the feedback session. The videotapes were reviewed to find examples for reinforcement or edification of content such as openended questions, examples of empathetic communication, or effective use of silence. Conversely, simulated patient feedback to the individual students and content that was potentially embarrassing for the students was edited. In the afternoon, the rules for group feedback were established. The afternoon session started as a brief review of the 3 cases and the key communication skills for each case. There was a brief opportunity for the students to comment on the teaching methodology and their particular likes and challenges with the process. The videotapes were appraised, with opportunities for the reviewed student to comment first on their strengths and areas for improvement. The group followed with critique. Faculty added few comments, instead challenging the individual and group to think about possible rephrasing of questions or missed opportunities for empathetic feedback. Workshop EvaluationEvaluation and Feedback There were 4 areas that were evaluatedthe post workshop evaluative survey, the simulated patient feedback to the students, the videotapes of the actual communication scenarios, and the students comments on open-ended questions. The 4 methods of formative evaluation were chosen based on previous well-documented experience with this evaluative methodology.23 No formal student grading was performed. The evaluations measured communication and interpersonal skills using the standardized patients rating with anchored statements of the desired communication skills for that scenario, faculty feedback based on viewed videotape, and students self-evaluation. In addition the students evaluated the overall workshop and components of the teaching methodology through Likert scale and open-ended
Journal of Cancer Education 2007, Volume 22, Number 3

question methodology. (1-7, ranging from not very helpful to 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 helpful to 7, very helpful. The first 3 questions assessed the helpfulness in learning communication skills through lecture, standardized patient encounters, and feedback sessions. The 3 educational components received the maximum score (7) from all respondents. The difference between the questions How would you rate your overall ability to communicate in difficult situations? before and after the workshop was determined to be key evaluative data. The mean response from the scale for communication ability 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 reinforcement of skills, and the need for placement of content earlier in the semester. Multiple uses for standardized patients within the nurse practitioner curriculum were proposed. See Table 1. Second, feedback from the standardized patient was analyzed. The standardized patients completed the checklist of what went well about the interview? and then what could 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 exploration 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 moderately well with empathetic communication. The third scenario requiring empathetic exploration of treatment options had the weakest demonstration of skills. Last, the review of videotape was tedious but beneficial. Without faculty prompt, the students were able to critique and identify areas for selfimprovement.

DISCUSSION
Communication skills must be incorporating into nursing curriculum.28 This workshop was designed in response to an educational need to teach specific communication skills for difficult conversations commonly encountered in the cancer care setting. The students demonstrated a relatively high level of communication competence during the workshops. Future workshops will incorporate the communication workshops 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 provided excellent feedback. The videotaping was helpful, but better editing would have shortened and enlivened the process.
151

TABLE 1. Themed Qualitative Responses with Examples

Open Ended Theme 1. Previous difficulty with communication Examples of Comments 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. 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. Earlier placement in the semester would be better. Have this earlier in the semester. This should be in the beginning of the curriculum.

2. Need for reinforcement of newly taught skills

3. Need for content placement earlier in the nurse practitioner curriculum

TABLE 2. Feedback from Simulated Patients: Example of Breaking Bad News Evaluation
What went well about the interview? 1. You set the stage through positioning and eye contact 2. You established what I knew about the illness 3. You established my main concerns 4. You determined how much I wanted to participate in decision making 5. You geared the discussion to my level of understanding 6. You discussed the next plan of care and left me with some hope What could have improved the interview? 1. If you set the stage to be more conducive to counseling and communication 2. If you established what I already knew about my cancer before sharing the news of the scan 3. If you helped to establish my main concerns 4. If you determined my level of wanting to participate in decision making. 5. If you facilitated communication by using appropriate vocabulary 6. If you left me with hope and an established plan of care.

The larger issue is the incorporation of this content into routine nursing curriculum. One problem with the integration of communication skills training into advanced practice nursing curriculum is the amount of communication expertise among clinical faculty.24 Feedback regarding communication techniques or presumed communication effectiveness will need to be taught to clinical nursing faculty before there can be wide-scale critique of student performance. Communication skills training for faculty is being offered through End of Life Nursing Education Curriculum, a train the trainer program for nursing faculty at the graduate and undergraduate level.25 The dissemination of this information to all nursing schools has a potentially profound impact on facultys ability to train students in difficult communication and other end-of-life skills. Another place where communications skills could be taught is oncology-nursing units. Nurses in cancer care need help in all communication skills, particularly end-of-life and advanced directives discussions.26,27 Health care institutions that have implemented this type of training have realized the incorporation of communication skills into
152

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 but needed to have focused and specific examples of ways to improve communication in the cancer clinical setting. There are ongoing attempts to finalize and incorporate communication skills workshops into the advanced nursing practice curriculum. The workshops are developed to meet the needs of acute care nurses, particularly within the critical care units. This didactic and skills content will be incorporated earlier in the curriculum so that ongoing evaluation and reinforcement can be provided in later clinical courses. The videotaped critique would benefit from more time for editing to use this evaluative tool more efficiently in reinforcement of the communication content. Last, the feasibility and acceptability of this teaching methodology needs to be evaluated on a larger scale with a more diverse student cohort.

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

References
1. Detmar SB, Muller MJ, Wever LD, Schornagel JH, Aaronson NK. Patient physician communication during outpatient palliative treatment visits: an observational study. JAMA. 2001;285:1351-1357. 2. Griffie J, Nelson-Martin P, Muchka S. Acknowledging the elephant: communication in palliative care. Am J Nurs. 2004;104:48-57. 3. Back A, Arnold R, Quill, T. Hope for the best and prepare for the worst. Ann Intern Med. 2003;138:439-442. 4. Wenrich MD, Curtis R, Shannon S, Carline JD, Ambrozy DM, Ramsey PG. Communicating with dying patents within the spectrum of medical care from terminal diagnosis to death. Arch Intern Med. 2001;161:868-874. 5. Maguire P. Improving communication with cancer patients. Eur J Cancer. 1999;35:1415-1422. 6. Linder JF, Blais J, Enders SR, Melberg SE, Meyers FJ. Palliative education: a didactic and experiential approach to teaching end of life care. J Cancer Ed. 1999;14:154-60. 7. Billings JA, Block S. Palliative care in undergraduate medical education. Status report and future directions. JAMA. 1997;278:733-738. 8. Curtis R, Wenrich D, Carline J, Shannon S, Ambrorozy D, Ramsey P. Understanding physicians skills at providing end of life care: perspectives of patients, families and health care workers. J Gen Intern Med. 2001;16:41-49. 9. AnneMei Them Hak T, Koeter G, vand der Wal G. Collusion if doctor-patient communication about imminent death: an ethnographic study. BMJ. 2000;321:1376-1381. 10. Sivesind D, Parker PA, Cohen L. Communicating with patients in cancer care, what areas do nurses find most challenging? J Cancer Ed. 2003;18:202-209. 11. Weissman DE, Ambuel B, Norton AJ, Wang-Chweng R, Schiedermayer D. A survey of competencies and concerns in end of life care for physicians trainees. J Pain Symptom Manage. 1998;15:82-90. 12. Wilkinson S, Gambles M, Roberts, A. The essence of cancer care: the impact if training in nurses ability to communicate effectively. J Adv Nurs. 2002:40:731-738. 13. Ferrrell B, Virani R, Grant M, et al. Beyond the Supreme Court decision: nursing perspectives on end of life care. Oncol Nurs Forum. 2000;27:445-455. 14. Ferrell B, Grant M, Virani R. Strengthening nursing education to improve end of life care. Nurs Outlook. 1999;47:252-256.

15. White K, Coyne P, Patel U. Are nurses adequately prepared for end of life care. J Nurs Scholarsh. 2001;33:147-151. 16. Kern D, Thomas P, Howard D, Bass, E. eds. Curriculum Development for Medical Education: A six step approach. Baltimore, MD: Johns Hopkins University Press; 1998. 17. Wakefield A, Cooke S, Boggis C. Learning together: use of simulated patients with nursing and medical students for breaking bad news. Int J Palliat Nurs. 2003;9:32-38. 18. Kruijver I, Kerskstra A, Bensing J, et al. Nurse-patient communication in cancer care: a review of the literature. Cancer Nurs. 2000;23:20-30. 19. Freer JP, Zinnerstrom KL. The palliative medicine extended standardized patient scenario: a preliminary report. J Palliat Med. 2001;4:49-56. 20. Back A L, Arnold RM, Tulsky JA, et al. Teaching communication skills to medical oncology fellows. J Clin Orthod. June 2003: 24332436. 21. Rollnick S, Heather N, Bell A. Negotiating behavior change in medical settings: the development of brief motivational interviewing. J Ment Health. 1992;1:25-37. 22. Baile WF, Buckman R, Lenzi R, et al. SPIKESa six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5:302-311. 23. Baile WF, Kudelka AP, Beale EA, et al. Communication skills training in oncology: description and preliminary outcomes of workshops on breaking bad news and managing patient reactions to illness. Cancer. 1999; 86:887-897. 24. Long F, Everett K, McGowan R. Faculty development in communication skills instruction: insights from a longitudinal program with real time feedback. Acad Med. 2000;75:1232-1228. 25. ELNEC Project, American Association of Colleges of Nursing. Available at: http://www.aacn.nche.edu/ELNEC/Graduate.htm. Accessed 22 December, 2005. 26. Jezewski MA, Meeker MA, Schrader M. Voices of oncology nurses: what is needed to assist patients with advanced directives. Cancer Nurs. 2003;26:105-112. 27. Williams SF, Medland D, Mast M. Low morale and high nursing turnover on an inpatient hematology/oncology unit at a major urban teaching hospital: improvement following strategic initiatives by nursing and medical leadership. Proc Am Soc Clin Oncol 2003;22:559. Abstract 2247.

Journal of Cancer Education 2007, Volume 22, Number 3

153