Introduction
Clinically significant levels of psychological morbidity are reported in up to a third of all cancer patients [
1]. Prevalence estimates for major depression (15%), minor depression or dysthymia (22%) and anxiety (10.3%) are also higher in cancer patients than those in the general population [
2‐
4]. Inadequate treatment of anxiety and depression results in poorer cancer outcomes, lower quality of life and higher health service use [
5‐
10]. There is a large evidence-base demonstrating psychological therapies, combined with medication where appropriate, are effective in improving outcomes of patients with anxiety and depression [
11‐
13]. However, symptoms of anxiety and depression are often undetected and undertreated. This occurs because oncology health professionals may not recognise the symptoms, normalise patients’ distress or attribute psychological symptoms to cancer [
14]. Patients are often not asked about their emotional distress and few patients volunteer this information during consultations, as they perceive it is not the role of medical staff to address emotional concerns, and some patients may decline referral or treatment for anxiety and depression [
15‐
17].
To overcome these barriers and in recognition that psychosocial care is integral to cancer care, routine distress screening using validated screening measures is internationally endorsed [
18]. The Psycho-oncology Co-operative Research Group (PoCoG) developed an evidence-based clinical pathway for the identification and management of anxiety and depression in adult cancer patients (ADAPT CP) [
19]. The pathway, developed through synthesis of the current evidence and wide stakeholder consensus [
20], provides recommendations to guide evidence-based practice using a stepped care model and outlines the roles and responsibilities of the clinical staff in identifying and managing anxiety and depression [
19].
Common barriers reported by health professionals to initiating discussions about emotional concerns include perceived lack of time, insufficient training and lack of confidence [
21,
22]. Therefore resources to support effective communication with patients to encourage anxiety/depression screening and referral, are critical to support implementation of the pathway into routine clinical practice. The aims of this research were to: (1) develop and then assess acceptability of an interactive on-line education program to support communication and increase confidence with anxiety/ depression screening and referral; and (2) assess the uptake of the training as a resource to support the implementation of the ADAPT CP across 12 Oncology services participating in the ADAPT Cluster randomised controlled trial (CRCT).
The CRCT evaluated the strategies required to achieve adherence to the recommendations of the ADAPT CP in routine clinical practice. The training modules formed part of a suite of resources that also included the ADAPT Portal (an online integrated pathway management system that tailored the ADAPT CP to local staff needs), patient education materials, and iCanADAPT, an online self-directed treatment program for patients. The resources were developed in response to a barrier analysis conducted to support implementation of the ADAPT CP [
23].
Discussion
Effective communication in cancer care requires complex communication skills, which are essential for patient-centred care [
28]. Inadequate communication can increase patient distress, [
29] and conversely skilled and empathic communication and promotion of psycho-social care by oncology health professionals can help to overcome barriers to accessing psychological support, leading to improved patient outcomes [
30,
31].
However discussing emotional concerns is reported to be challenging, in part because most clinicians have not received the formal evidence-based communication skills training they need to provide high-quality communication [
32]. Nurses in particular report the need for training in communicating with patients about emotional concerns [
33]. Given evidence that communication skills training is effective in increasing patient-centred care [
34,
35], an interactive online training program for health professionals on how to discuss screening and management of anxiety and depression was developed and assessed.
The pilot pre-post simulation study demonstrated the program was effective in improving communication and increasing participant confidence. These results are in line with previously reported acceptability of online training to support routine screening and management of distress in the context of cancer in the Canadian context, [
36] but no such training had been developed for the Australian context. In line with the roles and responsibilities outlined in the ADAPT CP, [
19] the majority of course participants were nurses, as they are most likely to discuss screening and referral with patients. These nurse participants reported high acceptance of the training; other disciplines who participated also found the program acceptable. However, the high acceptability reported during the pilot study did not translate to wider uptake in the clinical setting, suggesting acceptability of the training more broadly was lower than expected. This was supported by our qualitative assessment of ADAPT resource uptake within the larger ADAPT CRCT, with a number of nurses interviewed reporting that they did not undertake the training as they perceived they already had the required experience and skills addressed in the training.
The online training was developed based on the key principles of the Comskil training program [
24] and evaluation of the effectiveness of the training was guided by the Kirkpatrick model [
25]. However, despite the use of these evidence-based principles in the development of the training and demonstrated effectiveness and acceptability in a pre-implementation pilot study, few health professionals accessed the training during the CRCT. Based on the results of this study, stakeholder advisory groups may not be sufficient to guide development, and future research aiming to implement online training programs need to consider wider engagement in the development phase to ensure the program meets the needs of end-users.
A key barrier highlighted by participants that influenced training uptake was organisational commitment to training. Such commitment needs to move beyond policy documents that espouse patient-centred care to concrete standards that prioritise core competencies of communication and protected time for staff to undertake the training. In this study, lack of protected time was relevant for nurses in particular, who reported workload and leadership reluctance to support training as limiting their willingness and capacity to complete the modules. This is consistent with the view more broadly that nurses receive fewer opportunities for professional development in relation to communication skills than do other disciplines in which the commitment to ongoing training is high [
36]. Participants also reported the time commitment to complete the training discouraged them from undertaking the modules in personal time as they needed to prioritise other mandatory training requirements over communication skills training. The lack of organisational support for training impacts not only on staff morale and levels of burnout [
37] but negatively impacts clinical efficiency and patient outcomes [
37]. Organisational commitment to improving communication is a key driver of communication skills training [
38].
Traditional methods of communication skills training involving immersive workshops, frequently as part of residential or multi-day programs, although effective, are costly in terms of financial and staff resources, making wider inter-disciplinary implementation challenging [
34]. The move to online learning in the health sector was perceived as a means of enabling staff to access learning opportunities at times and places that best fit in with their work and lifestyle [
39]. Completion of online training is reportedly six times higher than face to face training, [
40] with a recent systematic review finding higher self-assessed communication skills, objective knowledge and confidence after online training [
41]. The module format of our training was designed to facilitate progress through the training in a staged way, with the ability to revisit components of the training as needed. Participants reported using the training across the 12-month implementation of the ADAPT CP and valued the ability to dip in and out of the training. However, the results of our study also highlight that consistent with previous research [
41,
42], for some, the online delivery format was less appealing due to the lack of synchronous interaction and individualised feedback. Future strategies to improve communication skills training could include offering a blend of workshops and online learning tailored to staff preferences, providing protected time in a designated education room within the workplace to complete online learning, and providing incentives to complete training such as accreditation for continuous professional development. The development of our online education modules was based on a barrier analysis highlighting the need for greater training. However, the analysis did not identify online as the preferred mode of delivery. In hindsight, exploring end user preferences for training may have identified a preference for more interactive training options. Prior to undertaking the development of future online education programs, researchers may consider conducting a more detailed needs assessment to identify not only delivery preferences but more targeted training to meet self-identified gaps in knowledge, thereby streamlining the training.
Based on the qualitative interviews, clinicians who undertook the training as part of the ADAPT CRCT found the training useful and did not highlight concerns about the training length or content, although those who failed to engage with the training may have perceived the training required significant time commitments, given they were not provided information about the training length prior to opening the EviQ link. However, interview participants reported the lack of engagement was primarily due to lack of time to complete non-mandatory training without protected time, which is an organisational issue of workload, and/or a preference for face to face training, particularly for communication skills. Decisions to undertake training were reportedly based on capacity; mandatory training, which is linked to ongoing employment, is prioritised over personal professional development. This suggests that researchers consider the value of online training to both end users and organisations and weigh up whether the investment in time by staff to complete complex communication training is supported by the health system. Greater engagement at an organisational level to guide development may have increased participants’ commitment to facilitating professional development of their staff. However even with protected time and organisational commitment, if staff are not personally committed to improving communication, they may complete training just to ‘tick the box’, without truly engaging in the content. Therefore, strategies to engage staff at the individual level, as well as management at the service level, are required.
The results of this research need to be considered in light of a number of limitations. While all training modules were used by nurses and reported to be useful, no information was collected about the length, frequency, and duration of their use. The limited analytics of wider uptake also does not provide any indication related to whether the training was effective in changing objective communication skill behaviours and therefore, further research to assess the impact of communication skills training on patient outcomes including referral to and uptake of psycho-oncology interventions is required. Participants in the initial pilot study may not have reflected the wider oncology health professional population in their interest in undertaking online communication skills training, meaning our initial results were biased by self-selection. Finally, the collection of training uptake and acceptability data was limited to the health professional data collected as part of the main CRCT. This prevented us exploring potential differences between those who did and did not access the training and clinical experience.
Acknowledgements
The authors would like to thank the health professionals who participated in this research. The authors acknowledge the support of The ADAPT Program Group* representing the investigators and advisors to the ADAPT Program. The authors would additionally like to acknowledge the commitment and contribution to this study of Dr. Melanie Price (1965–2018). Dr. Price was a respected member of the psycho-oncology and palliative care community in Australia for over 22 years. She was a tireless advocate for people affected by cancer, their families and psycho-oncology as a discipline. We acknowledge and thank the 12 cancer services, their clinical and administrative staff who participated in the cluster randomised trial.
Participating services and staff included: Alan Coates Cancer Centre, Dubbo NSW, Tim Williams, Dr. Florian Honeyball; Blacktown Cancer & Haematology Centre, Western Sydney LHD, Blacktown, NSW, Dr. Purnima Sundaresan, Colette Cole; Chris O’Brien Lifehouse, Camperdown, NSW A/Prof Peter Grimison, Dr. Toni Lindsay; Concord Cancer Centre, Concord Hospital, SLHD, A/Prof Philip Beale, Dr. Alex Withers, Jessica Medd; Sydney Adventist Hospital, Dr. Katharine Hodgkinson, Kate Wilson; Manning Hospital Cancer Care Services, Taree NSW, Rachel Pitt; Nepean Cancer Care Centre, Penrith NSW, Dr. Laura Kirsten, Louise Maher, Betsy Sajish and Renee Grant; North West Cancer Centre, Tamworth Hospital, NSW – A/Prof. Mathew George, Margaret Chamen, and Rebecca Griffiths; Prince of Wales Hospital, Head and Neck Cancer Service, Randwick, SESLHD, Dr. Kerry Tiller, Penelope Burdekin, Dareneth Place; St George Cancer Centre, Kogarah, SESLHD, NSW, Natalie Katalinic, Alison Szwajcer, Moira Way, Pauline Thomson, Emma Hair, Bronwyn King; Sydney Cancer and Haematology Services, Royal Prince Alfred Hospital, SLHD John Chalmers, Hannah Blyth.
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