Efficacy of Communication Skill Training on Knowledge and Skill of Nursing Students in Conveying Diagnosis to Patients with Cancer: A Pilot Study Approach

Abstract Introduction  Procuring communication skills that enable nurses to be effective yet person-centeredness is increasingly a hallmark of quality cancer care. The growing importance of patient outcomes and experiences in health care may mean that communication skill training is finally getting the attention it so clearly deserves. Objectives  The main objectives of the study were to assess the efficacy of communication skill training on knowledge and skills of nursing students in conveying diagnosis to patients with cancer. Materials and Methods  Quasi-experimental pretest–posttest with control group research design was adopted for the study. A total of 32 third-year BSc nursing students (intervention group, 16; control group, 16) were selected by nonprobability purposive sampling technique from two selected colleges at Mangaluru. Baseline proforma, self-administered knowledge questionnaire, and breaking bad news assessment schedule were used for data collection. Tools were validated by 11 subject experts. Communication skill training was provided for 8 hours (2 hours of theory and 6 hours of skill training on conveying diagnosis). A blinding method was adopted to assess the skill of the students that enable to avoid subjectivity. Results  The mean age of participants in the intervention group was 20.56 and of participants in the control group was 20.94. All participants (100%) of both the intervention and control groups were females. The results showed there was a significant difference found in knowledge scores ( t  = 8.52, p  = 0.000) between the intervention and control groups after the intervention. There was a significant improvement found in conveying diagnosis skills among students between the intervention and control groups in different time periods. There was a slight positive correlation found between pretest knowledge scores and eliciting concerns domain of conveying diagnosis skill ( r  = 0.57, p  = 0.023). Conclusion  The study results revealed that communication skill training session was very effective for improving the knowledge and skills of students, and it enables them in providing quality care to patients with cancer through effective communication.


Introduction
The quality of nurse-patient interaction is enhanced through effective communication, which also has a significant impact on the patient's perceptions toward the effectiveness of treatments. 1 For nurses, communicating with cancer patients is a recognized challenge and a persistent problem, with emphasis placed on having difficult conversations. 2 Staff nurses are expected to take on this significant responsibility given the regular contact they have with patients.It is well known that patients with cancer have a significant need for knowledge and emotional support, and that need can only be met through efficient communication. 3 Many cancer patients have been receiving long-term curative or palliative cancer care for many years due to early detection and advancements in medical treatment. 4They often have physical symptoms and distress throughout their cancer trajectory, either as a result of the illness itself or as a result of the anticancer treatment. 5However, the results reveal that $50% of those with newly diagnosed cancer and those with recurring cancer do not receive enough psychosocial assistance and exhibit a considerable level of distress. 6s a chronic disease, cancer patients face many psychosocial problems and often lack adequate support due to ineffective nurse and patient communication.Nurse shortages and their impact on patient care are well-documented global problems.A literature review on factors influencing the provision of psychosocial care to cancer patients shows that the provision of psychosocial support for routine cancer care in the health care system has not been thoroughly explored. 7nderstanding emotional feelings and responding to them empathically are fundamental communication skills.Patients' emotional reactions to medical information may make it more difficult for them to understand their illness. 8verything we do in cancer care is based on how well we communicate with our patients and their families.The patient, their carers, and our health care systems are all adversely influenced by poor communication. 9Many medical professionals, including nurses, believe that they lack the necessary training to carry out tough conversations, 10 such as those about explaining surgical risks, 11 communicating a diagnosis or prognosis, 12 and discussing available treatment. 9The majority of health care systems suggest that poor communication is still one of the major causes of complaint. 13Health care professionals frequently have the challenging task of conveying bad news to their patients, families, and care providers.In a survey of 250 patients at an oncology facility in Scotland, 91 and 94% of patients wanted to know the possibility that their disease will be cured and the potential negative effects of treatment. 14he process of conveying bad news to a patient or their caretakers is a challenging task.Communicating bad news is more challenging when the patient is young, the health care providers and patients have a long-standing relationship, or when the patient has expressed strong expectation for a positive outcome. 15Unfavorable news is always bad news, regardless of how it is delivered.Nonetheless, the manner in which information is conveyed can significantly affect both the patient and the practitioner.The patient's wellness, quality of life, and capacity to get in touch with a doctor later on will all suffer if it is done wrong.There are efficient ways to train these competencies, which medical professionals and other health care providers must acquire. 16Effective communication is necessary to provide patient-centered, high-quality cancer care, 17 and communication skills can be improved through training and practice. 8Hence, the researcher felt the need to evaluate the effectiveness of communication skill training in gaining knowledge and improving skill of nursing students in conveying diagnosis (breaking bad news) to patients with cancer.

Materials and Methods
Quasi-experimental pretest and posttest with control group design was adopted for the study.The study was conducted in two selected colleges of nursing at Mangaluru.A total of 32 third-year BSc nursing students were selected using nonprobability purposive sampling technique.

Inclusion Criteria
• Nursing students who were studying in third-year BSc nursing and willing to participate in the study.A baseline proforma, a self-administered knowledge questionnaire on conveying diagnosis consisting of 30 questions, and a breaking bad news assessment schedule (standardized rating scale developed by Miller et al 18 ) consisting of 23 statements were adopted to collect data from the participants.The split-half method using Pearson's correlation coefficient and Spearman's prophecy formula was used to test the reliability of the self-administered knowledge questionnaire and r value was 0.78.The reliability of breaking bad news assessment scale was assessed using Cronbach α and r value obtained was 0.93.A basic communication skill module (developed by a researcher) and the SPIKES 19 model were used to train nursing students in gaining knowledge and improving skill in conveying diagnosis to patients with cancer.Data collection tools and training modules were validated by subject experts, and the researcher modified the knowledge questionnaire based on the experts' suggestions.The content validity index (S-VI/Ave) was 0.92.A total of 8 hours of communication skill training on conveying diagnosis (2 hours of theory and 6 hours of practical sessions) were provided for the intervention group.To prevent subjectivity, a blinding method was adopted to assess the effectiveness of a training program on conveying diagnosis skills.Using a skill training module, the researcher trained the personnel to assess the communication (conveying diagnosis) skill.Role playing, video-based learning, and lecture-discussion were the approaches used to train the evaluator.The trained evaluator observed the interaction of study participants with a simulated patient and placed score marks in the score sheets.
The study was conducted at two selected colleges of nursing in Mangaluru, and data were collected as planned.Lottery method was used to allot the participants into the intervention and control groups.Formal administrative permissions were obtained from the heads of the institutions.Self-introduction and the establishment of rapport were done by the researcher.An explanation of the importance of the study was given to the participants.A written informed consent was obtained from the students for their willingness to participate in the study and participant information sheet was provided to them.The questionnaires were administered to the study participants on a selected date.A pretest was conducted to assess the knowledge and skills of the undergraduate students.A demographic proforma, a selfadministered knowledge questionnaire on conveying diagnosis, and a breaking bad news assessment schedule were used in the pretest.Following this, 8 hours of communication skill training on conveying diagnosis (2 hours of theory and 8 hours of practical sessions) were implemented for the intervention group.Two hours of theory sessions regarding basic communication skills and conveying diagnosis using the SPIKES model were given to the study participants.A total of 6 hours of practice sessions were provided.During the practice sessions, role plays were adopted and pre-and postbriefing sessions were also conducted.Lecture, group discussion, video-based learning, and role play were adopted as teaching methods to train students.A simulated patient was used to assess the communication skills (conveying diagnosis) of the nursing students.The control group did not receive any interventions during the data collection period.After exposure to this training program, posttests for skill assessments were conducted after 1 week and 2 weeks for both the intervention and control groups.Knowledge assessment was done only after 1 week of training sessions.

Ethical Considerations
Prior to the data collection, approval was obtained from the scientific review board and the institutional ethics committee.The emphasis was placed on the voluntariness of participation.After the researchers had further explained the project, written informed consent was obtained before any data were collected.Participants' inquiries were welcomed.

Statistical Analysis
Descriptive and inferential statistics were used in data analysis.Baseline data were presented as frequency and percentage.The knowledge scores were expressed as range, mean, and standard deviations (SDs).Paired and unpaired ttests were adopted to interpret the difference in knowledge scores within and between groups.Repeated two-factor analysis of variance (ANOVA) and post hoc analysis were used to determine the difference between pretest and posttest skill scores in repeated intervals for both knowledge and skill assessments.The Pearson correlation coefficient was used to correlate the knowledge and skills of conveying diagnosis among students.The level of significance was set at p < 0.05.

Results
►Table 1 depicts that the mean age of students in the intervention group was 20.56 (SD, 0.814) and in the control group was 20.94 (SD, 1.12).Majority (68.8%) of the students did not have any significant one affected with cancer and 31% of them had relatives with cancer in the intervention group, whereas in the control group 50% of them had significant one affected with cancer.
The data in ►Table 2 show that there was a significant difference between pretest (mean AE SD ¼14.19 AE 2.46) and posttest knowledge scores (mean AE SD ¼ 24.19 AE 2.26) within the intervention group (t ¼ 17.11, p ¼ 0.000), whereas in the control group there was no significant differences found between pretest and posttest scores (t ¼ 1.14, p ¼ 0.27).There was a significant difference found in all knowledge domains (impact of cancer: t ¼ 4.96, p ¼ 0.000; communication skill: t ¼ 7.68, p ¼ 0.000; overall knowledge scores: t ¼ 8.52, p ¼ 0.000) between intervention and control group after the training program.The p-value showed that there was a highly significant improvement in posttest knowledge of participants in the intervention group.
The data in ►Table 3 reveal the difference in mean and SD of skill scores in both intervention and control group before and after the intervention.Two-factor repeated ANOVA showed that there were differences in conveying diagnosis skill scores within the intervention group (overall score: t ¼ 809.00, p ¼ 0.000) as well as between groups (overall score: t ¼ 359.25, p ¼ 0.000) and highly significant at 0.05 level of significance.
The data in ►Table 4 show post hoc test (Bonferroni) was applied to test the significant difference in mean scores of pretests, posttest 1, and posttest 2 in the intervention and control groups.The findings revealed that significant differences were found in skill scores of pretests, posttest 1, and posttest 2 within and between groups (p ¼ 0.000) at p < 0.05, whereas no significant differences were found in mean of posttest 1 and posttest 2 skill scores of the intervention group (within group, p ¼ 0.94) at p < 0.05.Hence, the communication  ►Table 5 shows the correlation between pretest knowledge and skill scores.The results showed that there was a slight negative correlation between pretest knowledge scores and settings, one of the domains of conveying diagnosis skill (r ¼ À 0.58, p ¼ 0.018), whereas there was a slight positive correlation between pretest knowledge scores and eliciting concern domain (r ¼ 0.57, p ¼ 0.023) in the intervention group, at p < 0.05.No correlation was found between pretest knowledge scores and conveying diagnosis skill domains in control group.

Discussion
The results of the current study showed that students' mean ages in the intervention group and the control group were 20.56 (SD, 0.81) and 20.94 (SD, 1.12), respectively.In both the intervention and control groups, all 32 participants (100%) were female.Similar findings were made by Gorniewicz et al in another study, which discovered that a student group consisting of 12 girls and 16 males had an average age of 25.40 years. 20he result of the present study showed that there was a significant difference in all knowledge domains (impact of cancer: t ¼ 4.96, p ¼ 0.000; communication skill: t ¼ 7.68, p ¼ 0.000; overall knowledge scores: t ¼ 8.52, p ¼ 0.000) between the intervention and control groups after the training program.A communication skill training program helped in gaining knowledge on conveying diagnoses.A cross-sectional descriptive study was done at Bushehr University of Medical Sciences to assess the knowledge of nursing students on the delivery of bad news to patients and their companions.The findings showed that nursing students were knowledgeable about breaking bad news to patients on a moderate to high level. 21According to these findings, which are consistent with another descriptive study by Mohamed and Abou-Abdou, just 25% of staff nurses had a sufficient level of knowledge on the processes involved in giving bad news, while 75% had an unsatisfactory level of knowledge. 22n the current study, more than average percentage of participants in both the intervention and control groups (56.25%, 9 participants) reported having difficulty in conveying information on illness or treatment to patients with cancer.Similar findings were found in a study by Konstantis and Exiara, which found that although 26 (44.07%) doctors thought discussing the prognosis was the most challenging assignment, 21 (35.59%)doctors said communicating the diagnosis was the most challenging portion.A majority of doctors (45, 76.27%) said they did not inform all cancer patients of bad news in the same way.The present study found significant differences in conveying diagnosis skill scores of students in different point of time both within and between groups (p ¼ 0.000) at p < 0.05, whereas no significant differences were found in mean of posttest 1 and posttest 2 skill scores of the intervention group (within group, p ¼ 0.94) at p < 0.05.In a related study, Fujimori et al found that in comparison to the control group, the performance scores of the intervention group who Comparison of knowledge scores within and between intervention and control groups (n ¼ 16 þ 16) Note: O1: pretest assessment; O2 and O3: posttest assessments (after 1 week and 2 weeks); X: communication (conveying diagnosis) skill training program; -: no intervention.Journal of Health and Allied Sciences NU © 2023.The Author(s).Conveying Diagnosis to Patients with Cancer Prasad et al.Table 1 Abbreviations: f, frequency; SD, standard deviation.Note: n ¼ 32 (intervention group: 16; control group: 16).

Table 2
Frequency, percentage, mean, and standard deviation of baseline characteristics of students (n ¼ 16 þ 16)

Table 4
Comparison of conveying diagnosis skill scores within and between the groups (post hoc analysis; n ¼ 16 þ 16)

Table 5
Correlation between pretest knowledge and skills on conveying diagnosis of students (n ¼ 16 þ 16) Pearson correlation coefficient.p < 0.05 significance.