Evidence Based Practice Formative Assignment

Communication Skills Training and Patient Satisfaction in Oncology Nursing


Communication, often undervalued as the mere transmission of information, is in fact a multifactorial experience between two or more parties with the aim of sharing thoughts, feelings, experiences, words, gestures and emotions via spoken content, affective components and non-verbal behaviours (Stiefel and Bourquin, 2016; NIH – National Cancer Institute, 2018).

It has long been recognised that good communication skills are fundamental to effective healthcare practice and the impact of good patient-clinician communication is now widely documented including its role in achieving important clinical outcomes, ensuring patient satisfaction and providing the highest quality care possible (Department of Health, 2000).

Effective communication allows participants to establish trust and rapport; encourages open and honest exchange of information; creates a safe space for the delivery of bad news and provides the clinician with an opportunity to elicit and address patients’ fear, concerns and emotion (Robert, Cox and Reintgen, 1994; Buckman, 2002). The impact of clinical encounters, underpinned by effective communication, include greater patient understanding of care, better treatment adherence, improved clinical outcomes and reduced stress and anxiety in patients (Epstein, Street and Bethesda, 2007; Fallowfield, Lipkin and Hall, 1998).

As a cancer diagnosis is often associated with a marked increase in stress and anxiety (Lancastle, Brain and Phelps, 2011), complex co-morbidities (Sarfati et al, 2016), significant symptom burden and a minefield of treatment options, a clinician’s ability to maintain effective lines of communication becomes increasingly important. Furthermore, in Oncology nursing, as key roles in cancer care include supporting patients with their wider holistic needs and acting as an advocate, transmitting patient preferences to multi-disciplinary teams, the ability to communicate effectively plays an even more central role (Wilkinson, 1999).

With this in mind, one would assume that communication skills development would be high on the educational agenda in nursing development. Sadly, many nurses acknowledge insufficient provision of training in communication skills throughout their careers, which impacts their practice and ability to provide high quality care (Fallowfield, Saul and Gilligan, 2001). Effective communication skills do not always come naturally, and evidence suggests that these skills do not reliably improve with experience alone (Cantwell, 1997). As such, over the last 30 years, significant resources have been poured into developing reliable and effective methods of improving communication skills with the outcomes of several studies suggesting that communication skills can be both taught and learnt.

Prominent research in this area include the work of Fallowfield, Maguire, Faulkner, Langewitz and Wilkinson (Moore et al, 2004). Training programmes, using a variety of methodological approaches have seen positive impacts on various elements of communication and nursing practice. 

Of the various techniques used to improve communication skills – including classroom based didactic training, coaching and mentoring (Miles et al , 2014) and embedded in-situ training – the only technique currently supported by RCT evidence is classroom-based training using simulated patients. Due to the strong evidential support for this approach it has been widely adopted by health educators across the UK with the National Cancer Action Team (NCAT) making the course mandatory for core members of Multi-Disciplinary Teams (MDT) (Department of Health, 2011; Rabiee and Bibila, 2012).


Research Question

Is simulated-patient based communication skills training an effective method of

improving patient satisfaction in relation to communication in Oncology nursing?


Rationale for Research Question

Although it is often argued that the use of actors in a classroom-based setting lowers the fidelity/ecological validity of the communication scenario – when compared to in-situ training or scenarios involving real patients – the ethical implications are significantly reduced. Furthermore, despite emerging evidence suggesting contextualised, embedded training, using covert observation, may result in greater retention of skills over time the costs and resources required for implementation are often too high. It is for this reason that this work will investigate the efficacy of simulated-patient based communication skills training models for use in future nursing communication skills training

Literature Search

Inclusion Criteria:


  • Registered nurses’ band 5-7
  • Nurses working in a primarily clinical role
  •  Staff working in secondary care/hospital setting


  • Training models that include actors/simulated patients/scenarios


  • Improved satisfaction – either self, patient or educator rated

Exclusion Criteria:


  • Primary care nurses
  • Non-nursing professionals (unless multidisciplinary courses with nurses included)
  • Un-registered nursing staff such as students or nursing assistants
  • Senior nurses working in primarily non-clinical roles (nursing management)
  • Gender specific articles


  • Didactic only training
  • In-situ training/working with a real patient

Duration of training removed from exclusion criteria as made the search too narrow, duration is now to become a sub-topic for investigation.

Search Terms

Patient or Population or Problem


Intervention or Exposure Comparison or Control (if applicable) Outcomes or Effects
Oncology Nursing Simulated-patient based communication N/A Improving






Senior Nurse*

Ward Nurse*


Staff Nurse*

Registred Nurse*

Nursing Practitioner

Nurse Specialist

Clinical Nurse Specialist





Patient Based




Training Programme











Rationale for Databases Searched


Cochrane Library, PubMed, CINAHL, TRIP and Scopus were all included in the search strategy as all are widely known expert sources of gold standard, peer reviewed, information including systematic reviews (completed to extremely high objective standards) RCT’s and other data of reputable source. All databases have an extensive collection of articles relating specifically to the subject matter of healthcare, nursing and health education making them suitable for the research question.


Additionally, Cochrane, PubMed, CIHNAL and Scopus are intelligently designed databases which allow for efficient searching of articles. It is possible to set up an account with each, enabling advanced searching to apply a systematic and structured search methodology using Boolean operators as well as being able to save your search history. Also, as a student with a login via a paying institution, an extensive number of full text papers are available through Cochrane, PubMed, CIHNAL and Scopus. For these reasons all core bibliographical databases were included in the search strategy.


Web of Knowledge (Science & Social Science)

Attempts were made to access this useful resource however it was not possible as access required an institutional login and UoH was not registered.

ASSIA (Social Sciences)

Attempts were made to access ASSIA though were unsuccessful as access required an institutional login and UoH are no longer registered – as such the database was excluded


Database was excluded as research question pertains to adults only

HMIC (DoH, Kings Fund, Nuffield Institute)

Delivered by OVID the HMIC database describes itself as ‘Bringing together the bibliographic database of two UK health and social care management organizations: The Department of Health’s Library and Information Services (DH-Data) and King’s Fund Information and Library Service. This Health Management and Policy Database, from The Healthcare Management Information Consortium (HMIC), is an invaluable source of information for health care administrators and managers.’

As the research question proposed forms part of a review of healthcare management and education processes, it was viewed that the database was highly likely to yield relevant sources of information. Unfortunately, a search using a simple collection of key terms yielded no suitable results, so was excluded.


Pedro (physiotherapy)

This database was excluded as the research question relates only to nursing professionals.


This database, despite being focused on behavioural and social science research, seemed relevant to the research question, the results found from a preliminary search were largely concerned with behavioural/psych therapies rather than training of staff, therefore it was excluded.

Social Care Online

This database was not included for the same reason as with Psych INFO; no relevant data were available.


ERIC (Education database)

ERIC’s information resources include journal articles, reports, conference papers and other materials which are indexed though a formal review process. As such ERIC is considered a primary database for the analysis of educational research and so considered a necessary inclusion in the search strategy. Searching was completed via institutional login providing access a significantly higher number of resources. Searching however was not as straightforward as with those outlined above as did not have advanced searching tools.

British Education index

A highly regarding database provided by EBSCOhost, BEI provides data on educational policy and administration, evaluation and assessment, technology and special educational needs. Unfortunately, it was not possible to access this database using the institutional EBSCOhost channels via Studynet or other channels, so it was excluded.

Education Research complete

While using EBSCOhost for CIHNAL searching and attempts to access BEI the ERC database was discovered. Offering similar advanced searches and an extensive educational research dataset similar to BEI this database was included in the search strategy.

International Education Research Database

A preliminary search of this education database found no results relating to nursing education/communication skills, so was excluded.

National Institute of Health Research NIHR – Portfolio database

http://public.ukcrn.org.uk/search/ – website expired

Now found at https://www.ukctg.nihr.ac.uk/ – No results

As a national research organisation NIHR is as regarded as highly as Cochrane and PubMed for quality, peer reviewed, information relating to healthcare and the medical sciences. A search using basic search terms however yielded no results, so was excluded.


The following databases were also excluded as non-relevant to the research question:

  • o National Research Register Archive (NHS Funded Research 2000-2007)
  • o metaRegister of Controlled Trials (UK)
  • o (http://www.controlled-trials.com/mrct/) – link broken
  • o Research Register for Social (http://www.researchregister.org.uk)
  • o OpenGrey (grey literature)
  • o Bandolier
  • o now found at – http://www.bandolier.org.uk/ – no results

US National Library of Medicine Database of Clinical Trials (http://www.clinicaltrials.gov/)

As a government archive of current and completed research, this database is considered an excellent source of alternative literature outside of the standard core bibliography information databases. It was not possible to use the full complete collection of search terms used in other databases but a few searches using more simple/common search terms yielded a few results (see below).

Biomed Central

Searching on Biomed Central, using a complex Boolean search, gave 175340 results. As the database had no filtering or limitation options I was unable to reduce the number of hits to a manageable amount of papers, so results were excluded from the search.


Guidelines sites e.g. NICE

Almost all clinical practice is now directed by NICE guidelines. A preliminary scoping exercise indicated that the NICE database included information on educational guidelines for health professionals. For this reason, the database was included in the strategy. A complex search using Boolean operators gave no results however a simpler search, using the terms outlined below, gave a more manageable number of results to work with.




Search Restrictions/limits per database searched

Cochrane Library

Cochrane searching yielded an effective number of studies so only the restriction ‘Human studies’ was applied (as the research question pertained only to this subject group).



Pubmed searching using boolean operators resulted in numerous hit so a number of filters/limitations were applied, and the total number of papers was added together. These included

– Cancer speciality

– Consumer and communication strategies

– Effective practice and health systems


Before including this strategy, the topics of papers were examined for relevance. Papers and subsequently the limitation were found to be suitable for the research question. Application of filters provided a more manageable number of papers to work with that were more specific to the subject area.



A search of CIHNAL provided a good number of hits. No limitations were applied as none of

the options available were suitable (time/subject limitations).


TRIP (Turning Research into Practice)

Searching using TRIP database resulted in an unmanageable 35,857 results. Unfortunately, without TRIP pro I was unable to restrict the search to access a more suitable number of papers. This seems extremely unfortunate as several papers which were examined for relevance were found highly relevant to the subject matter. The university information manager for biosciences and health was contacted with the hope of securing a login for TRIP pro. I feel this database would be extremely useful to my final submission. No university login was accessible so a less systematic search, using only key search terms, was later employed to ensure the database did not go unused.



Like TRIP Scopus yielded an extensive number of results; however, it also provided a good collection of limitation/restrictions. The following were applied with subsequent results:

– Nursing

– Open access

– Humans/human studies


ERIC (Education database)

Only 12 papers were found using the ERIC database so there was no need to apply any further search restrictions.


Education Research complete

Similar to ERIC, a smaller number of papers (51) were discovered during searches of the ERC database. It would be preferable to reduce his number further by applying search limitation but, like CIHNAL, none of the limitation options were suitable for the research question.



US National Library of Medicine Database of Clinical Trials (http://www.clinicaltrials.gov/)

A few papers were found on the clinical trials website using the search restriction ‘completed trials’. This was necessary to ensure results included outcomes as to the effects of communication skills training.


Guidelines sites e.g. NICE

Several papers were found using the NICE dataset (using modified search terms). I would have liked to reduce the total further; however, the only limitations available were ‘document type’ and ‘date’, neither of which were useful restrictions to apply for the research question.


The results of the literature search are presented in the Appendix. Boolean operators have been combined according to the concepts of the research question.

Rationale for exclusion of literature

  • The titles of all 412 papers (found from the systematic search of databases and other sources) were screened
  • 374 papers were excluded as the title suggested that the research was not pertinent to the question
  • Of the 38 articles remaining, 20 further papers were excluded as screening of abstracts found the content to be irrelevant
  • Papers were excluded for the following reasons:
    • Training did not include simulated-patients
    • CST involved the study of medics only
    • Participants were largely non-Cancer Professionals
    • Patients involved were largely non-Cancer patients
    • Training was focussed on palliative care communication (or other specialist communication)
    • The paper looked at the transfer of communication skills only
    • Studies were highly unsystematic/poor quality
  • The final 18 papers were read thoroughly and the data were assessed for potential to answer research question
  • From this, 8 papers were found to possess a sufficient similar PICO as the research question

5 papers (systematic reviews) (Moore et al, 2004; Moore et al 2011; Moore et al 2013; Barth et al, 2010 and Kissane 2012) were  excluded as they all evaluated the same papers as another, higher-quality, more recent, Cochrane Review (Moore at al, 2018). Moore et al (2004), Moore et al (2011) and Moore et al (2013)  are previous iterations of Moore et al (2018) and therefore excluded.


Buckman R (2002) Communications and emotions. BMJ 325 (7366), 672


Cantwell, B.M., Ramirez, A.J. (1997) Doctor-patient communication: a study of junior house officers. Medical Education 31 (1), 17–21.


Epstein, R., Street, R.L., Bethesda, M.D. (2007) Patient-Centered Communication in Cancer Care: Promoting Healing and Reducing Suffering. National Cancer Institute, NIH publication. 07–6225.

Fallowfield, L., Lipkin, M., Hall, A. (1998) Teaching senior oncologists communication skills: results from phase I of a comprehensive longitudinal program in the United Kingdom. Journal of Clinical Oncology. 16 (5), 1961–8.


Lancastle D., Brain K., Phelps C. (2011) Illness representations and distress in women undergoing screening for familial ovarian cancer. Psychology and Health. 26 1659–1677.


Miles L.W., Mabey, L., Leggett, S., Stansfield, K.J (2014) Teaching communication and therapeutic relationship skills to baccalaureate nursing students: a peer mentorship simulation approach. Psychosoc Nurs Ment Health Serv.



Moore, P.M., Wilkinson. S.S.M., Rivera Mercado (2004) Communication skills training for health care professionals working with cancer patients, their families and/or carers (Review). Cochrane Database of Systematic Reviews. 2, 1-20


National Cancer Institute (2018) Communication in Cancer Care (PDQ®)–Health Professional Version. National Institute of Health Publication. Retrieved May, 21, 2019, from



Rabiee, F., Bibila S. (2012). Communication in Cancer Care: Evaluating the Connected© 2-day Advanced Communication Skills Training Programme. Report produced for the NHS – NCAT, Connected Programme. Birmingham city University: Birmingham.


Roberts, C.S., Cox, C.E., Reintgen, D.S., et al (1994) Influence of physician communication on newly diagnosed breast patients’ psychologic adjustment and decision-making. Cancer 74 (1), 336-41


Sarfati, D. Koczwara,B., Jackson, C. (2016) The Impact of Comorbidity on Cancer and Its Treatment. CA Cancer J Clin. 66, 337-350.


Stiefel, F., Bourquin, C. (2016) Communication in oncology: now we train – but how well?, Annals of Oncology. 27 (9), 1660–1663


United Kingdom. Department of Health. (2000)The NHS Cancer Plan. London: HMSO.


United Kingdom. Department of Health. (2011) Improving Outcomes: A Strategy for Cancer. London: HMSO.


Wilkinson, S. (1999) Schering plough clinical lecture communication: it makes a difference. Cancer Nursing 22, 1720.



Results of Search Strategy


# Keyword/Search Term(s) PubMed Cochrane CINAHL TRIP Scopus ERIC ERC Total
1 Oncology 3822514 132932 342,775 1,008,236 6,105,110 171 60,820 11472558


2 Cancer 3352241 55692 42,383 183,937 2,557, 509 2,441 5,597



3 Nurs* 265523 13477 440,682 132,425 868,806 8,176 73,135 1802224


4 RGN 958 13 105 203 5836 3 179 7297


5 RN 23470 3489 13,341 24,067 153,166 856 20,266 238655


6 Matron* 429 5 814 208 4621 13 1,852 7734
7 Sister* 40877 224 3,730 8,886 182,118 1,507 126,796


8 Senior Nurse* 111496 18 555 313 2,426 16 129
9 Ward Nurse* 431 63 49 252 1,318 4 59
10 CNS 2321 3882 334 134,896 609,782 193 4,247
11 Staff Nurse* 557 107 9,631 687 13,122 102 660
12 Registered Nurse* 3611 328 36,994 2,888 39,218 938 2,953
13 Nursing Practitioner 27 1 38 1,414 432 18 17
14 Nurse Specialist 3693 306 2,760 1,414 18,558 225 565
15 Clinical Nurse Specialist 2669 139 1,942 722 15,195 65 459
16 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 55000 60000 40000 200000 190000 10000 130000 230000
17 Simulated 133010 5409 14,564 102,890 1,39,779 5,815 20,193
18 Role-Play 521129 11020 74,728 5,379 11,491 7,070 13,173
19 Simulation 351472 7905 41,532 102,890 6,106,560 23,495 53,289
20 Scenario 46677 3050 18,805 37,488 976,547 7,327 84,140
21 Patient-based 503 87 1,615 687 13,122 102 660
22 Communication 519516 14,056 156,448 588,976 10,552,260 156,990 489,728
23 Nontechnical 695 12,056 231 576 7,065 961 4,142
24 Course 530480 47145 97,436 188,219 2,930,073 189,410 673,485
25 Training 1605419 6185 176,583 435,671 2,190,073 191,436 578,512
26 Programme 116024 80587 412,557 64,781 6,886,268 20,297 1,292,660
27 Education 1376294 59470 581,119 465,566 4,775,941 20,297 2,017,390   9296077
28 17 OR 18 OR 19 OR 20 OR 21 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27 550000 65000 600000 600000 5000000 200000 30000000 10000000
29 Improving 563950 62404 294,578 238,445 926,192 18,017 174,799
30 Patient 1605419 6184 176,583 435,671 2,190,073 191,436 578,512
31 Satisfaction 185973 36046 115,549 75,957 876,074 36,277 115,267
32 Feedback 3352241 55692 42,383 183,937 2,557, 509 2,441 5,597   3642291
33 Effec* 3063653 431171 1,010,127 1,866,474 26,229,506 185,163 631,086
34 29 OR 30 OR 31 OR 32 OR 33 57000 44000 1111111 2000000 3000000 200000 700000 70000
35 16 AND 28 AND 34 10000 12000 10000 20000 9000 150 6000 8397
36 35 WITH LIMITS APPLIED 100 500 200 300 800 60 50 579


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