Palliative and Supportive Care (2010), 8, 27 33. # Cambridge University Press, 2010 1478-9515/10 $20.00 doi:10.

1017/S1478951509990678

Beyond communication: The development of a training program for hospital and hospice staff in the detection and management of psychological distressPreliminary results

KATE JENKINS, B.SC., D. CLIN. PSY., BECCY ALBERRY, B.SC., JANE DANIEL, B.A., LAURA DIXIE, B.SC., VIVIEN NORTH, M.S.W., LAWRENCE PATTERSON, B.SC., SARAH PESTELL, B.A., AND NIGEL NORTH, B.A., M.SC., M. PHIL., P.H.D.
Salisbury NHS Foundation Trust, Salisbury, Wiltshire, United Kingdom (RECEIVED January 6, 2009; ACCEPTED April 19, 2009)

M.SC.,

ABSTRACT Objective: In the United Kingdom, a Four-Tier Model of Psychological Support has been recommended for all patients with cancer and their families. This model suggests that staff at Tier 2, such as nurses, doctors, and allied health professionals, should be procient in screening for psychological distress and intervening with techniques such as psycho-education and problem solving. Research has suggested that although communication skills training is essential for staff working in cancer services, it does not necessarily improve the detection of specic psychological disorder or staff condence in intervening with highly distressed patients. The objective was therefore to design a training program that addressed this decit and was easily accessible to hospital staff. Method: A training package was developed to train staff in the recommended skills. A literature review of teaching modalities and the effectiveness of different formats was conducted. A four-session program was developed, to be administered by staff at Tiers 3 and 4 of the model, such as clinical psychologists and counsellors. Results: Over 3 years, 255 sets of data were collected from staff who attended the course. Precourse, postcourse, and 6-month follow-up data were collected through the use of condence questionnaires, developed from the literature. The data show a signicant improvement in staff condence across all domains measured, including condence in the detection and management of psychological distress ( p .0001). Signicance of results: Although the results have limitations and the data are subjective, we can conclude that this course signicantly improves staff condence in dealing with psychological distress and that this increased condence is maintained over a 6-month follow-up period. KEYWORDS: Cancer, Oncology, Teaching, Distress, Communication INTRODUCTION Background In March 2004, The National Institute for Health and Clinical Excellence (NICE) published the
Address correspondence and reprint requests to: Kate Jenkins, Clinical Psychology (Health), Salisbury District Hospital, Salisbury, Wiltshire, SP2 8BJ, UK. E-mail: kate.jenkins@salisbury. nhs.uk

guidance Improving Supportive and Palliative Care for Adults with Cancer. NICE is a UK organization that produces clinical guidance on the optimal treatment of various disorders and conditions, based on the latest available evidence. This document set out a system for providing psychological support to patients with cancer within the context of holistic supportive and palliative care. The guidance describes the pathway that cancer patients should take through support services and explicitly states
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28 the requirement for access to formal psychological support for patients and their family members who are identied through screening protocols as requiring it. NICE recommended a Four-Tier Model of psychological provision structured around the level of complexity of a patients needs (Table 1). The model also emphasizes the importance of self-help and informal support that patients may draw upon to help them cope with the experience of cancer. Problems in accessing support are noted, as symptoms of psychological difculties are often not identied in the rst place, and there is limited access to professionals providing psychological therapies to cancer patients. A key recommendation is to provide front-line staff with training in communication skills and assessment of psychological needs to address this decit. Importantly, the guidance describes how Regional Cancer Networks, working across organizational boundaries, should coordinate the provision of training to front-line staff from professionals with expertise in psychological assessment and treatment. It is recommended that the training given to practitioners in Tier 2 should include listening for symptoms of psychological problems and simple therapeutic skills for handling distress. This would enable professionals in Tier 2 to provide interventions to enhance self-help skills and be more able to identify those patients who require referral to Tier 3 or 4. The guidance suggests that specialists should work in an integrated psychological support service, which receives referrals from Tier 2 professionals. NICE also highlights the psychological needs of the staff that care for cancer patients and suggests that professionals providing support at Tier 2 of the model need to be supervized by those at Tier 3 or 4 in order to help them manage their own psychological needs.

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This study forms part of a large 3-year project funded by Wessex Cancer Trust, a regional charity, involving the implementation of the Four-Tier model as a whole, but focuses on the development of a training package for staff working in Tier 2, delivered by those in Tiers 3 and 4. Designing Training for Tier 2 The evidence base for various forms of training and course formats was examined in order to design a program that provides the optimum opportunity for learning in the most cost-effective way that is accessible to staff in the UK national health service. Communication/Listening Skills Programs Fellowes et al. (2004) reviewed three large studies of communication skills training in cancer care and concluded that providing training has a positive effect in improving some areas of cancer care professionals communication skills. They noted signicant positive changes in rates of leading questions, focused questions, open questions, and empathy. Overall, however, they concluded that the effectiveness of the training is likely to be linked to the enthusiasm and/or skill of the facilitators and/or participants, and the long-term efcacy of such training was not clear. The methods of providing training in communication skills to oncology professionals are varied. Back et al. (2007) measured the effects of a 4-day residential workshop with 115 medical oncology fellows and found it to be a successful model. Grassi et al. (2005) used a mix of educational and experiential training in two modules with 30 oncologists from southern Europe, using formal teaching and small group exercises as well as large group discussions.

Table 1. Recommended Four-Tier Model of professional psychological assessment and support (National Institute of Health and Clinical Excellence, 2004)
Tier 1 2 3 Group All health and social care professionals Health and social care professionals with additional expertise Trained and accredited professionals Mental health specialists Assessment Recognition of psychological needs Screening for psychological distress Assessed for psychological distress and diagnosis of some psychopathology Diagnosis of psychopathology Intervention Effective information giving, compassionate communication, and general psychological support Psychological techniques such as problem solving Counseling and specic psychological interventions such as anxiety management and solution focused therapy, delivered according to an explicit theoretical framework Specialist psychological and psychiatric interventions such as psychotherapy, including cognitive behavioral therapy (CBT)

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29 that up to 50% of patients with cancer can suffer from clinical levels of psychological distress that would benet from an intervention at Tier 3 or 4 of the model (Carlson & Bultz, 2003). Unfortunately, there is also striking evidence that few of these cases are identied by nursing or medical staff (Keller et al., 2004), and so specic training in symptom recognition and screening techniques is recommended, if not essential, in order to ensure that patients receive the appropriate support (Ryan et al., 2005). Many screening tools exist, with varying levels of validity and reliability, depending on the population being screened and the stage in the care pathway. This program focused on two of the most widely used screening tools in regular use in health care settings, The Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983) and The Distress Thermometer (DT; National Comprehensive Cancer Network, 2005). Both of these screening tools have been shown to have good validity and reliability in detecting clinical levels of distress in cancer patients (Zwahlen et al., 2008). Specic Psychological Interventions Appropriate for Tier 2 Staff Soothill et al. (2001) described cancer patients unmet needs as falling into various categories, including managing aspects of daily life, managing emotions, and social identity. These needs are often above and beyond the remit of basic services provided to treat the physical disease. Although nursing staff recognize the importance of attending to psychosocial need, this can be blocked by the perceived extra time required and a lack of condence or knowledge of what to do with the information (Frost et al., 1997). Specic interventions such as relaxation training, psychoeducation, active behavioral problem solving, and cognitive challenging are all seen as effective interventions that can be provided at varying points along the care pathway, but the importance of being exible in responding to individual patient need should not be underestimated (Fawzy, 1999). In particular, relaxation and systematic desensitization programs, administered by nursing staff in a chemotherapy outpatient department, have been shown to be effective in reducing nausea and vomiting as well as reducing psychological distress (Carlson & Bultz, 2003). Psychoeducation has also been shown to be an important element in treating psychological distress in patients with cancer and can be very effective when given relatively briey by supportive nursing staff (McArdle et al., 1996; Helgeson et al., 1999). We therefore designed a program that attempted to

Their method of teaching was found to be mostly well accepted and was subjectively reported to be useful for clinical practice. Jenkins and Falloweld (2002) asserted that in order to improve interviewing styles and alter cancer professionals attitudes and beliefs, training must include behavioral, cognitive, and affective aspects, which help participants to focus on acquiring skills and strategies for dealing with specic situations. Wilkinson et al. (2003) found evidence that supported the use of 3-day training courses to effect clinically relevant behavioral change, improvements in perceived condence in communication, and dissemination of skills. However, Merckaert et al. (2005) evaluated the inuence of communication skills training on physicians ability to identify distress in cancer patients. They found no statistically signicant improvement in the ability to specically detect distress following training including a brief theoretical information course, a 2.5-day basic training program, and six 3-hour consolidation workshops. Although communication skills are an essential aspect of supportive and palliative care, research evidence indicates that these skills alone are not sufcient to increase the specic detection of psychological distress and acquisition of skills to ameliorate this distress. It could be hypothesized that communication skills training is the mechanism by which staff moves from Tier 1 to Tier 2 of the model, but does not address the issue of a lack of recognition of specic symptoms of psychological disorder or how to intervene. Maguire and Pitceathly (2003) identied several reasons why cancer professionals may distance themselves from discussing patients distress, including lack of communication training, fear of difcult questions, fear of causing distress or thoughts of self-harm, and a lack of practical and emotional support. They state that key tasks in communication include eliciting patients perspective of their own problems and checking understanding of those issues. They also describe in detail the cognitive input of training courses, which should include detailed handouts and evidence of the effectiveness of the skills being acquired. Modeling is recommended, through the use of audiotaped or videotaped sessions with patients or, alternatively, the use of simulated patients in an interactive demonstration. Finally, the ability to practice the skills and get feedback from the facilitators is seen as a benecial element to any training course. Offering doctors feedback on real consultations was seen as preferable to simulated patients. Screening Depending on the population reviewed and the criteria used to dene distress, studies have shown

30 address these issues, including communication skills, screening tools, detection of distress, appropriate interventions with patients, and support for the staff themselves.

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that facilitators were condent in staff support and being reective with participants. Sample Participants were recruited through lead cancer nurses in NHS Trusts located within the Central South Coast and Dorset Cancer Networks. Flyers for the training course were emailed to the lead cancer nurses for dissemination among Tier 2 staff working in cancer services. Specic staff groups, such as clinical nurse specialists, were individually invited to attend the training, as these staff members were deemed to have the highest degree of patient contact in terms of supportive care. In addition, many participants were recruited through word of mouth as staff informed colleagues of the benets of attending. Measures Condence Questionnaires

METHOD Design Based on the recommendations of the NICE Guidance for Supportive and Palliative Care and the available literature, a four-session workshop was developed (see Table 2). Sessions 1, 2, and 3 are each 1 week apart, and Session 4 followed a month after Session 3 in order to allow staff to practice and consolidate the skills. Each session is run over half a day to make it easier for staff who may work shifts to attend.

Training Administrators Six different members of the Psychological Support Team for Patients with Cancer from Salisbury District Hospital administered the training over the course of 2 years. Facilitators included a clinical psychologist, an oncology counsellor, two assistant psychologists, and two senior social workers. Each team member was trained to deliver the training in a standardized way by the clinical psychologist. Due to the uid nature of Session 4, it was important Table 2. Format of teaching sessions
Session 1 Topics

Condence Questionnaires were developed for the purposes of the study to measure participants levels of condence in nine key areas. These nine areas were identied through the NICE Guidance (National Institute of Health and Clinical Excellence, 2004), relevant evidence from the literature (e.g., Maguire & Pitceathly, 2003), and a small focus group where staff working in cancer services were asked their opinion on what they perceived to be areas of difculty in terms of providing psychological support.

Modalities Observation of videotaped assessment examples. Small group exercises. Didactic teaching. Group discussion of clinical cases. Didactic teaching, audiotaped assessment examples. Small group exercises examining clinical cases. Large group discussion of small group exercises. Didactic teaching. Small group exercises linking the examples used in Session 2 to Session 3. Large group discussion and input into generation of list of local services. Discussion of individual clinical cases Large group discussion.

Rationale and introduction of the Four-Tier Model. Listening skills. Elicitation of distress. Basic counseling skills such as empathy, reection, open questions, and summarizing. Detection of specic symptoms of depression, anxiety disorders, PTSD, OCD, nonnite grief, body dysmorphic disorder. Suicidal ideation and risk assessment. Screening tools (HADS and DT). Looking after ourselves. Interventions. Introduction to a basic cognitive behavioral model. Anxiety: psycho-education about ght and ight response, relaxation, distraction. Depression: activity scheduling, exercise, distraction, problem solving. Functional analysis and basic behavioral techniques. Mood and pain. Onward referral to local services. Follow-up. Unstructured session to be used as the participants want to. Agenda taken by facilitators. Topics may include troubleshooting, examples of interventions that have gone well, clinical cases for discussion, staff support, examination of how to structure a support service.

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31 Work Place Environments Of those who completed the teaching, 51% worked within a hospital environment, 23% within a hospice setting, 18% worked with patients in the community, and 8% worked in other settings, such as nursing homes. It should be noted that some participants worked in more than one environment. Comparison of Precourse, Postcourse, and 6-month Follow-Up Scores Mean scores were calculated for each of the nine questions for the precourse, postcourse, and 6-month follow-up questionnaires (see Figure 1 and Table 3). T tests were then performed to allow for comparisons to be made between levels of condence; pre- to postcourse and precourse to 6-month followup. Results show that participants condence between pre- and postcourse measures signicantly increased in all areas ( p .0001) Participants condence increase between precourse and 6-month follow-up measures were also highly signicant ( p .0001), indicating that the improvements are maintained. Evaluation Results All participants who had attended the nal session of the teaching completed the evaluation form (n 255). All elements were rated at a mean of between 8 and 9 out of 10 (see Table 4). DISCUSSION This study found that a four-session, evidence-based teaching program, administered by staff at Tiers 3 and 4, was successful in improving the condence of staff at Tier 2 in eliciting and managing psychological distress in patients with cancer and their families.

Participants rated their condence in each area on a 10-point Likert scale, where 1 not at all condent and 10 very condent. The questionnaire comprised nine questions and asked participants how condent they felt about their ability to (1) discuss psychological problems with patients with cancer, (2) elicit worries or concerns from patients with cancer and their families, (3) use specic screening tools to detect psychological problems, (4) recognize symptoms of psychological disorders, (5) manage a patient or family member who is describing symptoms of psychological distress, (6) provide information to patients or family members about how to manage their psychological distress, (7) discuss concerns about a patients psychological distress with other members of their team, (8) discuss suicide with patients and families, and (9) manage their own feelings when dealing with high levels of psychological distress. The questionnaire was administered at three time points: precourse, postcourse, and at 6-month followup in order to evaluate whether participants condence levels had increased and been maintained over time.

Practical Evaluation A subjective evaluation form assessed participant ratings of the following areas: (1) the usefulness of the handouts given out during the training course, (2) the relevance of the content of training sessions to their work, (3) the presentation of training, (4) the training venue, (5) how easy it was for participants to attend each session, and (6) the length of the training sessions. A 10-point Likert scale was used, where 1 the lowest and 10 the highest rating.

RESULTS A total of 325 participants began the teaching program; however, 70 people did not complete the course. A total of 255 participants completed at least the pre- and postcourse condence questionnaires and 66 completed all three measures (precourse, postcourse, and 6-month follow-up questionnaires).

Professional Groups The most represented group was nursing (61%). A further 8% of the participants were doctors, 18% were allied health professionals, such as physiotherapists, occupational therapists, radiographers, and social workers, and 13% were nonqualied staff, such as health care support workers and volunteers.

Fig. 1. Precourse, postcourse, and 6-month follow-up mean scores. Pre- and postcourse, N 255; 6-month follow-up, N 66. 1 not at all condent, 10 very condent.

32 Table 3. Mean condence scores by question at precourse, postcourse, and 6-month follow-up (where 1 not at all condent and 10 very condent)
Question 1. How condent do you feel about discussing psychological problems with patients with cancer? 2. How condent do you feel about your ability to elicit worries or concerns from patients with cancer and their families? 3. How condent do you feel about using specic screening tools to detect psychological problems in patients with cancer and their families? 4. How condent do you feel about your ability to recognize symptoms of psychological disorders (e.g., depression) in patients with cancer and their families? 5. How condent do you feel about your ability to manage a patient or family member who is describing symptoms of psychological distress? 6. How condent do you feel about providing information to patients or family members about how to manage their own psychological distress? 7. How condent do you feel about discussing concerns about a patients psychological distress with other members of your team? 8. How condent do you feel discussing suicide with patients and families? 9. How condent do you feel about managing your own feelings when dealing with patients in psychological distress? Precourse 6.07 6.2 3.56 5.82 5.31 4.94 7.11 4.34 6.44 Postcourse 7.99 7.88 7.43 7.86 7.54 7.49 8.7 6.95 7.9

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6-month follow-up 7.88 7.85 7.11 7.72 7.36 7.02 8.77 6.84 8.03

The preliminary long-term results also indicate that this program was successful in consolidating these skills, as illustrated by the long-term maintenance of increased condence. The course has also shown to be acceptable to a range of professional groups and levels of experience and was well received by staff. These results should be interpreted with care for a number of reasons. First, the training was delivered by a number of different facilitators who, although all trained in the same way, inevitably had slightly different styles of delivery. Further studies will examine whether the qualication of the facilitator had a signicant impact on the increase in condence Table 4. Mean evaluation by question (where 1 low/poor and 10 high/very good; N 255)
Question 1. How useful were the handouts given out during the training (such as the Hospital Anxiety and Depression Screening tool)? 2. How relevant was the content of the training sessions to your work? 3. How would you rate the presentation of the training? 4. How would you rate the venue of the training sessions? 5. How easy was it for you to attend all four training sessions? 6. How would you rate the length of the training sessions? Mean rating 8.59 8.58 8.67 8.31 7.94 8.37

levels, as hypothesized in the literature (Fellowes et al., 2003). Second, the condence questionnaire itself is a subjective measure that has not been tested for reliability or validity. In the future, it is hoped that examination of referrals to psychological support services as well as patient experience may give an indication of whether increased staff condence is relayed into their clinical practice. Although the course was designed to be as accessible as possible for NHS staff, there were inevitably those who could not attend all four sessions, so data was lost on occasion. The course was able to address many of the issues raised in the literature. Communication skills, the use of screening tools, specic symptoms of psychological disorder, and interventions were all included in the program (Carlson & Bultz, 2003; National Institute of Health and Clinical Excellence, 2004; Ryan et al., 2005). The course also made use of a number of different teaching methods as recommended, including small group exercises, modeling, videotaped examples, detailed handouts, and opportunity for feedback on real clinical examples (Jenkins & Falloweld, 2002; Maguire & Pitceathly, 2003). Finally, the course was designed to fulll the requirements of the Four-Tier Model recommended by NICE (National Institute of Health and Clinical Excellence, 2004). It achieved this by providing a structured, streamlined framework for staff at Tier 2 to identify those in distress, assess the severity of this distress, intervene themselves if appropriate, but know when an intervention at Tier 3 or 4 was

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Fellowes, D., Wilkinson, S., & Moore, P. (2004). Communication skills training for healthcare professionals working with cancer patients, their families and/or carers. Cochrane Database of Systematic Reviews. Issue 2, Art. No: CD003751. Frost, M., Brueggen, C., & Mangan, M. (1997). Intervening with the psychosocial needs of patients and families: Perceived importance and skill level. Cancer Nursing, 20, 350 358. Grassi, L., Travado, L., Gil, F., et al. (2005). A communication intervention for training southern European oncologists to recognize psychosocial morbidity in cancer. I-development of the model and preliminary results on physicians satisfaction. Journal of Cancer Education, 20, 79 84. Helgeson, V., Cohen, S., Schulz, R., et al. (1999). Education and peer discussion group interventions and adjustment to breast cancer. Archives of General Psychiatry, 56, 340 347. Jenkins, V. & Falloweld, L. (2002). Can communication skills training alter physicians beliefs and behaviour in clinics? Journal of Clinical Oncology, 20, 765 769. Keller, M., Sommerfeldt, S., Fischer, C., et al. (2004). Recognition of distress and psychiatric morbidity in cancer patients: A multi-method approach. Annals of Oncology, 15, 1243 1249. Maguire, P. & Pitceathly, C. (2003). Improving the psychological care of cancer patients and their relatives. The role of specialist nurses. Journal of Psychosomatic Research, 55, 469 474. McArdle, J., George, W., McArdle, C., et al. (1996). Psychological support for patients undergoing breast cancer surgery: A randomized study. British Medical Journal, 312, 813 816. Merckaert, I., Libert, Y., & Razavi, D. (2005). Communication skills training in cancer care: Where are we and where are we going? Current Opinion in Oncology, 17, 319 330. National Comprehensive Cancer Network, Inc. (2005). Clinical Practice Guidelines in Oncology: Distress Management. Retrieved July 2007 from http://www.nccn. org/professionals/physician_gls/f_guidelines.asp. National Institute of Health and Clinical Excellence (March 2004). Improving Supportive and Palliative Care for Adults with Cancer. London, UK: Nice. Ryan, H., Schoeld, P., Cockburn, J., et al. (2005). How to recognise and manage psychological distress in cancer patients. European Journal of Cancer Care, 14, 7 15. Soothill, K., Morris, S., Harman, J., et al. (2001). The signicant unmet needs of cancer patients: Probing psychosocial concerns. Supportive Care in Cancer, 9, 597 605. Wilkinson, S., Leliopoulou, C., Gambles, M., et al. (2003). Can intensive three-day programs improve nurses communication skills in cancer care? Psycho-oncology, 12, 747 759. Zigmond, A.S. & Snaith, R.P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67, 361 370. Zwahlen, D., Hagenbuch, N., Carley, M., et al. (2008). Screening cancer patients families with the distress thermometer (DT): A validation study. Psych-Oncology, 17, 959 966.

required. We would recommend the implementation of similar training programs across the United Kingdom in order to fulll the requirements of the FourTier Model. The program has now been written up into a complete pack, which is available from the authors for the purposes of replication in other areas. Future Directions During the course of this study, the authors were approached by departments in other countries, such as Australia and Canada, who are keen to pilot the teaching program with a non-UK audience. Hopefully, this will lead to joint research in order to validate the program with a non-UK sample. The authors are also currently in the process of training staff at Tier 2 in the facilitation of the program. There are long-term plans to see if the program is as effective when delivered by Tier 2 staff, as in the United Kingdom there is a shortage of staff at Tiers 3 and 4. If this proves to be as effective, then it will increase the accessibility of the course in all areas, as counsellors and psychologists will not be essential as facilitators, but will be able to use their advanced skills to train Tier 2 staff in the delivery of such programs. Notwithstanding the limitations discussed, this program has been shown to be accessible and relevant to staff working at Tier 2 in the United Kingdom. It has signicantly improved staff condence in exploring the psychological impact of cancer with their patients and family members. Finally, it is hypothesized that ongoing data analysis will show a signicant impact of the training on the patient experience during the cancer journey and on referrals to a formal Psychological Support Team. ACKNOWLEDGMENTS
This project would not have been possible without the generous support of the Wessex Cancer Trust, Southampton, UK.

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Back, A., Arnold, R., Baile, W., et al. (2007). Efcacy of Communication Skills Training for giving bad news and discussing transitions to palliative care. Archives of Internal Medicine, 167, 453 460. Carlson, L.E. & Bultz, B. (2003). Cancer distress screening: Needs, models and methods. Journal of Psychosomatic Research, 55, 403 409. Fawzy, F. (1999). Psychosocial interventions for patients with cancer. What works and what doesnt? European Journal of Cancer Care, 35, 15591564.