Transfer of communication skills training from workshop to workplace: The impact of clinical supervision
Introduction
Communication skills training is an integral part of undergraduate and post graduate education for health care professionals [1], [2], [3], [4], with recent UK guidelines recommending that communication skills training is available to all health professional working with cancer patients [5]. Despite research evidence that communication skills training programmes are effective [3], [4], [6], [7], [8], [9], [10], [11], [12], there remains much concern about deficient basic skills [2], [13], [14], [15] and poor communication [8], [16], [17], [18], [19]. The most recent UK Ombudsman's report sites communication as a key factor in many health service complaints ([20], Chapter 4, p. 19). One potential explanation for this apparent disparity is the gap between competence (what a person can or is able to do), and performance (what a person actually does) in the real situation.
Transfer, “the degree to which trainees effectively apply the knowledge, skills and attitudes gained in a training context to the job” [21] is a well documented and researched phenomena in the applied psychology literature relating to management training. Transfer is said to have occurred when learned behaviours are generalised to the job context and maintained over a period of time; i.e. when they are integrated into normal practice [21]. Authors agree that a key factor in transfer is the trainee's perception of the consequence of using new skills; a belief that positive benefits will outweigh negative outcomes is crucial [22], [23]. The literature argues that negative experiences, when attempting to implement new behaviours will influence whether a trainee continues or abandons new skills, irrespective of motivation to change or learning that has occurred. Research has shown that an intervention aimed at ameliorating negative influences can assist in securing the transfer process [24], [25]. It is believed that influences on transfer start within 24 h of returning to the workplace [26], [27].
Exploratory investigations of health care professionals use of key communication behaviours with patients has shown that negative beliefs exist about the benefits of open communication, and that both nurses and doctors are aware of active distancing behaviour. For example nurses and doctors report their fears that asking certain types of questions may make the situation worse for the patient, or that beliefs about talking in certain situations may be unhelpful [3], [27], [28], [29], [30], [31]. Within the communication skills training literature a model of enhancing transfer has never been developed. In 1997, a model of communication skills training, based on Bandura's Social Cognitive Learning Theory [32] was put forward which supported the notion that an intervention aimed as enhancing self-efficacy, outcome expectancy and support within the workplace following training could increase skills integration and transfer [33], but this has never been tested experimentally.
The management training literature puts forward two types of transfer intervention, goal setting and self-management programmes. Goal setting involves the individual in setting time orientated deadlines by which they aim to achieve certain goals, for example using a certain skills, or asking a specific questions. The self-management programmes have a number of key facets [34], [37]. Firstly they aim to set up supportive environment for the trainee, secondly they provide a forum to discuss the experience of attempting to integrate skills into practice, and thirdly they aim to facilitate the trainee to look objectively at positive and negative experiences creating an environment of self-directed understanding of the difficulties. For the transfer of complex heuristic tasks, like communication or assessment, it has been shown that the latter (self-management programmes) are more effective [33], [35], [36].
Within the nursing literature the issue of ‘bridging the gap’ between classroom and the workplace has been largely restricted to student nurse education [38], [39], [40], and a number of roles have been developed to help students gain clinical skills. These include clinical tutors, lecturer practitioners and nurse teachers [40], [41]. The key to all these roles has been support in linking theory taught in the classroom to clinical skills used on a ward, i.e. making the theory relevant to practice [41], [42], [43]. In post registration education, educational support in the workplace is not widely available. Courses are often run in training centres or departments which are disconnected from the work environment on a practical and managerial level. Thus the majority of support for implementing new behaviours falls to senior colleagues on the ward who may, or may not, have either experienced the training or have a clear idea of the skills the trainee is aiming to transfer. With the advent of post registration education and practice within nursing [44], the issues of support and continuing professional development have been debated [39], [45], [46]. The primary mechanisms to emerge have been mentoring and preceptorship for newly qualified level staff [41] and the use of reflection and clinical supervision to enable qualified professional nurses to apply their learning [45], [47], [48].
Linking the management training and nursing literatures this study aimed to investigate the potential of clinical supervision to form a bridge between the classroom and workplace following communication skills training.
That nurses who have received clinical supervision after training will show more evidence of transfer of newly acquired communication skills to real patient encounters, than those who have not.
Section snippets
Method
This was a randomised controlled trial in which 61 clinical nurse specialists were randomised to receive either communication skills training followed by clinical supervision (intervention group) or communication skills training alone (control group). For the main study outcomes, each nurse's communication skills with real patients were assessed a three time points. (1) Before training and supervision (baseline), (2) immediately after the supervision intervention (post) and (3) 3 months after
Recruitment
78/206 nurses responded to the initial invitation (37.9%). Of those who declined the invitation (n = 128), 28 (22%) did not respond despite follow-up phone calls, 57 (45%) returned their form, but gave no reason for refusal, whilst 43 (34%) gave reasons. These were predominantly related to issues of workload, for example covering ongoing sickness in the team or acting up as team leader, but included issues relating to individual circumstances, for example pregnancy or other educational
Discussion and conclusions
This study objectively explored transfer of communication skills training for the first time and has shown that the problem of changing clinical practice is not one experienced in management training alone. The study attempted to experimentally affect the process of transfer through using a method already established within the ‘helping professions’, i.e. clinical supervision. Despite the complexity of study the results are encouraging as they demonstrated that even with a restricted
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