Communication skills training for health professionals working with cancer patients
Submitting InstitutionUniversity of Sussex
Unit of AssessmentPsychology, Psychiatry and Neuroscience
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Nursing, Public Health and Health Services
Summary of the impact
Fallowfield designed, ran and demonstrated the long-term effectiveness of
a comprehensive three-day training programme that significantly improved
cancer doctors' communication skills. Publications from a major randomised
trial showed that improvements transferred into the clinical setting and
were enduring. These findings were pivotal and led to key components of
courses being embedded in a Department of Health initiative called Connected;
this trained facilitators, and provided materials for training all
health-care professionals (HCPs). Attendance at Connected courses
became mandatory for all consultant staff. Over 16,000 UK HCPs have
participated since 2008.
Communication is a core clinical skill. Poor or insufficient training of
HCPs in communication skills has several negative effects for staff and
patients alike [see Section 3, R1]. These include stress, lack of job
satisfaction and burn-out in health-care professionals. Poor communication
may also lead to increased levels of patient dissatisfaction and anxiety,
confusion about the significance of a diagnosis and its prognosis,
questionable consent to diagnostic and therapeutic procedures and
decreased treatment adherence. Recognition of these issues underpinned a
commitment in the NHS Cancer Plan to make advanced communication skills a
part of continuing professional development.
Some used to doubt that communications skills could be taught and assumed
that HCPs were intrinsically either good or bad communicators. Most
medical training also relied heavily on an apprenticeship model of
learning — namely, watching senior colleagues and mimicking their variable
behaviours with patients. However, pioneers in adult-learning theory such
as Rogers, Knowles and Friere demonstrated that more appropriate
educational interventions could enhance any individual's skills, and
Lipkin showed that this could be applied to general communication in
medicine. In the 1990s, Fallowfield developed an innovative
communication-skills training programme aimed specifically at doctors and
nurses working in cancer medicine. This training model is learner-centred
and integrates exercises and activities designed to create simultaneous,
in contrast to sequential, skills development, knowledge acquisition and
personal awareness of how these factors impact upon both clinician and
Following Fallowfield's arrival at Sussex in 2001, she completed the
analysis of, and then published, a major randomised controlled trial (RCT)
conducted in 34 UK cancer centres with 160 oncologists and >3,000
cancer patients [R2]. This RCT evaluated the effectiveness of her three-
day training programme and provided clear evidence that it resulted in
positive behavioural changes amongst oncologists three months after
training. Most notably, oncologists used fewer leading questions, had
higher rates of use of focused and open questions, showed increased levels
of empathy and responded more appropriately to patients' cues. The
behavioural data were obtained from video-recordings of consultations with
real patients and were reliably coded by independent observers.
Subsequent analyses and publications showed that most of these benefits
were still observable at 12-month follow-up (i.e. 15 months post-training)
and that, as these earlier skills became embedded into the doctors'
repertoires, further skills emerged — such as an increased ability to
summarise information, and not interrupting patients [R3]. No previous
research had ever demonstrated transfer into a clinical setting or the
long-term efficacy of training. Most work relied on pre- and immediate
post-course changes, self-evaluated and/or using patient simulators rather
than real patients. The measured improvements in communication skills
shown following participation in Fallowfield's courses were mirrored by
more favourable self-reported beliefs and psychosocial attitudes among
physicians [R4]. For example, trained physicians were more likely to agree
that considering patients' psychosocial concerns alongside their organic
problems was important. Two systematic reviews have concluded that
Fallowfield's research is one of only three adequate evaluations of
communication-skills training courses out of >50 published studies [R5,
References to the research
R2 Fallowfield, L., Jenkins, V., Farewell, V., Saul, J., Duffy, A.
and Eves, R. (2002) `Efficacy of a Cancer Research UK communication skills
training model for oncologists: a randomized controlled trial', The
Lancet, 359(9307): 650-656.
R3 Fallowfield, L., Jenkins, V., Farewell, V. and Solis-Trapala,
I. (2003) `Enduring impact of communication skills training: results of
12-month follow-up', British Journal of Cancer, 89(8): 1445-1449 .
R5 Gysels, M., Richardson, A. and Higginson, I.J. (2005)
`Communication training for health professionals who care for patients
with cancer: a systematic review of training methods', Supportive Care
in Cancer, 13(6): 356-366.
R6 Moore, P.M., Wilkinson, S.M. and Mercado, S.R. (2009)
`Communication skills training for health care professionals working with
cancer patients, their families and/or carers', The Cochrane Library:
Outputs can be provided by the University on request.
Details of the impact
The NHS Cancer Plan [see Section 5, C1] noted that
...some patients say they receive excellent care, with sensitive and
thoughtful communication, clear information about their disease and its
treatment, and good support when it is needed. Others report being given
bad news in a deeply insensitive way, being left in the dark about their
condition and badly informed about their treatment and care.
The Plan proposed that all hospital consultants working in cancer would
have to demonstrate competence in communication with patients and that
advanced communication-skills training would form part of their continuing
professional development. This was subsequently reinforced by NICE
guidelines which proposed that accredited training courses should be made
available for all health professionals working with cancer patients [C2].
On the strength of the RCT validating Fallowfield's training course [see
Section 3, R2, R3], many of the teaching components designed by
Fallowfield became incorporated into Connected [C3], a national
communication-skills training course for cancer clinicians that was
launched in 2008. The scheme uses a cascade model in which
communication-skills facilitators are initially trained at Cancer Network
level to deliver the Connected workshops to HCPs [C4]. Completion
of this training package and the associated workshops has been mandatory
for all clinicians working with cancer patients from 2008-2013. Over that
period more than 16,600 health professionals from 48 Cancer Networks in
the UK have participated [C5]. Essential elements of the three-day
workshops are that they are learner-centred and involve role-play with
trained actors (patient simulators) taking the role of patients and
carers. Participants are also provided with feedback on their performance.
Course evaluation data indicated that 95 per cent of attendees said the
course met their training needs and 84 per cent said they would definitely
recommend the course to a colleague [C5]. Fallowfield is acknowledged as
one of the authors of the Participant Handbook that accompanies
the workshops, and her work is extensively referenced in the Appendices on
supporting evidence and further reading [C4].
As a result of the international recognition of Fallowfield's work,
similar training programmes are being implemented in Europe and elsewhere.
For example, in Switzerland, communication-skills training for medical
oncologists was made compulsory in 2006, in large part because of the
findings described in R2 above [C7]. In Australia, a large programme of
communication-skills training has been implemented, involving many
hundreds of health-care professionals. Fallowfield was directly involved
in initial training, again as a result of her international research
profile in the area and her publications [R1, R2, R3, R4), demonstrating
the benefit of such programmes to both patients and health-care
Sources to corroborate the impact
C1 Department of Health (2000) The NHS Cancer plan.
C2 National Institute for Clinical Excellence (2004) Improving
Supportive and Palliative Care for Adults with Cancer. London: NICE.
C3 Connected website link at: https://www.connectedonlinebookings.co.uk.
The `Evidence' tab acknowledges the input of Fallowfield in the design and
implementation of the package and also cites the references in Section 3
as part of the supporting evidence base.
C4 Connected Handbook: Advanced Communication Skills.
Participant Handbook published by National Cancer Action Team.
C5 Connected Final Report published by National Cancer
C6 Testimonial from Consultant Medical Oncologist and Lead Cancer
Clinician at the Whittington NHS Trust. She was national clinical lead on
the Expert Advisory Group overseeing Connected, has run many
training workshops herself after being trained as a communication-skills
facilitator by Fallowfield, and has written a short testimonial about
Lesley Fallowfield's contribution to Connected. It includes the
Lesley's work was integral to the development of Connected© and many of
her original course materials were donated to the Connected© programme.
C7 Testimonial from Professor at Universitätsspital Basel who is a
senior medical oncologist, involved in the implementation of
communication-skills training in Switzerland since the 1990s. He is senior
author on position papers on this topic published in Annals of
Oncology in 1999 and 2009. His testimonial includes the following
The publication of the Lancet paper in 2002 (Fallowfield, L., Jenkins,
V., Farewell, V., Saul, J., Duffy, A. and Eves, R. (2002) `Efficacy of a
Cancer Research UK communication skills training model for oncologists: a
randomised controlled trial', The Lancet, 359(9307): 650-656) was
extremely helpful in making CST mandatory for every medical oncologist in
Switzerland since 2006.
C8 Testimonial from Senior Principal Research Fellow of NHMRC and
Co-Director of the Centre for Medical Psychology and Evidence-Based
Decision-Making. University of Sydney.