Original Research
The Impact of the SAGE & THYME Foundation Level Workshop on Factors Influencing Communication Skills in Health Care Professionals
MICHAEL CONNOLLY, MPHIL; JOANNE M. THOMAS, PHD; JULIE A. ORFORD, MA; NICOLA SCHOFIELD, MPHIL; SIGRID WHITESIDE, MSC; JULIE MORRIS, MSC; CATHY HEAVEN, PHD Introduction: The “SAGE & THYME Foundation Level Workshop” delivers evidence-based communication skills training to 30 health care workers in 3 hours. It teaches a structured approach (the SAGE & THYME model) to discuss patient/carer concerns. The aim of this study was to determine whether the workshop had a positive outcome on factors that influence communication skills. Methods: The study had a pragmatic, mixed methods design. Workshops were run in an acute hospital. One hundred seventy health care workers completed questionnaires pre- and post-workshop; 141 were sent follow-up questionnaires at 2 weeks and 2 months; and 9 were filmed talking to a simulated patient pre- and post-workshop. Results: From pre- to post-workshop, there was a significant increase in knowledge (p < 0.001), self-efficacy (p < 0.001), and outcome expectancy (p < 0.001). An expert’s rating of behavior with the simulated patient also significantly increased after the training (p = 0.011). Motivation to use the training, and the perceived usefulness of the SAGE & THYME model, were high post-workshop. There was a poor response rate in the follow-up period; hence, the quantitative data are not reported. The qualitative data are described, however, as they give an insight into the impact of the training on staff and their patients. Discussion: The SAGE & THYME Foundation Level Workshop significantly increases communication skills knowledge, self-efficacy, and outcome expectancy of hospital health care workers who are predominantly white, female, nursing, or nonclinical staff. This suggests that the workshop may have a positive impact on some factors influencing communication skills in this group. Key Words: emotional support, training, psychological support, patient-centered care, health care, communication skills, knowledge translation, workplace learning
Introduction Disclosures: The authors report a £25,000 TRUSTECH Pathfinder Development Fund grant funded this study. The University Hospital of South Manchester NHS Foundation Trust provides the SAGE & THYME training on a commercial basis and shares some of the income generated with Central Manchester University Hospitals and the Christie Hospital. Mr. Connolly: Macmillan Nurse Consultant, Macmillan Palliative Care Service, University Hospital of South Manchester NHS Foundation Trust; Dr. Thomas: Senior Technology Manager, TRUSTECH, Central Manchester University Hospitals NHS Foundation Trust; Ms. Orford: Breast Care Nurse, Nightingale Centre, University Hospital of South Manchester NHS Foundation Trust; Ms. Schofield: Senior Trainer, Maguire Communication Skills Training Unit, The Christie NHS Foundation Trust; Ms. Whiteside: Medical Statistician, University Hospital of South Manchester NHS Foundation Trust; Ms. Morris: Head of Medical Statistics, University Hospital of South Manchester NHS Foundation Trust; Dr. Heaven: Associate Director of Education, Maguire Communication Skills Training Unit, The Christie NHS Foundation Trust. Correspondence: Michael Connolly, Macmillan Palliative Care Service, University Hospital of South Manchester NHS Foundation Trust, Manchester, M23 9LT, UK; e-mail: [email protected].
Effective communication between health care workers and patients has been shown to improve patient adherence to treatment,1 recovery and psychology,2 and increase patient satisfaction and quality of life.3 Evidence relating to listening and responding to patient concerns as a component of effective communication has been in the literature for decades.4 Health care workers who lack confidence in their communication skills with patients may have a poor understanding of their patients’ concerns.5,6 This represents a missed opportunity to improve patient health outcomes, as resolution of concerns is known to benefit adjustment to illness.7 It has also been found that © 2014 The Alliance for Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on Continuing Medical Education, Association for Hospital Medical Education. • Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/chp.21214
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FIGURE 1. SAGE & THYME Model
disclosure of potentially unresolvable concerns can be helpful for patients.8 Furthermore, there is some evidence that patients who are anxious do not readily disclose concerns but express cues or hints about their concerns.9 Thus, the ability to detect cues is of central importance for health care workers. Communication skills, however, do not necessarily improve by experience alone.10 Thus, educators and researchers have focused on ways to improve the communication skills of health workers, by developing a range of courses.11–14 Current research on the effectiveness of such training favors long courses (≥20 hours) for small groups (3 to 12 learners), often at an advanced level.12–17 These are expensive and available primarily in the context of cancer and end-oflife care. Thus, there is a need for shorter, less expensive courses that are accessible and suitable for all staff groups and specialties.18 However, a recent systematic review concluded that courses greater than 24 hours were more effective than those shorter than 24 hours.18 Furthermore, the effectiveness of short courses (4.5 to 6 hours) for large groups (15 or more), in changing communication skills, has not been demonstrated.9,19 Leading researchers have used social learning theory (SLT) to develop training for communication with cancer patients.14,20 SLT states that for training to change a learner’s behavior, it must (1) keep their attention, (2) aid information retention, (3) allow reproduction of the required behavior, and (4) motivate the learner to imitate the behavior.21 It is also recognized that high self-efficacy16,17 (perceived mastery over skills) and outcome expectancy20 (anticipated positive outcomes from the behavior) are required to transfer skills into practice. The SAGE & THYME Foundation Level (S&T FL) Workshop lasts 3 hours. SAGE & THYME is a mnemonic for a sequential structure (S&T model) that guides learners to apply patient-centered care for listening and responding to concerns by listening fully, holding back with ad38
vice/information, and inquiring about the patient’s own support and solutions before offering any advice or information (FIGURE 1). The workshop is described as foundation level because it was designed to provide a starting point for health workers as they learn about emotional support. The workshop is run by 3 facilitators and taught to 30 participants. It fits with SLT by including small group discussions (what participants already know), an explanation of the S&T model and how it fits with the evidence, and 2 experiential rehearsals using the S&T model. The workshop and model have been previously described in detail.22 This study investigated whether the S&T FL Workshop had a positive outcome on factors that influence communication skills by assessing whether participants (1) gained knowledge on helpful communication behaviors, (2) changed their behavior when talking to a simulated patient, (3) were likely to use the S&T model in practice (by measuring self-efficacy and outcome expectancy), and (4) felt the model was useful and were motivated to use it. Information was also obtained on whether participants changed their practice. Methods Methodological Approach This was a pragmatic, mixed methods study, designed within the resources available, to assess participant reactions and learning (Levels 1 and 2, respectively, of Kirkpatrick’s 4level evaluation for determining a training effect).23 Level 3 (behavior on the job) was partially evaluated using participants’ subjective reports of use of the model. Recruitment and Study Time Points Recruitment occurred over a 12-month period. Approximately 1 workshop was run per month in an acute hospital for its clinical and nonclinical employees. All attendees were
JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—34(1), 2014 DOI: 10.1002/chp
SAGE & THYME Workshop: Impact on Communication
FIGURE 2. Summary of Assessments Completed at Each Time Point
invited to participate in the study before the workshop. The same trainer led all the workshops, but the other 2 facilitators varied. Demographic information was collected pre-workshop. Participants completed several questionnaires immediately pre- and post-workshop (see FIGURE 2). Follow-up questionnaires were sent at 2 weeks and 2 months post-workshop (FIGURE 2). These were initially sent to 50% of participants in each workshop (selected randomly) due to limited resources. However, after the first 5 workshops, only 32% of those randomized to follow-up responded at 2 months, so about halfway through the study, an amendment was accepted by the ethics committee to follow up all participants. Questionnaires were anonymous (each participant had a unique identification number). A comparator group was used for the knowledge test. Participants were recruited from an office administration course or staff “induction” course run within the hospital. These courses had the same duration as the S&T FL workshop, involved a variety of staff groups and specialties, and did not provide communication skills training.
edge test was also completed by the comparator group before and after their training, to assess whether the knowledge score improved by only seeing the same test film twice, 3 hours apart. Behavior A subjective assessment of whether participants could reproduce behaviors taught in the workshop, was carried out by filming a small number of participants individually having a one-to-one mock conversation with a simulated patient (SP) (an established method for practicing communication skills1,24–26 ) pre- and post-workshop (“participant film”). Each SP was briefed to act distressed (anxious but not angry) as they waited for test results. A communications expert (NS) rated each participant’s behavior against 12 criteria using a 0 to 4 Likert scale using an instrument available as supporting information (APPENDIX S1) in the online version of this article. This instrument was not validated but was adapted from another communication skills assessment tool.27 The order of the films (pre versus post) was randomized, with the expert blinded to the order.
Knowledge Change in knowledge was tested by twice showing the participants a 6.5-minute film (pre- and post-workshop) of a conversation between actors playing a health care professional and a patient, which (unknown to the participants) was based on the S&T model (“test film”). Participants were asked to list helpful nonverbal and verbal behaviors and skills and anything helpful about the structure of the interaction. Two researchers (NS, JO) scored each participant’s list independently, using a rating sheet developed for the study of 20 helpful communication behaviors evident in the test film and taught in the workshop (eg, body language, screening concerns, using empathy) (maximum score 20). The assessors compared their scores for consistency, and rerated any inconsistent scores following discussion. This knowl-
Self-Efficacy Participants subjectively rated self-efficacy between 0 and 100 for 16 skills/situations, such as their ability to “create a setting in which patients can speak openly about their concerns, using a modified version of a self-efficacy questionnaire (available as supporting information [APPENDIX S2] in the online version of this article),20 based on Bandura’s assessment28 and used in communication skills training,29 pre- and post-workshop, and at 2 weeks and 2 months. Outcome Expectancy Participants’ attitudes and beliefs toward the likely consequences of their behavior were assessed subjectively using
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Connolly et al.
a modified outcome expectancy questionnaire (available as supporting information [APPENDIX S3] in the online version of this article) with a Likert scale (1 to 9), which included statements such as “asking your patient to talk about their concerns and emotions will be of benefit to them.” The original questionnaire was developed following a literature review of factors affecting health care professionals’ assessment of their patients’ concerns and has good content validity.20 No other formal testing has been conducted, but it has been used with a variety of professionals and has been assessed for face validity.14 In some questions, a positive response received a high score; in others, it received a low score, to avoid response bias. During data analysis, scores were reversed as needed so positive responses had higher scores. This questionnaire was completed pre-workshop, post-workshop, at 2 weeks and 2 months.
an estimated standard deviation of differences of 14 (from a pilot study of 37 participants). The sample size calculation was based on self-efficacy, as this is important in transferring skills into practice.28 Due to the protocol amendment to increase follow-up data, more than 100 people were recruited. The knowledge test comparator group was smaller than the study group, due to the limited recruitment resources available. With 25 in the comparator group and 158 in the study group, the study had 80% power to detect differences in the change in knowledge score of 1.2 or more (using a simple 2-sided t-test on the changes with estimated standard deviation of 2 and a 5% significance level). This was thought to be a “worthwhile” difference. The number of participants intended to be filmed was limited to 10 by the financial resources available.
Motivation and Usefulness
Greater Manchester North Research Ethics Committee approved the study in 2009. All participants gave written informed consent.
Participants rated their motivation to use S&T in their practice. They scored between 0 and 100 (totally motivated) on 3 questions—motivation to use S&T generally, motivation to use all of the S&T structure, and motivation to use some of the S&T structure. They also rated how useful they felt the S&T model was, between 0 and 100 (totally useful) for (1) enabling patients, (2) working with patients, and (3) leaving them more satisfied when working with patients. These unvalidated questionnaires were completed post-workshop, and at 2 weeks and 2 months. Total scores were calculated for each questionnaire and averaged over the 3 questions. Qualitative Data on Transfer of Skills into Practice This was measured subjectively at 2 weeks and 2 months by participants completing an unvalidated questionnaire (designed specifically for this study, but based on a questionnaire used previously29 ) on their use of the model. It included open-ended questions on the reason why they had or had not used the S&T model; if they had used it, how they felt afterwards and the impact it had on the patient; and if they had not used the model, what the barriers were. Two researchers (JO, JT) analyzed the text together and identified the main theme for each response. Similar themes were then grouped together, until no further reduction of themes was possible. Sample Size The intention was to recruit 100 participants. With this number, the study could detect changes in self-efficacy of 4 or more (an increase of 7 was significant in 61 nurses attending a 3-day communication skills course29 ), using a paired t-test with a conventional 2-sided 5% significance level, based on 40
Ethical Approval
Statistical Analysis Data distributions were assessed for normality. The comparison of changes from pre- to post-workshop was only carried out for those participants with both pre- and post-data. The number of participants with missing information pre and post-workshop was relatively small (eg, 9% for knowledge test). Changes in normally distributed data from pre- to post-workshop were analyzed using paired Student’s t-tests. Changes in non-normally distributed scores were analyzed by paired Wilcoxon signed ranks test. A direct comparison of changes in knowledge scores, between study and comparator groups, was made using the 2-sample t-test. The primary endpoint was immediately post-workshop. Analyses were carried out using SPSS version 15.0, using the conventional 2sided 5% significance level. The low number of participants returning questionnaires at 2 weeks and 2 months did not allow comparative statistical analysis. Results Participant Numbers FIGURE 3 summarizes the number of participants involved at each stage of the study. A total of 173 people were recruited: of the first 58 people, 29 were randomly selected for follow-up at 2 weeks and 2 months. Due to the protocol change mentioned previously, all further people recruited were followed up and in total 141 participants were sent follow-up questionnaires. Nine participants volunteered to be filmed.
JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—34(1), 2014 DOI: 10.1002/chp
SAGE & THYME Workshop: Impact on Communication
FIGURE 3. CONSORT-Style Flowchart for the SAGE & THYME Participants
Not all participants completed all questionnaires at each time point (see FIGURE 3). The number who returned all questionnaires at each time point was 146 pre-workshop, 126 post-workshop, 53 at 2 weeks, and 41 at 2 months. Only 18 completed questionnaires at each of the 4 time points. However, we were able to analyze the data for each measure as long as we had both pre- and post-data. Therefore, FIGURE 3 also shows the number of participants who completed at least 1 questionnaire. Due to the low response rate, the quantitative follow-up data are not presented, as it is possible that only participants who responded had used the workshop skills taught. However, the qualitative data are summarized to highlight the
views on using the model, of the participants who responded, to inform future studies. Twenty-five people were recruited into the comparator group for assessing knowledge.
Demographics Study participants were predominantly white, female hospital workers (TABLE 1). The majority were 25 to 54 years old. The knowledge test comparator group had similar demographics and proportion of nurses, but had more 18- to 24-year-olds, and more people with an “other” occupation.
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Connolly et al. TABLE 1. Study Participant and Comparator Group Demographics
Comparator group for Study group (n = 173)
knowledge testing (n = 25)
Descriptor
Detail
n
%
n
%
Gender
Female
151
90.4
23
92.0
Male Age
Ethnic origin
16
9.6
2
8.0
18–24 yrs
6
3.6
4
16.0
25–34 yrs
40
24.1
9
36.0
35–44 yrs
62
37.3
6
24.0
45–54 yrs
44
26.5
5
20.0
55–64 yrs
14
8.4
1
4.0
147
88.0
25
100.0
20
12.0
0
0
White Other ethnic origins
Employer
Occupation
136
82.4
25
100.0
Community
Acute hospital
15
9.1
0
0
Hospice
14
8.5
0
0
Nurse
86
51.5
13
52.0
Allied health professional
29
17.4
0
0
5
3.0
0
0
Medical Student Other
5
3.0
0
0
42
25.1
12
48.0
TABLE 2. Knowledge Test Score for Comparator and Study Groups
Mean (SD)
Mean (95% CI)
Mean (95% CI)
Paired t-test
Post (n = 25)
Change (n = 25)
6.0 (2.1)
0.5 (−0.1, 1.1)
Post (n = 159)
Change (n = 158)
7.9 (2.9)
2.3 (1.9, 2.8)
p < 0.001
Mean (95% CI)
Two-sample t-test
1.8 (0.9, 2.8)
p < 0.001
Comparator group Pre (n = 25) 5.5 (1.8)
p = 0.12
Study group Pre (n = 164) 5.7 (2.7) Difference in change between study group and comparator
SD = standard deviation, CI = confidence interval. Maximum score achievable was 20.
Knowledge and Behavior TABLE 2 shows the knowledge test data. There was little difference in the knowledge score for the comparator group from pre- to post-training (p = 0.12). Conversely, the 42
S&T participants’ score significantly increased after attending their workshop (p < 0.001). The increase in knowledge score was significantly higher for S&T participants, compared with the comparator group (p < 0.001).
JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—34(1), 2014 DOI: 10.1002/chp
SAGE & THYME Workshop: Impact on Communication TABLE 3. Self-Efficacy and Outcome Expectancy
TABLE 4. Motivation to Use and Perceived Usefulness of SAGE & THYME Post-Workshop
a. Self-efficacy (scored between 0 and 100) Mean (SD) Pre
(n = 163) 66.3 (15.5)
Mean (SD)
Mean (95% CI)
Post
Pre to post
(n = 158)
(n = 155)
87.2 (10.5)
21.1 (18.8, 23.4)
Median (range) % with scores of 100
Motivation
Usefulness
(n = 145)
(n = 144)
100 (73, 100)
100 (67, 100)
58%
56%
Paired t-test; p < 0.001 Scored between 0 and 100.
b. Outcome expectancy (scored on a Likert scale of 1 to 9) Mean (SD)
Mean (SD)
Mean (95% CI)
Post
Pre to post
(n = 156)
(n = 151)
(n = 142)
6.31 (0.92)
7.04 (0.87)
Pre
0.72 (0.58, 0.86) Paired t-test; p < 0.001
SD = standard deviation, CI = confidence interval.
The expert’s rating of the participant films increased significantly from pre- to post-workshop, from a median of 0.8 to 1.8; median change of 0.8 (0.07 to 1.63); paired Wilcoxon signed ranks p = 0.011. This suggests that the S&T participants demonstrated more helpful communication behaviors after the workshop. Self-Efficacy and Outcome Expectancy Participants’ self-efficacy significantly increased after the workshop (p < 0.001, TABLE 3). Participants also became more positive about the benefits of helpful communication behaviors post-workshop, with a small but significant increase in outcome expectancy (p < 0.001) (TABLE 3). Motivation and Usefulness Motivation and usefulness scores were high post-workshop, with 58% of participants scoring the maximum of 100 for motivation and 56% scoring the maximum of 100 on usefulness (TABLE 4). Qualitative Data on Transfer of Skills Into Practice Forty-one percent of participants (58/141) answered openended questions on the training at 2 weeks, but only 26% (37/141) provided comments at 2 months. TABLE 5 shows a summary of the themes identified. Sixteen participants had not had the opportunity to use the S&T model (due to lack of contact with someone distressed, or lack of privacy). Some
participants found it hard to remember the whole model, but still felt that they had used elements. The participants commonly reported that the model’s structure was helpful; it made starting and ending conversations easier and encouraged listening. Using the model increased their confidence in dealing with distressed patients, gave them control, and helped them feel satisfied that they were able to support patients. A number of participants thought the model made conversations more patient focused and left the patient feeling satisfied and empowered. Some also reported using the model with other groups such as students.
Discussion This study expands on previous research on the workshop, which found significant increases from pre- to postworkshop in the participants’ self-rated competence, confidence, and willingness to talk to people about their concerns, by providing more in-depth data on the effect of the workshop on factors influencing communication.22 Due to the pragmatic approach, this study had some limitations. For example, while the knowledge test was objective and showed no change in the comparator (control) group, the remaining assessments were subjective. While the questionnaires used were not validated—which means that their ability to measure what was intended to be measured has not been demonstrated—they were based on questionnaires used previously by others. In addition, all participants filmed for the behavior assessment volunteered, which may have biased the findings. A major limitation is that the 2-week and 2-month questionnaire response rates were low, despite reminding participants once to respond. It could therefore be argued that the follow-up data were biased and not representative of the whole sample. Thus, the quantitative follow-up data collected are not reported. The qualitative data are, however, described, as they provide an insight into the views of some of the participants on the use of the S&T model in practice.
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Connolly et al. TABLE 5. Qualitative Data
Theme
Quotes
Hard to remember
“I can’t remember what the SAGE & THYME stood for but there were definitely things that were said in the
Used elements of the model
“As a chaplain, I felt that not all elements are relevant in every case, but having a structure to the interview
Structure
“Interview is more structured. I don’t ‘rush in’ and try and solve problems. I listen to the whole story first.”
Ease in starting and ending conversation
“A patient was distressed by cancer diagnosis—used structured approach to support and find out patient’s
Listening
“I felt as though I had really listened, taking into account body language/managing silences/nonverbal signs
training that made me think and I found useful.” (Clinical Training Superintendent)
is very helpful.” (Hospital Chaplain/Team Leader)
(Nurse Practitioner)
concerns. Also used ‘can we leave it there’ to get back to my other patient.” (Staff Nurse)
and feelings. It made me feel appreciated that I actually listened and I felt good about myself.” (Medical Student Support Officer) Confidence
“I feel more confident in dealing with upset patients and their relatives.” (Staff Nurse)
Control
“Felt I had been of benefit to the patient and felt in control.” (Staff Nurse)
Satisfied
“I felt I had fulfilled my role much more than previous. I often avoided conversations around prognosis and death as I found it difficult to conduct a conversation. Now I feel satisfied I am confident to lead a structured interview.” (Staff Nurse)
Patient focused
“Patient had just been told that his treatment did not appear to be working and he may need to consider the prospect he may die. The whole interaction was one of reflection on the part of the patient and cathartic. He said at the end, ‘Wow, I have done all the talking!’ ” (Specialist Clinical Research Nurse)
Patient satisfied
“Helpful to the patient. In control of the situation—not out of my depth. Happy to encourage patient to talk. Able to complete conversation without resolving anything but leaving the patient more satisfied.” (Physiotherapy Team Leader)
Patient empowered
“I felt that I had empowered the patient into making decisions for themselves. That I had listened and allowed time for the discussion. The outcome I predicted was different in a positive sense.” (Motor Neuron Disease Specialist Nurse)
Useful in other situations
“I have a role in student support so have found SAGE & THYME especially useful in interacting with students who have ‘problems.’” (Consultant Pathologist)
Despite these limitations, this study suggests that the workshop participants gained knowledge: They identified significantly more helpful communication behaviors likely to elicit patient concerns5 in a test film than the comparator group (with similar baseline knowledge). In a “real world” setting, this indicates that workshop attendees should know and therefore be more likely to use effective communication skills such as nonverbal behavior (eg, eye contact), verbal behavior (eg, using open questions and clarifying), and structuring the conversation (eg, screening concerns, showing empathy). The 9 participants filmed talking to an SP exhibited significantly more helpful communication behaviors postworkshop, suggesting that the expert detected a more com44
passionate, empathic, and respectful approach. It could be that this behavior change was only observed, as the participants had just completed the training. Alternatively, as the participants had not had the opportunity to practice the skills first, their initial attempt at using the skills taught may have been poor. A previous study on a 3-day communication course for nurses also identified an increase in key communication skills when comparing a pre- and post-course conversation with an SP, but only those who received post-course supervision actually transferred the skills into practice.14 Participant self-efficacy (perceived sense of mastery over communication skills) increased significantly after the workshop. A rise in self-efficacy has also been observed following longer communication skills courses (≥ 20 hours)
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along with a change in practice demonstrated over at least 6 months.16,17,30 However, while a shorter, 7-hour communication course for nurses also observed a significant increase in self-efficacy, this did not lead to a change in practice.31 Due to the low response rate at follow-up, no conclusions can be drawn about whether the workshop resulted in participants using communication skills with patients. Outcome expectancy was significantly higher postworkshop. This is important, as professionals who believe their own actions influence outcomes are more likely to demonstrate effective communication following training.32 Participant motivation to use the S&T model and its perceived usefulness in clinical practice showed high levels post-workshop, which may also encourage the participants to use the model when talking with patients.20 Note that as many participants scored the maximum motivation and usefulness score, there was a ceiling effect, which means that this outcome measure is sensitive only to changes in midlow scores—a different measure should be used in future studies. A larger and more in-depth assessment of participant behavior in the months following the workshop is now required to objectively assess participants’ communication skills with real patients (Kirkpatrick’s Level 3) and the impact of the use of these skills on the patient23 ideally using a single patient outcome as the primary measure.9 The qualitative data from the follow-up questionnaires provide an insight into the workshop’s impact on those who responded. Participants found the structure helpful. They described feeling a greater sense of control, knowing how to start and finish a conversation. Participants described feeling confident, being able to listen without interrupting, and being patient focused. There was also anecdotal evidence that patients seemed satisfied after having a conversation based on the S&T model. Increased patient satisfaction has been demonstrated for other health care communication skills training courses lasting 3 hours33 and 3 days.34 Further research should quantitatively determine whether the workshop training is transferred into practice and has an impact on staff and patients/carers.
Lessons for Practice ●
●
●
●
The SAGE & THYME Foundation Level Workshop increases knowledge of communication skills such as effective listening, clarifying concerns of patients and showing empathy. The workshop increases participant selfefficacy (perceived mastery of communication skills) and outcome expectancy (anticipated positive outcomes) in relation to discussing patient concerns, which may lead to the participants using the skills in practice. Participants find that the SAGE & THYME structure is useful, and they feel motivated to use it. This 3-hour workshop for 30 participants achieves some of the outcomes of longer communication skills courses for fewer participants.
Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s web site: APPENDIX S1: Behaviors Assessed in the Participant Films APPENDIX S2: Self-Efficacy Skills/Situations APPENDIX S3: Outcome Expectancy Statements As a service to our authors and readers, this journal provides supporting information supplied by the authors. Such materials are peer reviewed and may be reorganized for online delivery, but are not copy edited or typeset. Technical support issues arising from supporting information (other than missing files) should be addressed to the authors.
Conclusion
Acknowledgments
The 3-hour S&T Foundation Level Workshop significantly increases communication skills knowledge, self-efficacy, and outcome expectancy of hospital health care workers who are predominantly white, female, nursing, or nonclinical staff. This suggests that the workshop may have a positive impact on some factors influencing communication skills in this group.
Our thanks go to the study participants, simulated patients, and SAGE & THYME trainers. References 1. Razavi D, Delvaux N, Marchal S, De Cook M, Farvacques C, Slachmuylder JL. Testing health care professionals’ communication skills:
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2. 3.
4.
5.
6. 7.
8. 9.
10.
11. 12.
13.
14.
15.
16.
17.
18.
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the usefulness of highly emotional standardized role-playing sessions with simulators. Psychooncology. 2000;9:293–302. Stewart MA. Effective physician-patient communication and health outcomes: a review. Can Med Assoc. 1995;152(9):1423–1433. Ong LM, Visser MR, Lammes FB, de Haes JC. Doctor-patient communication and cancer patients’ quality of life and satisfaction. Patient Educ Couns. 2000;41(2):145–156. Zimmerman C, Del Piccolo L, Finset A. Cues and concerns by patients in medical consultations: a literature review. Psychol Bull. 2007;133:438–463. Langewitz WA, Eich P, Kiss A, W¨ossmer B. Improving communication skills—a randomized controlled behaviorally oriented intervention study for residents in internal medicine. Psychosom Med. 1998;60(3):268–276. Beach MC, Inui T. Relationship-centered care: a constructive reframing. J Gen Intern Med. 2006;21(Suppl 1):S3–S8. Fallowfield LJ, Hall A, Maguire GP, Baum M. Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial. Brit Med J. 1990;301:575–580. Pennebaker JW. Putting stress into words: health, linguistic and therapeutic implications. Behav Res Ther. 1993;31:539–548. Uitterhoeve RJ, Bensing JM, Grol RP, Demulder PHM, Van Achterberg T. The effect of communications skills training on patient outcomes in cancer care: a systematic review of the literature. Eur J Cancer Care. 2009;19:442–457. Sargeant J, MacLeod T, Murray A. An interprofessional approach to teaching communication skills. J Contin Educ Health Prof. 2011;31(4):265–267. Maguire P, Faulkner A, Booth K, Elliot C, Hillier V. Helping cancer patients disclose their concerns. Eur J Cancer. 1996;32A:78–81. Fallowfield L, Jenkins V, Farewell V, Saul J, Duffy A, Eves R. Efficacy of a Cancer Research UK communication skills training model for oncologists: a randomised controlled trial. Lancet. 2002;359:650– 656. Wilkinson S, Perry R, Blanchard K, Linsell L. Effectiveness of a threeday communication skills course in changing nurses’ communication skills with cancer/palliative care patients: a randomised controlled trial. Palliat Med. 2008;22:365–375. Heaven C, Clegg J, Maguire P. Transfer of communication skills training from workshop to workplace: the impact of clinical supervision. Patient Educ Couns. 2006;60:313–325. Razavi D, Delvaux N, Marchal S et al. Does training increase the use of emotionally laden words by nurses when talking with cancer patients? A randomised study. Br J Cancer. 2002;87:1–7. Nørgaard B, Ammentorp J, Ohm Kyvik K, Kofoed P. Communication skills training increased self-efficacy of health care professionals. J Contin Educ Health Prof. 2012;32(2):90–97. Gulbrandsen P, Jensen BF, Finset A. Changes in self-efficacy among hospital doctors after a training course in clinical communication. Tidsskr Nor Legeforen. 2009;129:2343–2346. Barth J, Lannen P. Efficacy of communication skills training courses in oncology: a systematic review. Ann Oncol. 2011;22:1030– 1040.
19. Levinson W, Roter D. The effects of two continuing medical education programs on communication skills of practicing primary care physicians. J Gen Intern Med. 1993;8:318–324. 20. Parle M, Maguire P, Heaven C. The development of a training model to improve health professionals’ skills, self efficacy and outcome expectancies when communicating with cancer patients. Soc Sci Med. 1997;44:231–240. 21. Bandura A. Social Learning Theory. New York: General Learning Press; 1977. 22. Connolly M, Perryman J, McKenna Y, et al. Sage and Thyme: a model for training health and social care professionals in patient-focussed support. Patient Educ Couns. 2010;79:87–93. 23. Barr H, Freed D, Hamminck M, Koppel I, Reeves S. Evaluations of interprofessional education: a United Kingdom review of health and social care. http://www.caipe.org.uk/silo/files/evaluationsof-interprofessional-education.pdf. Published August 2000. Accessed May 28, 2012. 24. Faulkner A. Using simulators to aid the teaching of communication skills in cancer and palliative care. Patient Educ Couns. 1994;23:125– 129. 25. Finlay IG, Stott NC, Kinnersley P. The assessment of communication skills in palliative medicine: a comparison of the scores of examiners and simulated patients. Med Educ. 1995;29:424–429. 26. Kruijver IP, Kerkstra A, Bensing JM, van de Wiel HB. Communication skills of nurses during interactions with simulated cancer patients. J Adv Nurs. 2001;34:772–779. 27. Mercer S, Maxwell M, Heaney D, Watt G. The consultation and relational empathy (CARE) measure; development and preliminary validation and reliability of an empathy-based consultation process measure. Fam Pract. 2004;21:699–705. 28. Bandura A. Self-Efficacy: The Exercise of Control. New York, NY: Freeman; 1997. 29. Heaven C. The role of clinical supervision in communication skills training (PhD thesis). Manchester, England: University of Manchester; 2001. 30. Gulbrandsen P, Jensen BF, Finset A, Blanch-Hartigan C. Long term effect of communication training on the relationship between physicians’ self-efficacy and performance. Patient Educ Couns. 2013;91(2):180– 185. 31. Doyle D, Copeland HL, Bush D, Stein L, Thompson S. A course for nurses to handle difficult communication situations. A randomized controlled trial of impact on self-efficacy and performance. Patient Educ Couns. 2011;82(1):100–109. 32. Libert Y, Merckaert I, Reynaert C, et al. Physicians are different when they learn communication skills: influence of the locus of control. Psychoncol. 2007;16(6):553–562. 33. Trumble SC, O’Brien ML, O’Brien M, Hartwig B. Communication skills training for doctors increases patient satisfaction. Clin Gov Int J. 2006;11(4):299–307. 34. Nørgaard B, Kofoed P, Ohm Kyvik K, Ammentorp J. Communication skills training for health care professionals improves adult orthopaedic patient’s experience of quality of care. Scand J Caring Sci. 2012;26(4):698–704.
JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—34(1), 2014 DOI: 10.1002/chp
The Impact of the SAGE & THYME Foundation Level Workshop on Factors Influencing Communication Skills in Health Care Professionals
MICHAEL CONNOLLY, MPHIL; JOANNE M. THOMAS, PHD; JULIE A. ORFORD, MA; NICOLA SCHOFIELD, MPHIL; SIGRID WHITESIDE, MSC; JULIE MORRIS, MSC; CATHY HEAVEN, PHD Introduction: The “SAGE & THYME Foundation Level Workshop” delivers evidence-based communication skills training to 30 health care workers in 3 hours. It teaches a structured approach (the SAGE & THYME model) to discuss patient/carer concerns. The aim of this study was to determine whether the workshop had a positive outcome on factors that influence communication skills. Methods: The study had a pragmatic, mixed methods design. Workshops were run in an acute hospital. One hundred seventy health care workers completed questionnaires pre- and post-workshop; 141 were sent follow-up questionnaires at 2 weeks and 2 months; and 9 were filmed talking to a simulated patient pre- and post-workshop. Results: From pre- to post-workshop, there was a significant increase in knowledge (p < 0.001), self-efficacy (p < 0.001), and outcome expectancy (p < 0.001). An expert’s rating of behavior with the simulated patient also significantly increased after the training (p = 0.011). Motivation to use the training, and the perceived usefulness of the SAGE & THYME model, were high post-workshop. There was a poor response rate in the follow-up period; hence, the quantitative data are not reported. The qualitative data are described, however, as they give an insight into the impact of the training on staff and their patients. Discussion: The SAGE & THYME Foundation Level Workshop significantly increases communication skills knowledge, self-efficacy, and outcome expectancy of hospital health care workers who are predominantly white, female, nursing, or nonclinical staff. This suggests that the workshop may have a positive impact on some factors influencing communication skills in this group. Key Words: emotional support, training, psychological support, patient-centered care, health care, communication skills, knowledge translation, workplace learning
Introduction Disclosures: The authors report a £25,000 TRUSTECH Pathfinder Development Fund grant funded this study. The University Hospital of South Manchester NHS Foundation Trust provides the SAGE & THYME training on a commercial basis and shares some of the income generated with Central Manchester University Hospitals and the Christie Hospital. Mr. Connolly: Macmillan Nurse Consultant, Macmillan Palliative Care Service, University Hospital of South Manchester NHS Foundation Trust; Dr. Thomas: Senior Technology Manager, TRUSTECH, Central Manchester University Hospitals NHS Foundation Trust; Ms. Orford: Breast Care Nurse, Nightingale Centre, University Hospital of South Manchester NHS Foundation Trust; Ms. Schofield: Senior Trainer, Maguire Communication Skills Training Unit, The Christie NHS Foundation Trust; Ms. Whiteside: Medical Statistician, University Hospital of South Manchester NHS Foundation Trust; Ms. Morris: Head of Medical Statistics, University Hospital of South Manchester NHS Foundation Trust; Dr. Heaven: Associate Director of Education, Maguire Communication Skills Training Unit, The Christie NHS Foundation Trust. Correspondence: Michael Connolly, Macmillan Palliative Care Service, University Hospital of South Manchester NHS Foundation Trust, Manchester, M23 9LT, UK; e-mail: [email protected].
Effective communication between health care workers and patients has been shown to improve patient adherence to treatment,1 recovery and psychology,2 and increase patient satisfaction and quality of life.3 Evidence relating to listening and responding to patient concerns as a component of effective communication has been in the literature for decades.4 Health care workers who lack confidence in their communication skills with patients may have a poor understanding of their patients’ concerns.5,6 This represents a missed opportunity to improve patient health outcomes, as resolution of concerns is known to benefit adjustment to illness.7 It has also been found that © 2014 The Alliance for Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on Continuing Medical Education, Association for Hospital Medical Education. • Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/chp.21214
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FIGURE 1. SAGE & THYME Model
disclosure of potentially unresolvable concerns can be helpful for patients.8 Furthermore, there is some evidence that patients who are anxious do not readily disclose concerns but express cues or hints about their concerns.9 Thus, the ability to detect cues is of central importance for health care workers. Communication skills, however, do not necessarily improve by experience alone.10 Thus, educators and researchers have focused on ways to improve the communication skills of health workers, by developing a range of courses.11–14 Current research on the effectiveness of such training favors long courses (≥20 hours) for small groups (3 to 12 learners), often at an advanced level.12–17 These are expensive and available primarily in the context of cancer and end-oflife care. Thus, there is a need for shorter, less expensive courses that are accessible and suitable for all staff groups and specialties.18 However, a recent systematic review concluded that courses greater than 24 hours were more effective than those shorter than 24 hours.18 Furthermore, the effectiveness of short courses (4.5 to 6 hours) for large groups (15 or more), in changing communication skills, has not been demonstrated.9,19 Leading researchers have used social learning theory (SLT) to develop training for communication with cancer patients.14,20 SLT states that for training to change a learner’s behavior, it must (1) keep their attention, (2) aid information retention, (3) allow reproduction of the required behavior, and (4) motivate the learner to imitate the behavior.21 It is also recognized that high self-efficacy16,17 (perceived mastery over skills) and outcome expectancy20 (anticipated positive outcomes from the behavior) are required to transfer skills into practice. The SAGE & THYME Foundation Level (S&T FL) Workshop lasts 3 hours. SAGE & THYME is a mnemonic for a sequential structure (S&T model) that guides learners to apply patient-centered care for listening and responding to concerns by listening fully, holding back with ad38
vice/information, and inquiring about the patient’s own support and solutions before offering any advice or information (FIGURE 1). The workshop is described as foundation level because it was designed to provide a starting point for health workers as they learn about emotional support. The workshop is run by 3 facilitators and taught to 30 participants. It fits with SLT by including small group discussions (what participants already know), an explanation of the S&T model and how it fits with the evidence, and 2 experiential rehearsals using the S&T model. The workshop and model have been previously described in detail.22 This study investigated whether the S&T FL Workshop had a positive outcome on factors that influence communication skills by assessing whether participants (1) gained knowledge on helpful communication behaviors, (2) changed their behavior when talking to a simulated patient, (3) were likely to use the S&T model in practice (by measuring self-efficacy and outcome expectancy), and (4) felt the model was useful and were motivated to use it. Information was also obtained on whether participants changed their practice. Methods Methodological Approach This was a pragmatic, mixed methods study, designed within the resources available, to assess participant reactions and learning (Levels 1 and 2, respectively, of Kirkpatrick’s 4level evaluation for determining a training effect).23 Level 3 (behavior on the job) was partially evaluated using participants’ subjective reports of use of the model. Recruitment and Study Time Points Recruitment occurred over a 12-month period. Approximately 1 workshop was run per month in an acute hospital for its clinical and nonclinical employees. All attendees were
JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—34(1), 2014 DOI: 10.1002/chp
SAGE & THYME Workshop: Impact on Communication
FIGURE 2. Summary of Assessments Completed at Each Time Point
invited to participate in the study before the workshop. The same trainer led all the workshops, but the other 2 facilitators varied. Demographic information was collected pre-workshop. Participants completed several questionnaires immediately pre- and post-workshop (see FIGURE 2). Follow-up questionnaires were sent at 2 weeks and 2 months post-workshop (FIGURE 2). These were initially sent to 50% of participants in each workshop (selected randomly) due to limited resources. However, after the first 5 workshops, only 32% of those randomized to follow-up responded at 2 months, so about halfway through the study, an amendment was accepted by the ethics committee to follow up all participants. Questionnaires were anonymous (each participant had a unique identification number). A comparator group was used for the knowledge test. Participants were recruited from an office administration course or staff “induction” course run within the hospital. These courses had the same duration as the S&T FL workshop, involved a variety of staff groups and specialties, and did not provide communication skills training.
edge test was also completed by the comparator group before and after their training, to assess whether the knowledge score improved by only seeing the same test film twice, 3 hours apart. Behavior A subjective assessment of whether participants could reproduce behaviors taught in the workshop, was carried out by filming a small number of participants individually having a one-to-one mock conversation with a simulated patient (SP) (an established method for practicing communication skills1,24–26 ) pre- and post-workshop (“participant film”). Each SP was briefed to act distressed (anxious but not angry) as they waited for test results. A communications expert (NS) rated each participant’s behavior against 12 criteria using a 0 to 4 Likert scale using an instrument available as supporting information (APPENDIX S1) in the online version of this article. This instrument was not validated but was adapted from another communication skills assessment tool.27 The order of the films (pre versus post) was randomized, with the expert blinded to the order.
Knowledge Change in knowledge was tested by twice showing the participants a 6.5-minute film (pre- and post-workshop) of a conversation between actors playing a health care professional and a patient, which (unknown to the participants) was based on the S&T model (“test film”). Participants were asked to list helpful nonverbal and verbal behaviors and skills and anything helpful about the structure of the interaction. Two researchers (NS, JO) scored each participant’s list independently, using a rating sheet developed for the study of 20 helpful communication behaviors evident in the test film and taught in the workshop (eg, body language, screening concerns, using empathy) (maximum score 20). The assessors compared their scores for consistency, and rerated any inconsistent scores following discussion. This knowl-
Self-Efficacy Participants subjectively rated self-efficacy between 0 and 100 for 16 skills/situations, such as their ability to “create a setting in which patients can speak openly about their concerns, using a modified version of a self-efficacy questionnaire (available as supporting information [APPENDIX S2] in the online version of this article),20 based on Bandura’s assessment28 and used in communication skills training,29 pre- and post-workshop, and at 2 weeks and 2 months. Outcome Expectancy Participants’ attitudes and beliefs toward the likely consequences of their behavior were assessed subjectively using
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Connolly et al.
a modified outcome expectancy questionnaire (available as supporting information [APPENDIX S3] in the online version of this article) with a Likert scale (1 to 9), which included statements such as “asking your patient to talk about their concerns and emotions will be of benefit to them.” The original questionnaire was developed following a literature review of factors affecting health care professionals’ assessment of their patients’ concerns and has good content validity.20 No other formal testing has been conducted, but it has been used with a variety of professionals and has been assessed for face validity.14 In some questions, a positive response received a high score; in others, it received a low score, to avoid response bias. During data analysis, scores were reversed as needed so positive responses had higher scores. This questionnaire was completed pre-workshop, post-workshop, at 2 weeks and 2 months.
an estimated standard deviation of differences of 14 (from a pilot study of 37 participants). The sample size calculation was based on self-efficacy, as this is important in transferring skills into practice.28 Due to the protocol amendment to increase follow-up data, more than 100 people were recruited. The knowledge test comparator group was smaller than the study group, due to the limited recruitment resources available. With 25 in the comparator group and 158 in the study group, the study had 80% power to detect differences in the change in knowledge score of 1.2 or more (using a simple 2-sided t-test on the changes with estimated standard deviation of 2 and a 5% significance level). This was thought to be a “worthwhile” difference. The number of participants intended to be filmed was limited to 10 by the financial resources available.
Motivation and Usefulness
Greater Manchester North Research Ethics Committee approved the study in 2009. All participants gave written informed consent.
Participants rated their motivation to use S&T in their practice. They scored between 0 and 100 (totally motivated) on 3 questions—motivation to use S&T generally, motivation to use all of the S&T structure, and motivation to use some of the S&T structure. They also rated how useful they felt the S&T model was, between 0 and 100 (totally useful) for (1) enabling patients, (2) working with patients, and (3) leaving them more satisfied when working with patients. These unvalidated questionnaires were completed post-workshop, and at 2 weeks and 2 months. Total scores were calculated for each questionnaire and averaged over the 3 questions. Qualitative Data on Transfer of Skills into Practice This was measured subjectively at 2 weeks and 2 months by participants completing an unvalidated questionnaire (designed specifically for this study, but based on a questionnaire used previously29 ) on their use of the model. It included open-ended questions on the reason why they had or had not used the S&T model; if they had used it, how they felt afterwards and the impact it had on the patient; and if they had not used the model, what the barriers were. Two researchers (JO, JT) analyzed the text together and identified the main theme for each response. Similar themes were then grouped together, until no further reduction of themes was possible. Sample Size The intention was to recruit 100 participants. With this number, the study could detect changes in self-efficacy of 4 or more (an increase of 7 was significant in 61 nurses attending a 3-day communication skills course29 ), using a paired t-test with a conventional 2-sided 5% significance level, based on 40
Ethical Approval
Statistical Analysis Data distributions were assessed for normality. The comparison of changes from pre- to post-workshop was only carried out for those participants with both pre- and post-data. The number of participants with missing information pre and post-workshop was relatively small (eg, 9% for knowledge test). Changes in normally distributed data from pre- to post-workshop were analyzed using paired Student’s t-tests. Changes in non-normally distributed scores were analyzed by paired Wilcoxon signed ranks test. A direct comparison of changes in knowledge scores, between study and comparator groups, was made using the 2-sample t-test. The primary endpoint was immediately post-workshop. Analyses were carried out using SPSS version 15.0, using the conventional 2sided 5% significance level. The low number of participants returning questionnaires at 2 weeks and 2 months did not allow comparative statistical analysis. Results Participant Numbers FIGURE 3 summarizes the number of participants involved at each stage of the study. A total of 173 people were recruited: of the first 58 people, 29 were randomly selected for follow-up at 2 weeks and 2 months. Due to the protocol change mentioned previously, all further people recruited were followed up and in total 141 participants were sent follow-up questionnaires. Nine participants volunteered to be filmed.
JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—34(1), 2014 DOI: 10.1002/chp
SAGE & THYME Workshop: Impact on Communication
FIGURE 3. CONSORT-Style Flowchart for the SAGE & THYME Participants
Not all participants completed all questionnaires at each time point (see FIGURE 3). The number who returned all questionnaires at each time point was 146 pre-workshop, 126 post-workshop, 53 at 2 weeks, and 41 at 2 months. Only 18 completed questionnaires at each of the 4 time points. However, we were able to analyze the data for each measure as long as we had both pre- and post-data. Therefore, FIGURE 3 also shows the number of participants who completed at least 1 questionnaire. Due to the low response rate, the quantitative follow-up data are not presented, as it is possible that only participants who responded had used the workshop skills taught. However, the qualitative data are summarized to highlight the
views on using the model, of the participants who responded, to inform future studies. Twenty-five people were recruited into the comparator group for assessing knowledge.
Demographics Study participants were predominantly white, female hospital workers (TABLE 1). The majority were 25 to 54 years old. The knowledge test comparator group had similar demographics and proportion of nurses, but had more 18- to 24-year-olds, and more people with an “other” occupation.
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41
Connolly et al. TABLE 1. Study Participant and Comparator Group Demographics
Comparator group for Study group (n = 173)
knowledge testing (n = 25)
Descriptor
Detail
n
%
n
%
Gender
Female
151
90.4
23
92.0
Male Age
Ethnic origin
16
9.6
2
8.0
18–24 yrs
6
3.6
4
16.0
25–34 yrs
40
24.1
9
36.0
35–44 yrs
62
37.3
6
24.0
45–54 yrs
44
26.5
5
20.0
55–64 yrs
14
8.4
1
4.0
147
88.0
25
100.0
20
12.0
0
0
White Other ethnic origins
Employer
Occupation
136
82.4
25
100.0
Community
Acute hospital
15
9.1
0
0
Hospice
14
8.5
0
0
Nurse
86
51.5
13
52.0
Allied health professional
29
17.4
0
0
5
3.0
0
0
Medical Student Other
5
3.0
0
0
42
25.1
12
48.0
TABLE 2. Knowledge Test Score for Comparator and Study Groups
Mean (SD)
Mean (95% CI)
Mean (95% CI)
Paired t-test
Post (n = 25)
Change (n = 25)
6.0 (2.1)
0.5 (−0.1, 1.1)
Post (n = 159)
Change (n = 158)
7.9 (2.9)
2.3 (1.9, 2.8)
p < 0.001
Mean (95% CI)
Two-sample t-test
1.8 (0.9, 2.8)
p < 0.001
Comparator group Pre (n = 25) 5.5 (1.8)
p = 0.12
Study group Pre (n = 164) 5.7 (2.7) Difference in change between study group and comparator
SD = standard deviation, CI = confidence interval. Maximum score achievable was 20.
Knowledge and Behavior TABLE 2 shows the knowledge test data. There was little difference in the knowledge score for the comparator group from pre- to post-training (p = 0.12). Conversely, the 42
S&T participants’ score significantly increased after attending their workshop (p < 0.001). The increase in knowledge score was significantly higher for S&T participants, compared with the comparator group (p < 0.001).
JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—34(1), 2014 DOI: 10.1002/chp
SAGE & THYME Workshop: Impact on Communication TABLE 3. Self-Efficacy and Outcome Expectancy
TABLE 4. Motivation to Use and Perceived Usefulness of SAGE & THYME Post-Workshop
a. Self-efficacy (scored between 0 and 100) Mean (SD) Pre
(n = 163) 66.3 (15.5)
Mean (SD)
Mean (95% CI)
Post
Pre to post
(n = 158)
(n = 155)
87.2 (10.5)
21.1 (18.8, 23.4)
Median (range) % with scores of 100
Motivation
Usefulness
(n = 145)
(n = 144)
100 (73, 100)
100 (67, 100)
58%
56%
Paired t-test; p < 0.001 Scored between 0 and 100.
b. Outcome expectancy (scored on a Likert scale of 1 to 9) Mean (SD)
Mean (SD)
Mean (95% CI)
Post
Pre to post
(n = 156)
(n = 151)
(n = 142)
6.31 (0.92)
7.04 (0.87)
Pre
0.72 (0.58, 0.86) Paired t-test; p < 0.001
SD = standard deviation, CI = confidence interval.
The expert’s rating of the participant films increased significantly from pre- to post-workshop, from a median of 0.8 to 1.8; median change of 0.8 (0.07 to 1.63); paired Wilcoxon signed ranks p = 0.011. This suggests that the S&T participants demonstrated more helpful communication behaviors after the workshop. Self-Efficacy and Outcome Expectancy Participants’ self-efficacy significantly increased after the workshop (p < 0.001, TABLE 3). Participants also became more positive about the benefits of helpful communication behaviors post-workshop, with a small but significant increase in outcome expectancy (p < 0.001) (TABLE 3). Motivation and Usefulness Motivation and usefulness scores were high post-workshop, with 58% of participants scoring the maximum of 100 for motivation and 56% scoring the maximum of 100 on usefulness (TABLE 4). Qualitative Data on Transfer of Skills Into Practice Forty-one percent of participants (58/141) answered openended questions on the training at 2 weeks, but only 26% (37/141) provided comments at 2 months. TABLE 5 shows a summary of the themes identified. Sixteen participants had not had the opportunity to use the S&T model (due to lack of contact with someone distressed, or lack of privacy). Some
participants found it hard to remember the whole model, but still felt that they had used elements. The participants commonly reported that the model’s structure was helpful; it made starting and ending conversations easier and encouraged listening. Using the model increased their confidence in dealing with distressed patients, gave them control, and helped them feel satisfied that they were able to support patients. A number of participants thought the model made conversations more patient focused and left the patient feeling satisfied and empowered. Some also reported using the model with other groups such as students.
Discussion This study expands on previous research on the workshop, which found significant increases from pre- to postworkshop in the participants’ self-rated competence, confidence, and willingness to talk to people about their concerns, by providing more in-depth data on the effect of the workshop on factors influencing communication.22 Due to the pragmatic approach, this study had some limitations. For example, while the knowledge test was objective and showed no change in the comparator (control) group, the remaining assessments were subjective. While the questionnaires used were not validated—which means that their ability to measure what was intended to be measured has not been demonstrated—they were based on questionnaires used previously by others. In addition, all participants filmed for the behavior assessment volunteered, which may have biased the findings. A major limitation is that the 2-week and 2-month questionnaire response rates were low, despite reminding participants once to respond. It could therefore be argued that the follow-up data were biased and not representative of the whole sample. Thus, the quantitative follow-up data collected are not reported. The qualitative data are, however, described, as they provide an insight into the views of some of the participants on the use of the S&T model in practice.
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Connolly et al. TABLE 5. Qualitative Data
Theme
Quotes
Hard to remember
“I can’t remember what the SAGE & THYME stood for but there were definitely things that were said in the
Used elements of the model
“As a chaplain, I felt that not all elements are relevant in every case, but having a structure to the interview
Structure
“Interview is more structured. I don’t ‘rush in’ and try and solve problems. I listen to the whole story first.”
Ease in starting and ending conversation
“A patient was distressed by cancer diagnosis—used structured approach to support and find out patient’s
Listening
“I felt as though I had really listened, taking into account body language/managing silences/nonverbal signs
training that made me think and I found useful.” (Clinical Training Superintendent)
is very helpful.” (Hospital Chaplain/Team Leader)
(Nurse Practitioner)
concerns. Also used ‘can we leave it there’ to get back to my other patient.” (Staff Nurse)
and feelings. It made me feel appreciated that I actually listened and I felt good about myself.” (Medical Student Support Officer) Confidence
“I feel more confident in dealing with upset patients and their relatives.” (Staff Nurse)
Control
“Felt I had been of benefit to the patient and felt in control.” (Staff Nurse)
Satisfied
“I felt I had fulfilled my role much more than previous. I often avoided conversations around prognosis and death as I found it difficult to conduct a conversation. Now I feel satisfied I am confident to lead a structured interview.” (Staff Nurse)
Patient focused
“Patient had just been told that his treatment did not appear to be working and he may need to consider the prospect he may die. The whole interaction was one of reflection on the part of the patient and cathartic. He said at the end, ‘Wow, I have done all the talking!’ ” (Specialist Clinical Research Nurse)
Patient satisfied
“Helpful to the patient. In control of the situation—not out of my depth. Happy to encourage patient to talk. Able to complete conversation without resolving anything but leaving the patient more satisfied.” (Physiotherapy Team Leader)
Patient empowered
“I felt that I had empowered the patient into making decisions for themselves. That I had listened and allowed time for the discussion. The outcome I predicted was different in a positive sense.” (Motor Neuron Disease Specialist Nurse)
Useful in other situations
“I have a role in student support so have found SAGE & THYME especially useful in interacting with students who have ‘problems.’” (Consultant Pathologist)
Despite these limitations, this study suggests that the workshop participants gained knowledge: They identified significantly more helpful communication behaviors likely to elicit patient concerns5 in a test film than the comparator group (with similar baseline knowledge). In a “real world” setting, this indicates that workshop attendees should know and therefore be more likely to use effective communication skills such as nonverbal behavior (eg, eye contact), verbal behavior (eg, using open questions and clarifying), and structuring the conversation (eg, screening concerns, showing empathy). The 9 participants filmed talking to an SP exhibited significantly more helpful communication behaviors postworkshop, suggesting that the expert detected a more com44
passionate, empathic, and respectful approach. It could be that this behavior change was only observed, as the participants had just completed the training. Alternatively, as the participants had not had the opportunity to practice the skills first, their initial attempt at using the skills taught may have been poor. A previous study on a 3-day communication course for nurses also identified an increase in key communication skills when comparing a pre- and post-course conversation with an SP, but only those who received post-course supervision actually transferred the skills into practice.14 Participant self-efficacy (perceived sense of mastery over communication skills) increased significantly after the workshop. A rise in self-efficacy has also been observed following longer communication skills courses (≥ 20 hours)
JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—34(1), 2014 DOI: 10.1002/chp
SAGE & THYME Workshop: Impact on Communication
along with a change in practice demonstrated over at least 6 months.16,17,30 However, while a shorter, 7-hour communication course for nurses also observed a significant increase in self-efficacy, this did not lead to a change in practice.31 Due to the low response rate at follow-up, no conclusions can be drawn about whether the workshop resulted in participants using communication skills with patients. Outcome expectancy was significantly higher postworkshop. This is important, as professionals who believe their own actions influence outcomes are more likely to demonstrate effective communication following training.32 Participant motivation to use the S&T model and its perceived usefulness in clinical practice showed high levels post-workshop, which may also encourage the participants to use the model when talking with patients.20 Note that as many participants scored the maximum motivation and usefulness score, there was a ceiling effect, which means that this outcome measure is sensitive only to changes in midlow scores—a different measure should be used in future studies. A larger and more in-depth assessment of participant behavior in the months following the workshop is now required to objectively assess participants’ communication skills with real patients (Kirkpatrick’s Level 3) and the impact of the use of these skills on the patient23 ideally using a single patient outcome as the primary measure.9 The qualitative data from the follow-up questionnaires provide an insight into the workshop’s impact on those who responded. Participants found the structure helpful. They described feeling a greater sense of control, knowing how to start and finish a conversation. Participants described feeling confident, being able to listen without interrupting, and being patient focused. There was also anecdotal evidence that patients seemed satisfied after having a conversation based on the S&T model. Increased patient satisfaction has been demonstrated for other health care communication skills training courses lasting 3 hours33 and 3 days.34 Further research should quantitatively determine whether the workshop training is transferred into practice and has an impact on staff and patients/carers.
Lessons for Practice ●
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The SAGE & THYME Foundation Level Workshop increases knowledge of communication skills such as effective listening, clarifying concerns of patients and showing empathy. The workshop increases participant selfefficacy (perceived mastery of communication skills) and outcome expectancy (anticipated positive outcomes) in relation to discussing patient concerns, which may lead to the participants using the skills in practice. Participants find that the SAGE & THYME structure is useful, and they feel motivated to use it. This 3-hour workshop for 30 participants achieves some of the outcomes of longer communication skills courses for fewer participants.
Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s web site: APPENDIX S1: Behaviors Assessed in the Participant Films APPENDIX S2: Self-Efficacy Skills/Situations APPENDIX S3: Outcome Expectancy Statements As a service to our authors and readers, this journal provides supporting information supplied by the authors. Such materials are peer reviewed and may be reorganized for online delivery, but are not copy edited or typeset. Technical support issues arising from supporting information (other than missing files) should be addressed to the authors.
Conclusion
Acknowledgments
The 3-hour S&T Foundation Level Workshop significantly increases communication skills knowledge, self-efficacy, and outcome expectancy of hospital health care workers who are predominantly white, female, nursing, or nonclinical staff. This suggests that the workshop may have a positive impact on some factors influencing communication skills in this group.
Our thanks go to the study participants, simulated patients, and SAGE & THYME trainers. References 1. Razavi D, Delvaux N, Marchal S, De Cook M, Farvacques C, Slachmuylder JL. Testing health care professionals’ communication skills:
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Connolly et al.
2. 3.
4.
5.
6. 7.
8. 9.
10.
11. 12.
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14.
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16.
17.
18.
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the usefulness of highly emotional standardized role-playing sessions with simulators. Psychooncology. 2000;9:293–302. Stewart MA. Effective physician-patient communication and health outcomes: a review. Can Med Assoc. 1995;152(9):1423–1433. Ong LM, Visser MR, Lammes FB, de Haes JC. Doctor-patient communication and cancer patients’ quality of life and satisfaction. Patient Educ Couns. 2000;41(2):145–156. Zimmerman C, Del Piccolo L, Finset A. Cues and concerns by patients in medical consultations: a literature review. Psychol Bull. 2007;133:438–463. Langewitz WA, Eich P, Kiss A, W¨ossmer B. Improving communication skills—a randomized controlled behaviorally oriented intervention study for residents in internal medicine. Psychosom Med. 1998;60(3):268–276. Beach MC, Inui T. Relationship-centered care: a constructive reframing. J Gen Intern Med. 2006;21(Suppl 1):S3–S8. Fallowfield LJ, Hall A, Maguire GP, Baum M. Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial. Brit Med J. 1990;301:575–580. Pennebaker JW. Putting stress into words: health, linguistic and therapeutic implications. Behav Res Ther. 1993;31:539–548. Uitterhoeve RJ, Bensing JM, Grol RP, Demulder PHM, Van Achterberg T. The effect of communications skills training on patient outcomes in cancer care: a systematic review of the literature. Eur J Cancer Care. 2009;19:442–457. Sargeant J, MacLeod T, Murray A. An interprofessional approach to teaching communication skills. J Contin Educ Health Prof. 2011;31(4):265–267. Maguire P, Faulkner A, Booth K, Elliot C, Hillier V. Helping cancer patients disclose their concerns. Eur J Cancer. 1996;32A:78–81. Fallowfield L, Jenkins V, Farewell V, Saul J, Duffy A, Eves R. Efficacy of a Cancer Research UK communication skills training model for oncologists: a randomised controlled trial. Lancet. 2002;359:650– 656. Wilkinson S, Perry R, Blanchard K, Linsell L. Effectiveness of a threeday communication skills course in changing nurses’ communication skills with cancer/palliative care patients: a randomised controlled trial. Palliat Med. 2008;22:365–375. Heaven C, Clegg J, Maguire P. Transfer of communication skills training from workshop to workplace: the impact of clinical supervision. Patient Educ Couns. 2006;60:313–325. Razavi D, Delvaux N, Marchal S et al. Does training increase the use of emotionally laden words by nurses when talking with cancer patients? A randomised study. Br J Cancer. 2002;87:1–7. Nørgaard B, Ammentorp J, Ohm Kyvik K, Kofoed P. Communication skills training increased self-efficacy of health care professionals. J Contin Educ Health Prof. 2012;32(2):90–97. Gulbrandsen P, Jensen BF, Finset A. Changes in self-efficacy among hospital doctors after a training course in clinical communication. Tidsskr Nor Legeforen. 2009;129:2343–2346. Barth J, Lannen P. Efficacy of communication skills training courses in oncology: a systematic review. Ann Oncol. 2011;22:1030– 1040.
19. Levinson W, Roter D. The effects of two continuing medical education programs on communication skills of practicing primary care physicians. J Gen Intern Med. 1993;8:318–324. 20. Parle M, Maguire P, Heaven C. The development of a training model to improve health professionals’ skills, self efficacy and outcome expectancies when communicating with cancer patients. Soc Sci Med. 1997;44:231–240. 21. Bandura A. Social Learning Theory. New York: General Learning Press; 1977. 22. Connolly M, Perryman J, McKenna Y, et al. Sage and Thyme: a model for training health and social care professionals in patient-focussed support. Patient Educ Couns. 2010;79:87–93. 23. Barr H, Freed D, Hamminck M, Koppel I, Reeves S. Evaluations of interprofessional education: a United Kingdom review of health and social care. http://www.caipe.org.uk/silo/files/evaluationsof-interprofessional-education.pdf. Published August 2000. Accessed May 28, 2012. 24. Faulkner A. Using simulators to aid the teaching of communication skills in cancer and palliative care. Patient Educ Couns. 1994;23:125– 129. 25. Finlay IG, Stott NC, Kinnersley P. The assessment of communication skills in palliative medicine: a comparison of the scores of examiners and simulated patients. Med Educ. 1995;29:424–429. 26. Kruijver IP, Kerkstra A, Bensing JM, van de Wiel HB. Communication skills of nurses during interactions with simulated cancer patients. J Adv Nurs. 2001;34:772–779. 27. Mercer S, Maxwell M, Heaney D, Watt G. The consultation and relational empathy (CARE) measure; development and preliminary validation and reliability of an empathy-based consultation process measure. Fam Pract. 2004;21:699–705. 28. Bandura A. Self-Efficacy: The Exercise of Control. New York, NY: Freeman; 1997. 29. Heaven C. The role of clinical supervision in communication skills training (PhD thesis). Manchester, England: University of Manchester; 2001. 30. Gulbrandsen P, Jensen BF, Finset A, Blanch-Hartigan C. Long term effect of communication training on the relationship between physicians’ self-efficacy and performance. Patient Educ Couns. 2013;91(2):180– 185. 31. Doyle D, Copeland HL, Bush D, Stein L, Thompson S. A course for nurses to handle difficult communication situations. A randomized controlled trial of impact on self-efficacy and performance. Patient Educ Couns. 2011;82(1):100–109. 32. Libert Y, Merckaert I, Reynaert C, et al. Physicians are different when they learn communication skills: influence of the locus of control. Psychoncol. 2007;16(6):553–562. 33. Trumble SC, O’Brien ML, O’Brien M, Hartwig B. Communication skills training for doctors increases patient satisfaction. Clin Gov Int J. 2006;11(4):299–307. 34. Nørgaard B, Kofoed P, Ohm Kyvik K, Ammentorp J. Communication skills training for health care professionals improves adult orthopaedic patient’s experience of quality of care. Scand J Caring Sci. 2012;26(4):698–704.
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