Difficult Conversations driving research into effective communications training

Dr Jonathan Koffman & Lisa Jane Brighton of KCL Cicely Saunders Institute take a look at the results from the first steps of a research collaboration with Difficult Conversations.

As researchers in palliative care, we’re always looking for ways to improve experiences and outcomes for patients living and dying from advanced diseases, and their families. Our work can range from interviewing individuals providing care to understand their training needs, to using big data to understand health inequalities.

One area of care we know is of great importance to patients and families is communication: what they are told, the manner in which they are told, and very often what they are not told. Evidence shows that having conversations about the end of life, before the end of life, can be beneficial in terms of satisfaction with care and compliance with patients’ wishes. However, we know these conversations happen infrequently, are poorly conducted and are a frequent common complaint around end of life care in the UK.  This is not acceptable.

To address this, there has been an increasing focus on supporting staff to have these potentially difficult conversations through communication skills training interventions. However, our review of existing research around end of life care communication skills training showed that we’re still not sure what the most effective training model is. Moreover, many of the communication skills training we see delivered in practice have not been formally evaluated in any way – we don’t know if they really make a difference.

We were therefore excited to have the opportunity to collaborate with the team at Difficult Conversations evaluate their training workshops. This would help the team understand what was working well, where there were areas for improvement, and think about what methods they could use in the future if they wanted to conduct a trial testing their training.

As a first step, we conducted a service evaluation where we analysed existing information the Difficult Conversations had collected from course participants over the last couple of years. This included qualified or trainee general practitioners (34%), community nurses and care coordinators (32%), social care professionals (7%), care home staff (6%), advanced practice/specialist nurses (5%), care workers (5%) and allied health professionals (3%).

From over 500 participants’ self-rated confidence, knowledge and skills before and after the workshop, we could see that there was a significant improvement across these areas immediately after the workshop (Figure 1). Free text comments from over 600 participants identified that participants valued role play, the communication framework acronym ‘SCARS’, and opportunities for discussion. They commended workshop facilitators’ skills, the safe atmosphere and inter-professional learning, but suggested there could be improvements in terms of having more prepared role play and greater coverage of the taught topics.

There are many things this data can’t tell us – for example it doesn’t tell us whether these effects lasted after the workshops, and whether participants changed the way they communicated with patients and families and if this led to more favourable patients and family outcomes.  However, it is a great starting point in terms of showing that this is an acceptable intervention to participants, and hints at the mechanisms that may be contributing to change (e.g. role play, the SCARS framework, and group discussions).

Since this service evaluation, we have been collecting data from workshop participants and facilitators, with a slightly longer follow-up, in order to map out in more detail the potential mechanisms of action within this communication skills training intervention. This will help us to inform evaluation using a more rigorous design (for example, a randomised trial), and share learning with others working to improve communication in palliative and end of life care. We have also developed a suite of e-learning sessions to complement and build on the training workshops. These e-learning sessions focus on improving knowledge around advance care planning, legal issues, grief and bereavement, culture and ethnicity, and those living with dementia. We look forward to feeding back our findings and progress on these pieces of work soon.

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By Lisa Jane Brighton (Research assistant) and Dr Jonathan Koffman (Reader in Palliative Care), Cicely Saunders Institute of Palliative Care, Policy, and Rehabilitation, King’s College London.

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