Effect of Communication Skills Training Program on Nurses-Cancer Patient Communication

Background: Effective communication between nurses and patients in cancer is central element of care. There is a lack of understanding of the value of interpersonal communication between the cancer patients and the professional. Purposes: this study was conducted to assess the effectiveness of Communication Skills Training Program (CSTP) for undergraduate nursing students in caring for cancer patients. Method: One group pretest and posttest quasi experimental design was used to assess the effectiveness of Communication Skills Training Program for undergraduate nursing students in caring for cancer patients. A sample of thirty three students was participated. Students' knowledge was assessed by using a knowledge test. Students' communication skills were observed and evaluated preand post-intervention by using Checklist observation sheet namely communication skills observation checklist (SEGUE). Results: there was a significant difference between the students’ level of knowledge pre-and post-intervention (t=–10.12, p=0.001). A significant difference between the students’ level of communication pre-and post-intervention (t=-4.67, p=0.001) was found. Conclusions and Implications: communication skills among undergraduate nursing students were improved by the training program. Different teaching aid such as role playing, open discussion, and bedside demonstration were effective in increasing the level of knowledge and skills. Findings indicate that having specific communication skills program is effective in increasing nurses’ knowledge and developing communication skills also.


Introduction
Effective communication between nurses and patients in cancer is central element of care.The nurse-patient communication regarded as the essence and root to the nursing science and practice.Effective communication is helping cancer patients facing their stress, enhancing utilizing of coping strategies, and improve clinical outcome.In the opposite side, failure to communicate effectively will impact negatively of the patients' satisfaction, outcome, hope, cope, and finally total outcome [1][2][3][4][5].
The results of our previous project should that nursing students facing many problem during the caring and communication with terminally ill patients especially with cancer.Fear, death avoidance, and escape are the major attitudes of nursing students during their caring of cancer patients [4].However, despite the pivotal role of nurse-patient communication concept, previous literature showed that there is lack of knowledge and skills to communicate with patients and families effectively [3,[6][7][8].In addition, limited researches were conducted to assess the effectiveness of communication training program on improving such skills among nursing students.In addition, investigating the quality of nurses-patient communication remains the interested area for researchers [9].Thus, development of effective communication among nurses should be started during their preparation in both academic and clinical courses.Researchers have defined communication as a dynamic, complex and context-related ongoing multivariate process in which the experiences of the participants are shared [10].Recently, effective communication required the existence of a good relationship between the clinical staff, particularly the nurse, the patients, and their families.The study highlighted the two main types of communication used between the professionals and the patients, namely: verbal and non-verbal communication.
Nursing communication/interaction played a key role in enhancing the participants' mindfulness, while utilizing different coping strategies, such as re-starting their life again, by engaging in a variety of activities, and becoming an active member of their family and community.Different styles of communication were used, including: careful listening, frequent enquiring, and encouraging the participants to express their feelings.These strategies were seen as most helpful and useful, and lead to the maintenance and improvement of the participants' psychological well-being.Importantly, the participants felt that they were cared about and treated nicely by another.These results point to the need to use a communication enhanced model, incorporating different styles of communication, such as: listening, conservations that will foster the patients' abilities to manage their sensitive situations, talking about their feelings, and, finally, those that will enable the nurse to identify the patients' needs.In contrast, ineffective communication between the professionals and patients will only lead to dissatisfaction, improper care, and a rise in the number of emotional problems, such as anxiety [11][12][13].
On the other hand, a valuable interpersonal communication procedure enhanced the participants' QOL through fostering their satisfaction with the care they were receiving, and increasing their positive engagement in their treatment plan.Additionally, effective communication between the nurses and their patients enables the nurse to assess and evaluate the patients' health status, obtain an accurate physical and psychosocial assessment, and evaluate their responses to the treatment and therapeutic interventions [14].Congruent with these findings, there are agreements with previous work on the importance of communication between health professionals and the patients [10,11,[14][15][16].
Consequently, effective and positive communication is a vital part of quality nursing care, constructively influencing the patients' satisfaction, and improving the patients' psychological status, particularly through giving them the opportunity to express their feelings and emotions.Undoubtedly, this communications approach will enhance the patients' QOL during their treatment/illness period.These results parallel the previous studies conducted in the past decades, namely, that the patients/families reported dissatisfaction with the hospital staff communication behaviour.Consistent with these findings, Williams indicated that non-professional caring/communication behavior's (emotional distancing, negative verbal/nonverbal body language) caused patients to feel helpless, have emotional problems, low self -esteem, and decrease their sense of control [17][18][19][20].
The results of previous work appeared to show that the communicative behaviors of the professionals (and nurses in particular) play an important role in meeting the participants' requests (emotionally and physically).To date, most of the earlier studies have focused on the communication between the patients and professionals in relation to only the giving of bad news (e.g. a cancer diagnosis) [21][22][23].Thus, there is a lack of understanding of the value of interpersonal communication between the cancer patients and the professional.Previous literature indicated that the lack of communication skills is related to inadequate training [24].

Design, Sampling, Participants and Measures
Direct observational evaluative approach using one group pretest and posttest quasi experimental design was used to assess the effectiveness of CSTP for undergraduate nursing students in caring for cancer patients.A Random sampling technique was used to select the participants from 4th year undergraduate nursing students.A sample of thirty three students was participated.Selected questions related to the students' gender and age were collected in the current study.In addition, students' knowledge was assessed by using a knowledge test.Twenty five multiple choice questions were developed by the researcher to test the students' knowledge level preand postintervention.The questions emerged from the related text book and literature.
Face and content validity were measured by the researcher with consultation with experts in the field in both clinical and academic fields of oncology nursing.The total score of the test was 25 (each question was weighted by a score of 1), and the critical score of 12.5.If the score was>75%: high level of knowledge, if the score was 50% to 75%: moderate level of knowledge, and if the score was<50%: inadequate level of knowledge.The knowledge base test was developed to assess nurse's knowledge about main standards for communication skills in cancer including set the stage, elicit information, give information, understand the patient's perspective, end the encounter, and therapeutic communications.Furthermore, students communication skills were observed and evaluated pre-and post-intervention by using checklist observation sheet namely communication skills observation checklist.It was used for the observation of student-patient communication.It consists of 32 items with yes/no options divided in six domains.Topics covered: set the stage, elicit information, give information, understand the patient's perspective, and end the encounter.The total score of the checklist was 32.

Intervention
The

Data Analysis
SPSS version 23 was used to run the analysis of the data.Descriptive analysis was used to describe the sample characteristics of the students and the scale' items.Paired t-test was run to examine if there is significant difference between the mean pretest and posttest scores in knowledge and communication skills.

Results
Thirty three nursing students participated in the current study (20 female and 13 male).Age of the participants ranged from 21 to 40 year, the mean age was 25.03 years (SD=4.75).The analysis performed to determine the students' knowledge regarding communication skills and standards with cancer patients.The knowledge-based questionnaire conducted pre-and post-interventions.The results of pre-intervention showed that students' scores ranged from 7 to 19 out of 25, mean was 13.57(SD=3.40).It determined that 14students (42.4%) had inadequate level of knowledge (less than 50%), and 14 students (42.4%) had moderate scores (between 50 to 75%).Significant improvement in the students' level of knowledge was determined after they attended the educational program.It determined that 10 students (30.3%) had moderate level of knowledge, and 23 students (69.9%) had high level of knowledge post the intervention.Furthermore, paired t-test analysis was run to examine if there is significant difference between the mean pretest and posttest scores in students' knowledge.The results indicated that there was a significant difference between the students' level of knowledge pre-and postintervention (t=-10.12,p=0.001).
Communication skills among the students were assessed by using SEGUE checklist pre-and post-intervention.Paired t-test analysis was run to examine if there is significant difference between the mean pretest and posttest scores in students' communication.The results indicated that there was a significant difference between the students' level of communication pre-and postintervention (t=-4.67,p=0.001).

Discussion
Nurses-patients relationship is the essential factor of nursing care.It helps in providing a better care.However, previous literature on nursing care complained from poor relationship between nurses and patients [4,6,8,9].In addition, patients unsatisfied about the communication skills provided by care providers, alarmingly, around 11% of patients stated that caregivers have problem in listening skills to them, unclear explanation, respect problem, and do not spend enough time with them .Furthermore, some patients reported that they faced inappropriate behavioral reactions from caregivers during their hospitalization [25].Such gap in communication will decreased the quality of care, have poor outcome, and affect the health system negatively [26].
Establishing a professional trust relationship between nurses and patients is important in the treatment process.However, previous studies showed that nurses have difficulty in establishing such relationship and have limited knowledge and skills that required and necessary in this context.Importantly, experts in communication science believe that ability of health care providers to establish a therapeutic relationship with patients is one of the most important characteristic.Effective communication influence the patients' outcomes such as improving vital sign, decreasing pain and anxiety levels, enhancing satisfaction, increasing patients engagement in the treatment plan [27][28][29].
Nurses as bedside care provider must have enough knowledge and communication skills in order to build an effective therapeutic relationship with patient with chronic illness such as cancer.The current study was conducted to assess the effectiveness of Communication Skills Training Program (CSTP) for undergraduate nursing students in caring for cancer patients.The program has both theoretical and clinical training parts as recommended by parry, he believed that enhancing communication skills should be by theoretical and experiential training [29].The results of the current study showed a significant improvement in the undergraduate nursing students' knowledge post-intervention (educational program).Increasing their knowledge will lead to improve their ability to communicate effectively, assess the patients, and build a trust therapeutic relationship with patients.These results supporting the previous results, both studies indicated that training program lead to better communication skills; therefore, this will improve the quality of health care [27].
In the current study, the students' knowledge about the communication with cancer patients was tested before the intervention.The result showed that the students had poor knowledge as the mean was 13.57(SD=3.40)and 14 students (42.4%) had inadequate level of knowledge (less than 50%), and 14 students (42.4%) had moderate scores (between 50to75%); in fact, all students were enrolled in communication course previously.This indicated that we have to think about the way in which communication course is taught.Communication course was taught via lectures and theory modalities only.The results of pre-intervention knowledge evidenced that this way of teaching is ineffective.The current results are supporting the previous conclusion stated by Parry [29].
The Results from the current study showed a significant improvement in the students' knowledge post-intervention.The results indicated that there was a significant difference between the students level of knowledge pre-and post-intervention (t=-10.12,p=0.001).This improvement in the knowledge might be related to use different teaching aids by the researchers including role play, lectures, hand-out, video watching, and open discussion.These results are consistent with the results by Managheb, Knowles, Abraham and Denve [7,30,31].They concluded that using different teaching aids such as role playing and workshops promoting the participants' knowledge and communication skills.
The results of paired t-test showed that the difference between mean of communication skills scores in the pre and post-intervention groups was statistically significant.The students showed more competencies in communication with cancer patients.They skills in initiating the conservation and communication such as greeting the patients, elicit information, give information, understand the patients'' perspective, end the encounter, and discus a suggested new or modified treatment/ prevention plan were improved post the educational program.These results evidenced that the educational program was effective and achieved its' goal to improve the students' communication skills.The current results are congruent with the previous literature.In their study, Rowan et al stated concluded that level of communication skills was improved among the participants from the interventional group comparing to the participants from the control group [32,33].Similar results were also highlighted by [33].In the same vein, Edward et al. [34] conducted a study in Ottawa University to evaluate the nurses' communication skills after the intervention.The results showed the training increased their skills and improve their communication ways with patients.

Conclusion
The results of the current study indicated that communication skills among undergraduate nursing students were improved by the training program.Different teaching aid such as role playing, open discussion, and bedside demonstration were effective in increasing the level of knowledge and skills.In addition, the results of this study to some extend improved the nursing students'' communication with cancer patients'.
students attended the educational program; the program consisted of 20 actual hours.The content covered the definitions and types of communication skills, needs assessment and identification, communication process, therapeutic communication with cancer patients, client-centered communication, responses, steps for resolving conflict between nurses and patients, breaking bad news, and managing obstacles for effective communication.Different teaching aids were utilized by the researchers including role play, lectures, hand-out, video watching, and open discussion.Furthermore, participants practiced communicating with cancer patients under direct one to one supervision of research team on oncology/hematology wards.Feedback and demonstration were provided.The education program was developed by the researchers with consultation with expert in the field.In addition, previous literature was used.The program was implemented over two week's period by the research's team.
Sharour AL.Effect of communication skills training program on nurses-cancer patient communication (2019) Nursing and Health Care 4: 86-89.87 facilitate many valuable and meaningful health outcomes, namely: symptoms control, pain control, resolution of physical and functional symptoms, and improvements to psychological functioning of patients.
Thus effective, patient/family-centered communication and interactions procedure will Citation:

Table 1
details the knowledge scores among the students pre and post-intervention
had moderate level of communication skills.Significant improvement in the students' communication skills was determined post-intervention.The result showed that 30 students (90.9%) had high level of communication skills, mean was 31.45 (SD 0.67).significantimprovement the students' communication skills post the educational program was achieved.Table2details the mean difference in communication skills pre-and post-intervention.