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Communication skills training for healthcare professionals working with people who have cancer

  1. Philippa M Moore1,*,
  2. Solange Rivera Mercado1,
  3. Mónica Grez Artigues1,
  4. Theresa A Lawrie2

Editorial Group: Cochrane Gynaecological, Neuro-oncology and Orphan Cancer Group

Published Online: 28 MAR 2013

DOI: 10.1002/14651858.CD003751.pub3


How to Cite

Moore PM, Rivera Mercado S, Grez Artigues M, Lawrie TA. Communication skills training for healthcare professionals working with people who have cancer. Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD003751. DOI: 10.1002/14651858.CD003751.pub3.

Author Information

  1. 1

    P. Universidad Catolica de Chile, Family Medicine, Santiago, Chile

  2. 2

    Royal United Hospital, Cochrane Gynaecological, Neuro-oncology and Orphan Cancer Group, Bath, UK

*Philippa M Moore, Family Medicine, P. Universidad Catolica de Chile, Lira 44, Santiago, Chile. moore.philippa@gmail.com.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 28 MAR 2013

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Characteristics of included studies [ordered by study ID]

MethodsRCT.


Participants30 medical and radiation oncologists from 6 Australian teaching hospitals: Age = 36.5 to 51 years; years of experience = 7.5 to 24.3 years.

343 cancer patients (60% women) answered questionnaires post-consultation.


Interventions1.5 day work-shop with 3 to 6 participants, followed by four 1.5 hour video conferences incorporating role-play of doctor-generated scenarios. Work shop included DVD modelling ideal behaviour; role-play and feedback with an SP using standardised cases and from own experience, booklet summarising evidence, video of own role-play. Emphasis on how to establish a collaborative framework, and how to respond to anxiety, depression, distress and anger.


OutcomesHCP (oncologist) outcomes on video of SP interview at baseline, immediately post-intervention and 6 months post-intervention (or equivalent timings for control group).

  • Communication skills (2 major categories: creating environment and responding to specific emotions) in SP encounters immediately and 6 months post-intervention.


HCP (oncologist) Burnout' measured using MBI*

Patient outcomes:

  • QOL (EORTC QLQ C30)*, Anxiety and Depression (HADS*) and perceived needs (SCNS*) measured by telephone interview 1 week and 3 months post-consultation.


NotesThere was a trend for training to be successful in increasing some HCP communication skills, however, no changes were statistically significant.

Anxiety was reduced in patients interviewed by oncologists from the intervention group one week later (P = 0.021) No other statistically significant differences were found in patient outcomes.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandomised at individual level using random number tables and Excel software.

Allocation concealment (selection bias)Low riskAllocated centrally by research team.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot described.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNo description of total number of HCP measured post-intervention. Low attrition in HCP and patient questionnaires.

Selective reporting (reporting bias)Low riskAll prespecified outcomes reported.

Other biasLow riskBaseline characteristics of the two groups were similar.


MethodsRCT.

Written feedback followed by course, or course alone, or written feedback alone, or control.


Participants160 medical, surgical and radiation oncologists from 34 cancer centres in the UK; 69% men.

640 cancer patients (60% women) participated in the videotaped consultations (2 video-tapes per oncologist at baseline and 3 months post-intervention).

2331 cancer patients answered questionnaires.


InterventionsCancer Research UK Communication Skills Program. Intensive 3-day residential course and/or feedback pack.


OutcomesHCP (oncologist) outcomes on video of RP interviews at baseline, and 3 months post-intervention (or equivalent timings for control group).:

  • Communication skills as assessed in 2 videotapes per oncologist of RP encounters, before and 3 months post-intervention, rated using MIPS*;
  • Attitudes and beliefs 3 months post-intervention, rated using PPSB*.


Patient outcomes:

  • Patient satisfaction with communication (PSCQ*) measured immediately after consultation with oncologist pre- and 3 months post-intervention.


NotesCST group had a statistically significant improvement in oncologists' attitudes to psychosocial issues (P = 0.002) and a non-significant positive effect on patient satisfaction. Follow-up for 12 months revealed no demonstrable attrition in most of the skills improvement, some new skills, but a decline in expressions of empathy.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot fully described.

Allocation concealment (selection bias)Unclear riskNot described.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskVideo raters blinded as far as possible for time-point of assessment and group.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskLow risk on HCP behaviour outcomes; 21% attrition for patient outcomes; only intervention group followed up at 12 months.

Selective reporting (reporting bias)Low riskAll prespecified outcomes were described.

Other biasLow riskBaseline characteristics of two groups were similar.


MethodsRCT conducted in Japan.


Participants30 oncologists


InterventionsA 2-day CST workshop (intervention) or 'no CST' (control).


OutcomesHCP outcomes:

  • Communication skills measured in SP encounters


  • Self-perception of self-confidence.


Patient outcomes:

  • Distress;
  • Satisfaction with doctor's communication and consultation.


Assessed at baseline, post-CST or one-week later.


NotesOnly the abstract, which contained no data, was available at the time of publication. The abstract reports that skills relating to emotional support and information-giving were higher in the intervention compared with the control group, patient distress scores were lower, and patient satisfaction scores were similar at the follow-up assessment.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk'Randomly assigned'.

Allocation concealment (selection bias)Unclear riskNot described.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot described.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNot described.

Selective reporting (reporting bias)Unclear riskOnly a conference abstract available. No data reported.

Other biasUnclear riskAttempts to contact the authors for data were unsuccessful.


MethodsRCT.


Participants80 participants of 4 radiotherapy teams comprising secretaries (16%), physicists (7.5%), nurses (49%), doctors (27.5 %).


Interventions38 hours of CST; not described in detail.


OutcomesHCP communication skills rated using the scale LaComm* on audio of simulated breast cancer patient (SP) interview at baseline and post-intervention (or equivalent timings for control group).


NotesFor some communication skill outcomes, course attendees (intervention group) had significantly more appropriate behaviours/skills than those who had not attended; these included a team orientated focus (P = 0.023), empathy (P = 0.037) and emotional words (P = 0.030).


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot described.

Allocation concealment (selection bias)Unclear riskNot described.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot described.

Incomplete outcome data (attrition bias)
All outcomes
Low risk83% follow-up.

Selective reporting (reporting bias)Unclear riskNo details of data extracted using LaComm*.

Other biasHigh riskSome differences in baseline characteristics of two groups including work experience in oncology, full-time occupation, and % of non-professionals.


MethodsRCT conducted from June 2007 - Feb 2009.


Participants41 doctors (39 from Department of Haematology/Oncology, one from Gynaecology, one from Surgery).


InterventionsCST in the form of COM-ON-p(COMmunication challenges in ONcology related to the transition to palliative care training program), including a one hour pre-assessment with SPs, an 11-hour training course (main focus practice with SPs using cases of participants) plus a half-hour individual coaching session two weeks later. The courses were run in groups of 8/9 participants by two experienced facilitators.


OutcomesHCP (Doctors') communication skills in video-recorded SP consultations pre-intervention and five weeks post-intervention using COM-ON-checklist included:

  • " specific skills for palliative care",
  • "general communication skills",
  • "involvement of significant other",
  • 2 global scores on "global communication skills" and "global involvement of significant other".


NotesThe average overall estimate of effect favoured the intervention group (P=0.0007). There was a statistically significant difference between intervention and control group in all sections in favour of the intervention group including: specific palliative communication skills (P<0.0026); general communication skills (P<0.0078); and involvement of significant others (P<0.0.0051).


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer-generated randomisation to two groups in blocks of 8 by an 'external statistician'.

Allocation concealment (selection bias)Unclear riskAllocation by fax.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessors blinded to group allocation.

Incomplete outcome data (attrition bias)
All outcomes
Low risk100% follow-up.

Selective reporting (reporting bias)Low riskAll pre-specified outcomes reported.

Other biasHigh riskDoctors in the intervention group had significantly more professional (P = 0.02) experience compared with those in the control group.


MethodsRCT.


Participants61 UK nurses all of who received basic 3-day CST training prior to randomisation: 68% working in palliative care; mean age 42 years; all but one female; 41% worked in community only, 21% hospital only, 38% hospital and community

366 RP encounters (75% women, mean age 61years)


InterventionsFour 3-hour supervision sessions plus feedback on video of interview with RPs.

Both intervention and control groups had basic training prior to baseline.


OutcomesHCP (nurses') communication skills assessed in audio-recording of 3-RP interviews at 1 and 3 months post-intervention, rated using MIARS:

  • 10 key interviewing skills,
  • psychological exploration,
  • overall communication profile.


NotesSome communication behaviours were enhanced in the intervention group after supervision, including psychological exploration (P = 0.039).


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot described.

Allocation concealment (selection bias)Unclear riskNot described.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskData collectors and judges were blinded to time and group.

Incomplete outcome data (attrition bias)
All outcomes
Low risk84% follow-up at 3 months.

Selective reporting (reporting bias)Low riskAll pre-specified outcomes were reported.

Other biasLow riskBaseline characteristics of two groups were similar except the control group had more communication skills training (P = 0.037).


MethodsRCT.


Participants53 nurses from 11 wards in 3 Dutch hospitals: mean age was 32 years, 83% women; mean of 5 years' experience in oncology.

265 recently diagnosed cancer patients admitted for treatment.

106 patient encounters (55% women, mean age 55 years).


InterventionsSix 3-hour sessions with 10-15 participants run by two trainers with experience in clinical patient care. CST included theory, demonstration of skills, and feedback on role-playing.


OutcomesHCP (nurses') communication skills assessed on video recordings of SP interviews (one month post-intervention) and 5 RP admission interviews between 1-7 months post-intervention using RIAS*:

  • Instrumental communication (information collecting and giving)'
  • affective communication (psychosocial and emotional topics).


Nurses' 'burnout' was measured using MBI.

Patients outcomes:

  • Satisfaction with care (PSQ-C)*; quality of life (EORTC QLQ-C30)* were measured after the video taped interview, at discharge and 3 months after discharge.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk53 participants " randomised at ward level".

Allocation concealment (selection bias)Unclear riskNot described.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskIndependent rater but blinded status not described.

Incomplete outcome data (attrition bias)
All outcomes
Low risk83% to 86% follow-up.

Selective reporting (reporting bias)Low riskAll pre-specified outcomes were reported.

Other biasLow riskBaseline characteristics of two groups were similar.


MethodsRCT.


Participants113 Belgian residents who had been, or were, working with cancer patients.

759 hospitalised patients answered questionnaires.

88 patient encounters analysed (56% women;.mean age 55 years).


Interventions40-hour training programme (17 hours on two-person interview skills, 10 hours on three-person interviews, 10 hours on stress management, 3 hours on integration of skills) bimonthly over an 8-month period. Small groups (maximum 7 participants). Comprised a one-hour theoretical session, role-plays of pre-defined cases, and cases from participants with immediate feedback.


OutcomesHCP (residents) communication skills were analysed in audiotapes of 1 SP encounter and 1 RP interview during a clinical round pre- and post-intervention or at 8 months (control group) using LaComm*:

  • type of question,
  • supportiveness,
  • information giving and negotiation.


Also time spent on the 3 phases of breaking bad news and precision of the delivery of diagnosis.

Residents' burnout was measured pre- and post-intervention using MBI.

Residents' physiological arousal was measured during the SP interviews.

Patient outcomes:

  • Satisfaction was measured on a three-item questionnaire using a visual analogue scale patients seen on a half-day clinical round per resident, pre- and post-intervention (mean of 4.5 patients per round).


NotesStatistically significant improvement was found in 2 of 12 items of HCP skills with RPs. No effect on empathy or supportive skills in RPs. Significant increase in open questions, empathy, and concise precise diagnoses in SPs, but significant decrease in other information with SP.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer-generated.

Allocation concealment (selection bias)Unclear riskNot described.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskAssessor blinded to time assessment and group allocation

Incomplete outcome data (attrition bias)
All outcomes
High riskTrained residents took part in an average of 25 hours (62%) of a training program (range 8-40 hours). 77% follow-up in RPs; 86% follow-up in SPs.

Selective reporting (reporting bias)Unclear riskSubgroup analysis of % training attendance.

Other biasHigh riskSelection of interview for HCP communication analysis unclear. Number of patients with cancer : < 40% of patient interviews analysed and numbers are unclear in 'patient satisfaction' outcome.


MethodsRCT.


Participants72 oncology nurses from 4 hospitals in France and Belgium participated.


Interventions24-hour training program taught in 8 weekly, 3-hour sessions.


OutcomesHCP (nurses') communication skills in first 5 minutes of video-taped SP interviews, pre- and 2 months post-training, rated using CRCWEM* (Cancer Research Campaign Workshop Evaluation Manual);

  • Information collecting skills,
  • creating relationship skills,
  • structure,
  • control of session.


Nurses' attitudes (SDAQ*), occupational stress (NSS*) and self-perception.


NotesTrained group were assessed as 'more in control of the interview' than the untrained group during the follow-up interview (P = 0.02).


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskTwelve participants per institution were "randomly assigned" to two groups.

Allocation concealment (selection bias)Low riskAllocation by sealed envelopes.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskVideo raters blinded for group; questionnaire assessors not blinded.

Incomplete outcome data (attrition bias)
All outcomes
Low riskLow attrition rates: one drop out, three incomplete data sets out of 72 participants.

Selective reporting (reporting bias)Low riskAll pre-specified outcomes were reported.

Other biasLow riskBaseline characteristics of two groups were similar.


MethodsRCT.


Participants115 oncology nurses from 33 hospitals in Belgium.

114 cancer patients during first week of hospitalisation.


Interventions105-hour communications skills workshop with 10 participants, run by psychologist, taught over 3 months for one week per month.


OutcomesHCP (nurses') communication skills in video-taped SP interviews and audio-taped RP interviews pre- and post-intervention (or equivalent timings for control group), and three months later rated using CRCWEM* (Cancer Research Campaign Workshop Evaluation Manual), plus dictionaries (HPSD* and MRID*) and LACOMM*

  • collecting information,
  • creating relationships, including empathy and depth of emotional words.


Nurses' Stress (NSS*) and Attitudes (SDAQ*).

Patient outcomes:

  • expression of affect (CRCWEM*),
  • quality of life,
  • satisfaction with interview (PSIAQ).


NotesPatients interviewed by trained nurses also used more emotional words associated with 'distress' than did those seen by untrained nurses (P = 0.005). There was a positive training effect on patient satisfaction (P < 0.01).


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskRandomisation was performed every time there were 20 nurses enrolled.

Allocation concealment (selection bias)High riskRandomisation was performed every time there were 20 nurses enrolled.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskRaters blinded by time and group.

Incomplete outcome data (attrition bias)
All outcomes
Low risk86% follow-up for HCP behavioural outcome.

Selective reporting (reporting bias)Low riskAll pre-specified outcomes were reported.

Other biasLow riskBaseline characteristics were similar in both groups.


MethodsRCT of follow-up consolidation sessions after both groups had basic training.


Participants63 physicians (62% oncologists) from Belgium hospitals, age 43+/-7, 55% men, with average 14 years of experience in oncology and 43% no prior CST. All had participated in a 19-hour CST workshop (consisting of two, 8-hour/day sessions and one, 3-hour evening session).

59 cancer patients, undergoing a 'breaking news' interview (67% women mean age 58 years).

53 cancer patients (65% women mean age 60 years) in encounters with relatives (48% women mean age 57 years).


InterventionsSix, 3-hour per evening, bimonthly, consolidation sessions over three months.


OutcomesHCP (doctors) outcomes:

  • Communication skills: assessment skills (collecting information), information (giving) skills and supportive skills (empathy and emotional depth) were measured in audio-taped SP 'breaking bad news' interviews and video-taped RP interviews, rated using CRCWEM* before basic training and 5 months after training. Some interviews with accompanying significant other.
  • Ability to detect distress (10-point visual analogue scale).


Patient outcomes:

  • anxiety (STAI)*,
  • anxiety and depression (HADS)*,
  • perception of interview (PIQ)*.


Significant other outcomes:

  • anxiety (STAI)*,
  • anxiety and depression (HADS)*.


NotesThere was no effect of consolidation workshops on doctors' ability to detect patient distress.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk72 participants "randomly assigned".

Allocation concealment (selection bias)Unclear riskNot described.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskRaters blinded for time (pre/post) and group.

Incomplete outcome data (attrition bias)
All outcomes
Unclear risk81% follow-up for SP and RP; and 77% follow-up for RP interview with significant other.

Selective reporting (reporting bias)Low riskAll pre-specified outcomes were reported.

Other biasLow riskBaseline characteristics of the two HCP groups were similar.

Baseline scores of patient anxiety were markedly higher in patients seen by the control group.


MethodsRCT.


Participants51 doctors (18 oncologists, 17 family doctors and 16 surgeons) from 3 towns in Canada.

102 cancer patients who attended outpatient clinics of oncologists and surgeons.


Interventions6-hour intensive CST course including literature, physicians and patients perspectives, video modelling poor and better behaviour, role-play, video and feedback with SP using standardized cases. Emphasis on exploring patients perspectives.

Control group received the standard 2hr small group discussion triggered by video of interview between physician and breast cancer standardised patient.


OutcomesHCP (doctors) communication skills in video-taped SP interviews at baseline and after intervention. Rated using PCCM*:

  • overall estimate of effect,
  • 7 subscores including validation of patient-expressed experiences, expression of support, building relationships, sharing information, control and mastering whole person experience.


Patient outcomes (measured only for surgeons and oncologists in both groups):

  • patient distress (BSI*),
  • perception of interview (CDIS*; PPPC*),
  • a single item ('Feel better?').


NotesTraining had a positive impact on patients' satisfaction (P = 0.03) and "feeling better" (P = 0.02).


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandom number table.

Allocation concealment (selection bias)Low riskRandomized done by project co-ordinator.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskRaters and patients were blinded.

Incomplete outcome data (attrition bias)
All outcomes
Low risk100% for HCP behaviour outcome; 44.3% patient response rate to patient questionnaire.

Selective reporting (reporting bias)Low riskSubgroup analysis (family physicians) on selected outcomes.

Other biasLow risk


MethodsSingle-blind RCT. Stratified by site, gender and oncologist speciality.


Participants48 oncologists (medical, gynaecological and radiation), all of whom received a one hour lecture on communication skills.

264 patients with advanced cancer (65% women mean age 60 years).


InterventionsComputerised intervention (interactive CD-ROM) organised in five 15-minute modules and included principles of effective communication, recognising and responding to empathic opportunities, conveying prognosis and answering difficult questions. Included tailored feedback from oncologists' own recorded conversations.


OutcomesHCP (oncologists) outcomes:

  • communication skills (empathic statements and empathetic response to patient expression of emotions) in audiotaped RP encounters at one month post-intervention.


Patient outcomes (measured one week after the encounter by telephone survey):

  • trust; perception of doctors' communication skills (empathy, knowledge of patient, therapeutic alliance).


NotesCST aimed to influence a limited number of skills. Median time of training program = 64 minutes (58-99).


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskBalanced randomisation in a 1:1 ratio by site, sex and speciality. Statistician performed minimisation method of randomisation to ensure balanced groups.

Allocation concealment (selection bias)Low riskStatistician revealed the randomisation results only to project co-ordinator and principal investigators.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskSingle-blind. Patients were blinded to their oncologists' group allocation, as were the two audio-coders.

Incomplete outcome data (attrition bias)
All outcomes
Low risk21/24 used CD-ROM in intervention, but all included in evaluation. 4/264 encounters could not be assessed due to technical problems. Overall missing data < 20%.

Selective reporting (reporting bias)Low riskAll pre-specified outcomes were reported.

Other biasLow riskBaseline characteristics comparable except for fewer Caucasian doctors in the intervention group (76% vs 92%). Unclear if scales/questionnaires used were validated.


MethodsRCT conducted in inpatients.


Participants48 hospital nurses providing patient education about chemotherapy;

210 older cancer patients receiving chemotherapy (35% women, mean age 72 years)


InterventionsIndividualised web-based video feedback; a 1-day CST conducted in groups of 6-11 nurses focusing on patient education about chemotherapy; observation and feedback of colleagues interviews; and a half-day follow-up session and booklet.


OutcomesHCP (nurses) outcomes:

  • communication skills (67 communication aspects in seven dimensions) coded from video-recordings of RP interviews pre- and post-intervention, rated by QUOTE*.


Patient outcomes:

  • recall of information immediately post-intervention.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot described.

Allocation concealment (selection bias)Unclear riskNot described.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskIndependent observers of videos were blinded to group.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNo description of the number of nurses who participated in the videos analysed post-treatment.

Selective reporting (reporting bias)Low riskAll 7 dimensions of communication reported.

Other biasLow riskBaseline characteristics comparable.


MethodsMulti-centre RCT.


Participants160 nurses (94% women) from hospices (60%) and community (30%) in UK.

312 cancer patients (85% women, mean age 32 years)


InterventionsA 3-day course for max. 12 participants run by 2 co-facilitators. Course included literature, nurses perspectives, video-modelling ideal behaviour, audio recording with RPs and role-play with SPs using standardised and participant cases, both with feedback. Emphasis on exploring nurses individual difficulties.


OutcomesHCP (nurses) outcomes (coded from audio-tapes of RP admittance interviews and 12 weeks' post-intervention; rated using CSRS*):

  • communication skills (structure, facilitating behaviours, blocking behaviours, depth of assessment),
  • interview content (physical and psychosocial assessment of patient).


Patient outcomes:

  • anxiety (STAI-s)*
  • general health (GHQ-12)*,
  • satisfaction (PSCQ)*.


NotesTendency to improve patient satisfaction and general health. No statistical difference in mean change of patients' anxiety.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandomisation using computer-generated numbers.

Allocation concealment (selection bias)Low riskStatistician performed randomisation before the study commenced and kept the results in sealed envelopes in the central research department.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskRaters blinded.

Incomplete outcome data (attrition bias)
All outcomes
Unclear risk90% follow-up but missing data stated.

Selective reporting (reporting bias)Low riskAll pre-specified outcomes described.

Other biasHigh riskHigher professional grades in control group.

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Acher 2004Not an RCT, no objective behavioural outcome measurement.

Ades 2001Not an RCT. No CST.

Alexander 2006Not an RCT. Case-control study of a course to improve residents' communication skills with patients at end of life.

Anderson 1982Not an RCT. No controls, post-CST course measurement only.

Andrew 1998Not an RCT. Qualitative study of CST in palliative care.

Arranz 2005Not an RCT. Post-intervention assessment counselling course for nurses. No objective measurements of skills.

Arrighi 2010Not an RCT. Exploratory study conducted in patients not HCPs.

Back 2005Not an RCT. Questionaire survey of bereaved relatives.

Back 2007Not an RCT. Pre-post cohort study of a 4-day residential workshop in oncology fellows with objective measurements of HCP behaviour.

Baile 1997Not an RCT. Pre-post cohort study of a 3-day CST. Only subjective measurement of behavioural change reported.

Baile 1999Not an RCT. Pre-post cohort study of a 2.5-day CST. Only subjective measurement of behavioural change reported.

Berman 1983Not an RCT. Post-study subjective measurement of behavioural change of an annual seminar for interns on caring for dying patients.

Bernard 2010Not an RCT. Case-control study of a course for medical oncologists and nurses with pre-post measurements of HCP skills and defence mechanisms.

Bird 1993Not an RCT. Post-study subjective measurement of behavioural change of 2.5-day residential workshop.

Booth 1996Not a RCT. Pre-post cohort study of a 6-session CST course for hospice nurses measuring HCP skills in audio-taped interviews.

Brown 1999An RCT of CST in ambulatory care, not in cancer care. No objective measure of HCP skills.

Brown 2007Not an RCT. A course of communication skills training for oncologists involved in conducting clinical trials in oncology. Training was aimed at improving patient understanding and acceptance of clinical trials.

Brown 2011Not an RCT. Study of oncologists communication during interviews when recruiting patients for Phase 1 trials.

Brown 2012HCP communication skills were not assessed.

Burgess 2008Not an RCT.

Bylund 2010Not an RCT. Pre-post study of CST course for oncologists.

Bylund 2011aNot an RCT.Description of implementation of CST curriculum and impressions of participants.

Bylund 2011bNot an RCT. Before-after assessment of a non-controlled study of CST for patients.

Cantwell 1997A qualitative study of junior doctors opinion of undergraduate communication skills in relation to patients with cancer.

Caps 2010Not an RCT.

Chandawarkar 2011Not an RCT. Pre-post assessment using simulated patients of CST for surgical residents.

Charlton 1993Not an RCT.

Clark 2009An RCT of patients with cancer receiving patient-centred care or usual care.

Claxton 2011An RCT of email education for residents about palliative care. Not specifically communication skills. No objective measurement of skills reported.

Connolly 2010Not an RCT. Post course measurement of "Sage and Thyme" communication course. No objective measurement of skills reported.

Cort 2009RCT studying the effect of a course on cognitive behaviour therapy. No objective measurement of behavioural change reported.

Cowan 1997Not an RCT. Measured changes in attitudes/knowledge, not behaviour. No separate control group.

Craytor 1978Not an RCT. Measured changes in attitudes/knowledge, not behaviour. No separate control group.

Crit 2006Not an RCT.

de Bie 2011Not communication skills training. Trial involved training patients to reduce anxiety prior to colonoscopy.

de Rond 2000Quasi-RCT on training nurses about pain management. Only subjective measurement of behavioural change.

Del 2009Not an RCT. Qualitative study of how experienced doctors give good and bad news.

Delvaux 1997Not an RCT. Psychological training programme.

Dixon 2001Not an RCT. Pre-post study of 12 week distance education for nurses working in breast cancer care. Only subjective measurement of behavioural change reported.

Durgahee 1997Not an RCT. 5 years experience of reflection through story-telling for students of palliative care.

Fallowfield 1998Not an RCT. Cohort of 178 senior oncologists who assisted 1.5 or 3 day CST. Only subjective measurement of behavioural change reported.

Fallowfield 2001Not an RCT. Cohort of 129 nurses. Only subjective measurement of behavioural change reported.

Faulkner 1984Not an RCT. Cohort of 8 nurses working in cancer who assisted CST.

Faulkner 1992Not an RCT. Evaluation of training programmes for communication skills in palliative care.

Favre 2007Not an RCT. Pre-post defence mechanism assessment of CST for oncologists.

Ferrell 1998aNot an RCT. Pre-post assessment of HOPE course for HCP in palliative care. Only subjective measurement of behavioural change reported.

Ferrell 1998bNot an RCT. Pre-post assessment of HOPE course for HCP in palliative care. Only subjective measurement of behavioural change reported.

Fineberg 2005Not an RCT. Quasi experimental design with pre-post assessment of a course on family communication in palliative care for interdisciplinary students. Only subjective measurement of behavioural change reported.

Finset 2003Not an RCT. Pre-post assessment of CST for HCP. Only subjective measurement of behavioural change reported.

Fujimori 2003Not an RCT.Post course assessment of CST for oncologists. Only subjective measurement of behavioural change reported.

Fukui 2008RCT of CST for nurses in cancer care. No objective measurement of behavioural change reported. Patient outcomes were only measured in the intervention group, not in the control group.

Girgis 1997Not an RCT. Measured change in attitude/knowledge not skills, not behaviour.

Glimelius 1995Not an RCT.

Gordon 1995Not an RCT. Post course assessment of 2.5-day or 5-day course of CST. Only subjective measurement of behavioural change reported.

Gutheil 2005Not an RCT. Patients not HCPs trained in communication skills.

Hainsworth 1996RCT of a course for nurses on death education. Not specifically for nurses working in cancer care. Only subjective measurement of behavioural change reported.

Hall 1999Not an RCT.

Hallenbeck 1999Not an RCT. A questionnaire of interns before and after their rotation in palliative care.

Heaven 1996Not an RCT. A 10 week CST for hospice nurses with assessment of ability to elicit patient concerns.

Heaven 1996bNot an RCT. A 10-week CST for hospice nurses with assessment of abiltity to elicit patient concerns.

Hellbom 2001Not an RCT. Post course assessment of a 4-session CST course. Only subjective measurement of behavioural change reported.

Hietanen 2007Not an RCT. Case control study of a course on communication skills training for physicians involved in conducting clinical trials in oncology. Training was aimed at improving patient understanding and acceptance of clinical trials.

Hoffman 2002Not an RCT. Description of CST course for oncology residents and their views about the course.

Hulsman 1997Not an RCT. Pre-post assessment of a computer-assisted CST for doctors in cancer care. Only subjective measurement of behavioural change reported.

Hulsman 2002Not an RCT. Pre-post assessment of a computer assisted CST for doctors in cancer care using videotapes of real patient encounter.

Hundley 2008An RCT of a course of delivering bad news. Only subjective measurement of behavioural change reported.

Jefford 2011Not an RCT. Patients received care package.

Ke 2008An RCT of 50-minute CST lecture for nurses. Only subjective measurement of behavioural change reported.

Kinnane 2011Not an RCT. Study conducted in volunteers not HCPs.

Kruse 2003Not an RCT. Pre-post assessment of a comparison between 6-hour and 24-hour CST programs.

La Monica 1987Not an RCT. Study of 4-week session on responding to empathy.

Ladouceur 2003Not an RCT. Post course assessment of course of breaking bad news. Only subjective measurement of behavioural change reported.

Larbig 2009Not an RCT. On-line counselling for patients.

Lenzi 2011Not an RCT. Pre- and post-assessment of a 3-day CST workshop in a cohort of 57 Italian oncologists. Only subjective measurement of behavioural change reported.

Libert 2003Not an RCT. A cohort of physicians were assessed with regard to their communication skills.

Linder 1999Measured change in attitude/knowledge not skills, not behaviour.

Liu 2007Not an RCT. Quasi-experimental study of CST in nurses.

Lloyd-Williams 1996Not an RCT. Measured change in attitude/knowledge not skills, not behaviour.

Loiselle 2011Not an RCT.

Macauley 2011Not an RCT.

Madhavan 2011Not an RCT.

Maguire 1996aNot an RCT. Pre-post assessment of a 3-5-day course on key communication skills for HCP in cancer care. Measurement with simulated and real patient encounters.

Maguire 1996bNot an RCT. Similar to Maguire 1996a.

Martinez 2009Not an RCT, a survey of patient satisfaction with communication/information.

Matrone 1990Not an RCT.

Melo 2011Not an RCT. A case-control study of a course on communication, spiritual advice and death for HCP. Only subjective measurements of behaviour change and measurement of burnout.

O'Connor 2011Not an RCT. A survey of focus groups including pharmacists, nurses and doctors.

Parle 1997Not an RCT. Post-course assessment of a 3-day workshop on difficult situations. Only subjective assessment of behavioural change reported.

Pekmezaris 2011Not an RCT. Pre-post assessment of a course for residents about end of life care. Only subjective measurement of behavioural change are reported.

Pelayo 2011RCT of on-line course on palliative care. Only subjective measurement of behavioural change reported.

Pieterse 2006Not an RCT. Pre- and post-test study of CST for genetic counsellors.

Rask 2009RCT of a 33-hour CST course for nurses. No objective measurement of behaviour change reported. Assessment of patient perception of HCP's skills.

Razavi 1991Not an RCT. Study of a brief psychological training for HCP working with terminal cancer patients. Only subjective measurements of behaviour and attitude change reported.

Razavi 2000Not an RCT. Study comparing different simulated patients to measure behavioural change after CST.

Razavi 2009Not an RCT, a summary of research.

Rose 2008Not an RCT. A review of psycho-oncology interventions for patients with cancer.

Rosenbloom 2007RCT of an intervention for patients with cancer comparing nurse assessment of quality of life compared to normal care.

Roter 1995RCT of CST for primary care physicians. Study not primarily related to cancer care. Assessment using audio-tapes of encounters with distressed and non-distressed real and simulated patients.

Rushton 2006Not an RCT.

Rutter 1996Not an RCT.

Schulman-Green 2003Not an RCT. Qualitative study of how HCP learn about caring for the dying.

Shannon 2011Not an RCT. Post assessment study of a brief CST for nurses. Only subjective assessment of change reported.

Shields 2010An RCT of coaching for survivors of breast cancer.

Shipman 2008Not an RCT.

Shorr 2000Not an RCT. Cohort study of invention to help HCP discuss end of life issues with patients, not specifically limited to cancer care.

Smith 1991Not an RCT. Case-controlled study of a 1-month CST for residents. Only subjective measurement of change reported.

Smith 2010An RCT of an intervention comparing a pain/communication session to normal care for patients with cancer.

Street 2010RCT of CST training (tailored education-coaching) for patients with cancer.

Szmuilowicz 2010An RCT of CST in HCPs who did not work specifically in cancer care.

Timmermans 2006Not an RCT. Pre-post study of CST training for radiation oncologists. Assessment of oncologists and patient communication in audiotapes of real patient encounters.

Ullrich 2011Not an RCT. Pre-post quasi-RCT of CST for speech therapists. Only subjective measurement of change were reported.

Von Gunten 1998Not an RCT. Measured change in attitude/knowledge not skills, not behaviour.

Wetzel 2011RCT of training in stress management for surgeons, not communication training. Not limited to cancer care.

Wilkinson 1998Not an RCT. Cohort study with pre-post assessment of 26-hour CST (including knowledge, attitude and skills training) for nurses. Audiotaped patient encounters measured behavioural change.

Wilkinson 1999Not an RCT. Long-term follow-up of cohort study.

Wilkinson 2003Not an RCT. Cohort study with pre-post assessment of 3-day CST for nurses. Audiotaped patient encounters measured behavioural change.

Wong 2001Not an RCT. Post-assessment of a course on death education for nurses. Only subjective measurement of changes reported.

Wuensch 2011RCT of communication skills training for physicians involved in conducting clinical trials in oncology. Training was aimed at improving patient understanding and acceptance of clinical trials.

 
Comparison 1. CST vs no CST: HCP communication skills

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Used open questions5679Std. Mean Difference (IV, Random, 95% CI)0.28 [0.02, 0.54]

   1.1 Simulated patients
5422Std. Mean Difference (IV, Random, 95% CI)0.38 [-0.01, 0.76]

   1.2 Real patients
3257Std. Mean Difference (IV, Random, 95% CI)0.09 [-0.15, 0.34]

 2 Clarified and/or summarised3422Std. Mean Difference (IV, Random, 95% CI)0.09 [-0.30, 0.49]

   2.1 Simulated patients
3253Std. Mean Difference (IV, Random, 95% CI)0.32 [-0.18, 0.81]

   2.2 Real patients
2169Std. Mean Difference (IV, Random, 95% CI)-0.20 [-0.50, 0.11]

 3 Elicited concerns2191Std. Mean Difference (IV, Random, 95% CI)0.31 [-0.10, 0.72]

   3.1 Simulated patients
2133Std. Mean Difference (IV, Random, 95% CI)0.27 [-0.42, 0.95]

   3.2 Real patients
158Std. Mean Difference (IV, Random, 95% CI)0.40 [-0.12, 0.93]

 4 Showed empathy6727Std. Mean Difference (IV, Random, 95% CI)0.21 [0.07, 0.36]

   4.1 Simulated patients
5422Std. Mean Difference (IV, Random, 95% CI)0.26 [0.07, 0.45]

   4.2 Real patients
4305Std. Mean Difference (IV, Random, 95% CI)0.15 [-0.07, 0.38]

 5 Gave appropriate information2342Std. Mean Difference (IV, Random, 95% CI)-0.09 [-0.31, 0.12]

   5.1 Simulated patients
2173Std. Mean Difference (IV, Random, 95% CI)-0.16 [-0.46, 0.14]

   5.2 Real patients
2169Std. Mean Difference (IV, Random, 95% CI)-0.02 [-0.32, 0.28]

 6 Gave facts only5663Std. Mean Difference (IV, Random, 95% CI)-0.24 [-0.53, 0.05]

   6.1 Simulated patients
5406Std. Mean Difference (IV, Random, 95% CI)-0.42 [-0.77, -0.06]

   6.2 Real patients
3257Std. Mean Difference (IV, Random, 95% CI)0.05 [-0.19, 0.30]

 7 Negotiation3386Std. Mean Difference (IV, Random, 95% CI)0.16 [-0.08, 0.41]

   7.1 Simulated patients
3240Std. Mean Difference (IV, Random, 95% CI)0.13 [-0.12, 0.39]

   7.2 Real patients
2146Std. Mean Difference (IV, Random, 95% CI)0.23 [-0.45, 0.92]

 
Comparison 2. CST vs no CST: HCP communication skills: doctors only

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Used open questions2306Std. Mean Difference (IV, Random, 95% CI)0.27 [0.05, 0.50]

   1.1 Simulated patients
2160Std. Mean Difference (IV, Random, 95% CI)0.34 [0.03, 0.66]

   1.2 Real patients
2146Std. Mean Difference (IV, Random, 95% CI)0.20 [-0.13, 0.52]

 2 Clarified and/or summarised1Std. Mean Difference (IV, Random, 95% CI)Totals not selected

   2.1 Simulated patients
1Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

   2.2 Real patients
1Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 3 Elicited concerns1120Std. Mean Difference (IV, Random, 95% CI)0.15 [-0.33, 0.63]

   3.1 Simulated patients
162Std. Mean Difference (IV, Random, 95% CI)-0.09 [-0.58, 0.41]

   3.2 Real patients
158Std. Mean Difference (IV, Random, 95% CI)0.40 [-0.12, 0.93]

 4 Showed empathy3354Std. Mean Difference (IV, Random, 95% CI)0.22 [0.01, 0.43]

   4.1 Simulated patients
2160Std. Mean Difference (IV, Random, 95% CI)0.27 [-0.05, 0.60]

   4.2 Real patients
3194Std. Mean Difference (IV, Random, 95% CI)0.18 [-0.12, 0.49]

 5 Gave appropriate information1Std. Mean Difference (IV, Random, 95% CI)Totals not selected

   5.1 Simulated patients
1Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

   5.2 Real patients
1Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 6 Gave facts only2306Std. Mean Difference (IV, Random, 95% CI)-0.19 [-0.74, 0.37]

   6.1 Simulated patients
2160Std. Mean Difference (IV, Random, 95% CI)-0.50 [-1.36, 0.35]

   6.2 Real patients
2146Std. Mean Difference (IV, Random, 95% CI)0.16 [-0.17, 0.49]

 
Comparison 3. CST vs no CST: HCP communication skills: nurses only

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Used open questions2293Std. Mean Difference (IV, Random, 95% CI)0.41 [-0.23, 1.06]

   1.1 Simulated patients
2182Std. Mean Difference (IV, Random, 95% CI)0.65 [-0.07, 1.37]

   1.2 Real patients
1111Std. Mean Difference (IV, Random, 95% CI)-0.04 [-0.42, 0.33]

 2 Clarified and/or summarised1Std. Mean Difference (IV, Random, 95% CI)Totals not selected

   2.1 Simulated patients
1Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

   2.2 Real patients
1Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 3 Elicited concerns1Std. Mean Difference (IV, Random, 95% CI)Totals not selected

   3.1 Simulated patients
1Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 4 Showed empathy2293Std. Mean Difference (IV, Random, 95% CI)0.19 [-0.04, 0.42]

   4.1 Simulated patients
2182Std. Mean Difference (IV, Random, 95% CI)0.23 [-0.06, 0.53]

   4.2 Real patients
1111Std. Mean Difference (IV, Random, 95% CI)0.11 [-0.27, 0.48]

 5 Gave appropriate information2342Std. Mean Difference (IV, Random, 95% CI)-0.09 [-0.31, 0.12]

   5.1 Simulated patients
2173Std. Mean Difference (IV, Random, 95% CI)-0.16 [-0.46, 0.14]

   5.2 Real patients
2169Std. Mean Difference (IV, Random, 95% CI)-0.02 [-0.32, 0.28]

 6 Gave facts only2293Std. Mean Difference (IV, Random, 95% CI)-0.24 [-0.65, 0.17]

   6.1 Simulated patients
2182Std. Mean Difference (IV, Random, 95% CI)-0.31 [-0.98, 0.37]

   6.2 Real patients
1111Std. Mean Difference (IV, Random, 95% CI)-0.09 [-0.47, 0.28]

 
Comparison 4. CST vs no CST: subgrouped by HCP type

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Used open questions4599Std. Mean Difference (IV, Random, 95% CI)0.34 [0.07, 0.61]

   1.1 Doctors
2306Std. Mean Difference (IV, Random, 95% CI)0.27 [0.05, 0.50]

   1.2 Nurses
2293Std. Mean Difference (IV, Random, 95% CI)0.41 [-0.23, 1.06]

 2 Clarified and/or summarised2342Std. Mean Difference (IV, Random, 95% CI)0.01 [-0.47, 0.48]

   2.1 Doctors
1120Std. Mean Difference (IV, Random, 95% CI)-0.30 [-0.66, 0.06]

   2.2 Nurses
1222Std. Mean Difference (IV, Random, 95% CI)0.28 [-0.45, 1.02]

 3 Elicited concerns2191Std. Mean Difference (IV, Random, 95% CI)0.31 [-0.10, 0.72]

   3.1 Doctors
1120Std. Mean Difference (IV, Random, 95% CI)0.15 [-0.33, 0.63]

   3.2 Nurses
171Std. Mean Difference (IV, Random, 95% CI)0.61 [0.14, 1.09]

 4 Showed empathy5647Std. Mean Difference (IV, Random, 95% CI)0.21 [0.05, 0.36]

   4.1 Doctors
3354Std. Mean Difference (IV, Random, 95% CI)0.22 [0.01, 0.43]

   4.2 Nurses
2293Std. Mean Difference (IV, Random, 95% CI)0.19 [-0.04, 0.42]

 5 Gave appropriate information2342Std. Mean Difference (IV, Random, 95% CI)-0.09 [-0.31, 0.12]

   5.1 Doctors
1120Std. Mean Difference (IV, Random, 95% CI)-0.02 [-0.38, 0.34]

   5.2 Nurses
1222Std. Mean Difference (IV, Random, 95% CI)-0.13 [-0.40, 0.14]

 6 Gave facts only4599Std. Mean Difference (IV, Random, 95% CI)-0.21 [-0.54, 0.12]

   6.1 Doctors
2306Std. Mean Difference (IV, Random, 95% CI)-0.19 [-0.74, 0.37]

   6.2 Nurses
2293Std. Mean Difference (IV, Random, 95% CI)-0.24 [-0.65, 0.17]

 
Comparison 5. CST vs no CST: Other HCP outcomes

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Emotional exhaustion: Maslach Burnout Inventory:2106Std. Mean Difference (IV, Random, 95% CI)-0.25 [-0.67, 0.18]

 2 Personal accomplishment: Maslach Burnout Inventory291Std. Mean Difference (IV, Random, 95% CI)0.26 [-0.24, 0.76]

 
Comparison 6. CST vs no CST: Patient outcomes

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Patient psychiatric morbidity (GHQ 12)1Std. Mean Difference (IV, Random, 95% CI)Totals not selected

 2 Patient anxiety: Spielberger's State Trait Anxiety Inventory2169Std. Mean Difference (IV, Random, 95% CI)0.40 [0.07, 0.72]

 3 Patient perception of HCPs communication skills2170Std. Mean Difference (IV, Random, 95% CI)-0.14 [-0.44, 0.16]

 4 Patient satisfaction with communication2429Std. Mean Difference (IV, Random, 95% CI)0.20 [-0.23, 0.63]

 
Comparison 7. Follow-up CST vs no follow-up CST: HCP communication skills

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Used open questions1Std. Mean Difference (IV, Random, 95% CI)Totals not selected

   1.1 Simulated patients
1Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

   1.2 Real patients
1Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 2 Clarified and/or summarised1Std. Mean Difference (IV, Random, 95% CI)Totals not selected

   2.1 Simulated patients
1Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

   2.2 Real patients
1Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 3 Elicited concerns1Std. Mean Difference (IV, Random, 95% CI)Totals not selected

   3.1 Simulated patients
1Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

   3.2 Real patients
1Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 4 Showed empathy2168Std. Mean Difference (IV, Random, 95% CI)0.23 [-0.07, 0.54]

   4.1 Simulated patients
162Std. Mean Difference (IV, Random, 95% CI)0.07 [-0.43, 0.57]

   4.2 Real patients
2106Std. Mean Difference (IV, Random, 95% CI)0.33 [-0.06, 0.72]

 5 Gave appropriate information1Std. Mean Difference (IV, Random, 95% CI)Totals not selected

   5.1 Simulated patients
1Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

   5.2 Real patients
1Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 6 Gave facts only1Std. Mean Difference (IV, Random, 95% CI)Totals not selected

   6.1 Simulated patients
1Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

   6.2 Real patients
1Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 7 Negotiation1Std. Mean Difference (IV, Random, 95% CI)Totals not selected

   7.1 Simulated patients
1Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

   7.2 Real patients
1Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 
Summary of findings for the main comparison.

Communication skills training compared with no communication skills training for improving healthcare professionals (HCP) communication with cancer patients

Patient or population: healthcare professionals working with patients with cancer

Settings: outpatient or primary care

Intervention: A communications skills training program

Comparison: No communication skill training

OutcomesRelative effect: (P value)No of participant interviews
(studies)
Quality of the evidence
(GRADE)
Comments

HCP showed 'empathy'Favoured the intervention

(P = 0.004)
727

(6 studies)
⊕⊕⊕⊕
high
These data were consistent and did not display statistical heterogeneity (I² = 0%).

HCP used 'open questions'Favoured the intervention

(P = 0.04)
679
(5 studies)
⊕⊕⊕⊝
moderate
We downgraded the quality of the evidence due to the statistical heterogeneity of the studies (I² = 65%).

HCP 'gave facts only' (simulated patients only)Favoured the control group

(P = 0.01)
406
(4 studies)
⊕⊕⊕⊝
moderate
We downgraded the quality of this evidence due to the clinical and statistical heterogeneity of the studies (I² = 70%).This effect was not evident in the subgroup of 'real patients'. Tests for subgroup differences were statistically significant.

Patient satisfaction with communicationNot significantly different

P = 0.36
429
(2 studies)
⊕⊕⊝⊝
low
We downgraded the quality of the evidence due to clinical and statistical heterogeneity (I² = 74%) and the fact that only two studies contributed data.

Patient anxiety: State trait Anxiety InventoryFavoured the control group

(P = 0.02)
169

(2 studies)
⊕⊝⊝⊝
very low
We downgraded the quality of the evidence due to the clinical heterogeneity of the studies and the fact that only two studies contributed data. In addition, one of these studies reported baseline differences in anxiety between the two groups (significantly higher in the control group) and it was not clear from the report whether the results were adjusted for this difference.

GRADE Working Group grades of evidence:
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 
Table 1. Scales used to measure HCP communication skills

AbbreviationName of scaleStudies included in review that used scaleValidation reference (if any)

Com-onCOMmunication challenges in ONcologyGoelz 2009Stubenrauch 2012

CRCWEMCancer Research Campaign Workshop Evaluation ManualRazavi 1993; Razavi 2002; Razavi 2003Booth 1991

CSRSCommunication Skills Rating ScaleWilkinson 2008Wilkinson 1991

HPSDHarvard Third Psychosociological Dictionary Razavi 2002

LaCommLaCommGibon 2011; Lienard 2010; Razavi 2002Gibon 2010

http://www.lacomm.be/index.php

MIARS  Medical Interview Aural Rating ScaleHeaven 2006Heaven 2001

MIPSMedical Interaction Process SystemFallowfield 2002Ford 2000

MRIDMartindale Regressive Imagery Dictionary Razavi 2002

PCCM Patient Centred Communication MeasureStewart 2007Brown 1995

QUOTEQuality of Care through Patient's Eyesvan Weert 2011van Weert 2009

RIAS Roter Interaction Analysis System Kruijver 2001http://www.riasworks.com/background.html

Roter 2002; Ong 1998

 
Table 2. Types of HCP communication skills *

OutcomeDefinitionExamples

Information gathering skills

Open questioning techniquesQuestions or statements designed to introduce an area of inquiry without unduly shaping or focusing the content of the response."How are you doing?"; "Tell me how you've been getting on since we last met..."

Half-open questioning techniquesQuestions that limit the response to a more precise field."What makes your headaches better or worse?"

Closed questioning techniqueQuestions for which a specific often one-word answer such as yes or no is expected, limiting the response to a narrow field set by the questioner."Do you have nausea?"; "How many days have you had the headaches for?"

Eliciting concernsA combination of open and closed questions to make a precise assessment of the patients perspective."Tell me more about it from the beginning..."; "What worries you the most?"; "What do you think might be happening?"

Clarifying/summarisingChecking out statements that are vague or need amplification and summarising (the deliberate step of making an explicit verbal summary to verify ones understanding of what the patient said)."Could you explain what you mean by light headed?" "Can I just see if I have got it right? You have had headaches before, but over the last two week you have had a different sort of pain . . . "


Explanation and Planning

Giving appropriate informationThe correct amount and type of information (procedural, medical , psychological) to address patient needs and facilitate understanding.''There are three important things I want to explain today. First I want to tell you what I think is wrong, second what tests we should do, and third what treatment options are available.''

Checking understandingChecking patients understanding by direct questions or asking the patient to restate in own words"Do you understand what I mean?";

NegotiatingNegotiating procedure or future arrangements by taking into account the patient's concerns.''Do you mind if I examine you today? Would you prefer it if your husband came with you?''


Supportive or relationship building skills

Acknowledging concernsVerbalising the thoughts and concerns expressed by the patient, and express acceptance."I can see that you are worried by all this"; "I sense that you feel uneasy about having to come to see me - that's ok, many people feel that way when they first come here."

Showing empathyVerbalising the feelings and emotions expressed by the patient.''I can sense how angry you have been feeling about your illness. I can understand that it must be frightening to think the pain will come back.''

ReassuranceTo reassure appropriately about a potential discomfort or uncertainty without providing false reassurance.''I will do my best to help you.''

 *Adapted from Silverman 2005 and LaComm.
 
Table 3. Scales used for other HCP outcomes

AbbreviationName of scaleStudies included in review that used scaleValidation reference (if any)

MBIMasslach Burnout inventory Butow 2008; Kruijver 2001;Lienard 2010Schaulell 1993

NSSNursing Stress ScaleRazavi 1993; Razavi 2002Gray-Toft 1981

PPSBPhysician Psychosocial Belief questionnaire; Fallowfield 2002Ashworth 1984

SDAQSemantic Differential Attitude Questionnaire Razavi 1993; Razavi 2002Silberfarb 1980

 
Table 4. Scales for measuring patient outcomes

AbbreviationName of scaleStudies included in review that used scaleValidation reference (if any)

BSIBrief Symptom InventoryStewart 2007Derogatis 1977

CDISCancer Diagnostic Interview ScaleStewart 2007Roberts 1994

EORTC QLQ-C30: European Organisation for Research and Treatment of Cancer, Quality of Life Questionnaire-Core 30; (hjemster) Aaronson 1993Butow 2008; Kruijver 2001Aaronson 1993; Hjermstad 1995

GHQ-12 General health QuestionnaireWilkinson 2008Williams 1988

HADSHospital Anxiety and Depression ScaleButow 2008; Razavi 2003Snaith 1986; Julian 2011

PIQPerception of Interview Questionnaire Razavi 2003

PPPCPatients perception of patient centeredness Stewart 2007Henbest 1990

PSCQPatient Satisfaction with Communication Questionnaire Fallowfield 2002; Wilkinson 2008Ware 1983

PSIAQPatient Satisfaction with Interview Assessment Questionnaire Razavi 2002

PSQ-CPatient Satisfaction Questionnaire (PSQ-C)Kruijver 2001Blanchard 1986

SCNSSupportive Care needs survey (Boyes) Butow 2008Samson-Fisher 2000

STAI-SState Trait Anxiety Inventory-StateRazavi 2003; Wilkinson 2008Speilberger 1983

http://www.theaaceonline.com/stai.pdf

Julian 2011

Single item ( Feel better?)Stewart 2007Henbest 1990