Introduction
Patients from minority backgrounds have poor cancer outcomes including lower survival rates, higher rates of reported side-effects and poorer patient quality of life [
1‐
4]. The term ‘Culturally and Linguistically Diverse’ (CALD) is the term currently used in Australia to refer to ‘minority’ groups in this context. Through the Australian policy of multiculturalism, the term ‘Culturally and Linguistically Diverse’ (CALD) has replaced the term ‘Non-English-Speaking Background’ (NESB)
. In research and practice, CALD “is mostly used to distinguish the mainstream community from those in which
English is not the main language and/or cultural norms and values differ” [
5]. Government-funded professional interpreting services are provided for members of CALD groups who may have low English proficiency. The disparities in cancer outcomes in patients from minority backgrounds may arise because of language and communication barriers, culturally divergent beliefs and attitudes about cancer and treatment, and a range of service/systems barriers such as lack of culturally competent healthcare providers and/or lack of familiarity with healthcare processes [
6‐
10]. In view of these barriers, the potential for misunderstanding, distress and difficulty accessing care for patients from minority backgrounds is likely to be even more acute than for the general cancer population. Thus, sensitive and effective health professional communication is particularly vital for this population.
Effective communication increases health professionals’ ability to assess and manage patients’ physical symptoms and psychological distress [
11], thereby increasing patient satisfaction, compliance with medications and improving clinical and psychosocial outcomes. Culturally competent health professionals communicate effectively with patients from minority groups because they use a set of attitudes and behaviours which enable this, regardless of race, ethnic or cultural background [
12,
13]. The key elements of becoming a culturally competent health professional include: awareness of the importance and impact of one’s own and the patient’s culture, positive attitudes toward cultural differences, having knowledge of a patient’s cultural context and developing the skills to elicit and meet the culturally unique needs of the patient and work effectively with interpreters [
14]. Regarding interpreters, oncology health professionals [
15,
16] need to effectively communicate with an interpreter present, and to negotiate patient expectations in relation to interpreters, such as when patients refuse a qualified interpreter in the presence of a family member to help with communication during the consultation.
Currently, communication with patients from minority backgrounds appears non-ideal. Audits of audiotaped consultations with patients from minority backgrounds, and interviews with interpreters, have indicated that health professionals often fail to check on interpreters’/patients’ language or dialect compatibility, do not use lay language and short utterances and speak in the third person about the patient, instead of speaking directly to their patient [
17,
18]. In addition, interpreters, cancer patients and their families describe mismatches of expectations about the interpreter’s role, with some patients expecting interpreters to overstep their professional role and offer emotional support, advice and advocacy [
17‐
19], which is clearly outside their professional Code of Ethics [
20]. Thus, oncology nurses are likely to benefit from specific training both to improve their interactions with patients and their families as well as to effectively engage interpreters and to clarify patient expectations regarding interpreters [
17,
21].
Health professionals’ communication skills do not improve naturally with time and experience [
22]. However, there is substantial evidence that communication skills can be taught [
11,
14,
23]. There is a strong evidence-base that communication skills training is effective in changing physicians’ and nurses’ attitudes regarding psychosocial issues, and subjective and objective ratings of their communication skills [
24] in both simulated and actual consultations following training [
25].
Despite the need for communication skills training specifically focusing on cultural competence, only three to four published studies describe such training [
21,
26,
27]. In one of these studies, a workshop including didactic instruction and roleplay practice improved medical students’ understanding of the meaning of accuracy and role of the interpreter and increased student awareness of the linguistic complexities involved in interpreting and importance of need to work with trained interpreters [
27]. However, the few existing programmes focused on cultural competence employ a face-to-face workshop model, which is costly and accessible only to a few. Online training overcomes these barriers, as it can be accessed at any time or place at low cost, by many. Some video and
online communication skills training programmes aimed at health professionals are available which focus on medical interns [
15,
28], primary care physicians [
29‐
32], senior clinicians [
33] and gastroenterologists [
34].
To address this gap, we developed and pilot-tested an online communication skills training intervention, which specifically addresses the unique and specific training needs that arise for oncology nurses in relation to patients from minority backgrounds, including communicating with patients who have limited English proficiency. Specifically, this prospective pilot study aimed to: (i) develop an interactive online communication skills training intervention targeting the training needs of oncology nurses and (ii) assess the feasibility, uptake, acceptability and impact on perceived competence in communication skills of the ‘online intervention’ with a ‘before’ and ‘after’ assessment.
Discussion
The design of the ECCO programme was tailored to the needs of oncology nurses based on a needs assessment carried through earlier qualitative research [
35]. The programme was considered highly satisfactory and participants reported increases in self-rated competence while communicating with patients from minority backgrounds after having used the programme. Many reported that the skills gained through completion of this programme would allow them to provide better patient care to patients from minority backgrounds. There were also significant improvements in self-report of increased utilisation of helpful practices while interacting with people with limited English proficiency.
In addition, the findings of our study demonstrate that after completion of the online programme, oncology nurses were more likely to think that they and hospitals should adapt to the needs of patients from minority backgrounds. These findings are consistent with those of Hudelson et al. (2010) [
37] who reported that a majority of the participants in their study (conducted at Geneva University Hospital) put the onus on the hospital and doctors to provide resources such as professional interpreters and translated information to patients and most expected the doctor to make an effort to adapt to patients’ belief systems.
In a study conducted with oncology fellows, Back et al. (2003) [
11] used actors as patients in simulated situations for practising communication skills. They reported that actors were able to present convincing degrees of emotions and can provide feedback to oncologists and reinforce learners’ communication skills. Research has also demonstrated that teaching by videos had a positive impact on doctors’ performance [
41] and web-based telehealth programmes are useful tools in teaching communication skills [
41,
42]. Our study underscores these findings and demonstrates this approach was positively received by oncology nurses and should be tested to train health professionals in cultural competence.
Although the positive feedback received for this programme is encouraging, the study has limitations. Only one oncologist completed all three questionnaires, so the study findings can only be generalised to oncology nurses. It was particularly challenging to recruit oncologists for this study, despite several reminders being sent, and we were not able to identify the reasons for non-participation by oncologists. A qualitative study can be undertaken in the future to understand their reasons for non-participation. Also, all but one participant were females, so it was not possible to ascertain the effectiveness of the intervention amongst male health professionals. It is unknown how many health professionals received the invitation and hence generalisability is difficult to assess. In addition, the small sample size prevented us from controlling for potential confounders and assessing the role of moderators of the impact of the intervention, in particular health professional group and gender. An important shortcoming of this pilot evaluation was that only self-rated, rather than objectively measured, competence was assessed, and cultural competence was not assessed before the intervention. Moreover, the translation of skills learned through e-learning to practice is less obvious [
33]. Future studies should measure competence objectively, for example by recording actual consultations pre- and post-intervention to demonstrate increases in cultural competence as well as assess the impact of training on patients through direct assessments of patient outcomes. Given this was a pilot evaluation of the programme, a randomised controlled trial may inform the effectiveness of this programme over a longer period of follow up.
Despite these limitations, this online programme provides an opportunity for health professionals to understand the issues and potential strategies required to improve communication with minority patients. It lays the foundations for the translation of teachable communication skills into clinical practice such that the quality of interactions between oncology nurses and their patients from minority backgrounds is likely to improve. Improved communication between health professionals and their patients from minority backgrounds may also improve the quality of patients’ cancer care, and cultural competence has been found to improve patient satisfaction.
The website also provides a framework for the development of culturally competent communication skills training programmes applicable to other health settings (e.g. cardiology and respiratory medicine). Furthermore, the modules can be readily adapted for training of undergraduate and postgraduate medical students and allied health professionals from both oncology and other medical disciplines.