Communication has long been considered crucial in healthcare and a vital skill for healthcare professionals (Buckman, 1992; Burnard, 1997; Crown Copyright, 2001; Smith and Pressman, 2010). Consequently, communication is regarded as one of the core competencies for healthcare students and professionals (Batalden et al, 2002; Verma et al, 2009).
The purpose of this study was to explore the experiences and opinions of students regarding how they are taught and learn about communication skills, with a specific focus on how prepared they felt for practice placements. Participating students were from two different healthcare programmes in the same faculty, namely, occupational therapy (OT) and paramedic practitioner (PP). The main reasons for this comparison included: 1) The opportunity to contribute to the limited, albeit growing research activity, in the field of paramedic education (Lowery and Stokes, 2005); 2) Both professions qualify to register with the Health and Care Professions Council (HCPC) in the UK and must adhere to the same standards of conduct, performance and ethics (HPC, 2008); 3) The PP programme has a communication skills-specific module, unlike the OT programme; it is possible PP students have a heightened awareness of communication skills for practice.
Debatably, communication for clinical practice is a skill that can purposely be taught and learnt (Kurtz et al. 2005). A variety of resources are available to support the teaching and development of communication skills; their focus being upon improving the way and means by which we communicate (Burnard, 1997). Nevertheless, even where communication skills are specifically taught on healthcare programmes, they have not always taught effectively (Hargie et al, 1998; Chant et al, 2002; Smith and Pressman, 2010). It is accepted that communication is a complex and challenging subject to teach (Kurtz et al. 2005). Arguably, teaching communication skills is not about teaching the right way to communicate; it is about facilitating students to consider how they present themselves to others and ensure they are understood in their daily work lives.
Considering communication as both a powerful and complex action, it is not surprising to discover it is one of the main reasons for complaints made to the Health Service Ombudsman every year (Nursing Times, 2007; Parliamentary and Health Service Ombudsmen, 2011). Apart form being one of the main sources of patient dissatisfaction, other consequences of poor communication in healthcare include: poor information gathering (Silverman, Kurtz and Draper, 2005); inadequate explanation (Kripalani et al, 2010); non person-centred planning (Laidlaw et al, 2001) and poor impact on quality of care provided and received (Crawford et al. 2006). Moreover, demanding workplace environments require healthcare professionals to have proficient communication skills to survive and remain fit-to-practice. For example, paramedics can work in particularly highly stressful incidents and consequently are at high risk of experiencing work-related stress (Bennett et al, 2004, Lowery and Stokes, 2005). Therefore, the Mid American Regional Council (MARC) (2011) asserts that paramedics ‘...must possess excellent verbal communication skills and be capable of adapting to situations with violence and emotional instability’. In their everyday working lives, all healthcare professionals require competent listening and communication styles to promote positive relationships with people and the patients they work with (Brown et al, 2011).
Evidently, effective communication is recognised as central to effective healthcare (Berry, 2007) and to clinical competence (Kurtz et al. 2005). Moreover, it is essential for client-centred practice (Stewart et al, 2000). Rightfully, much research undertaken in this area has informed the teaching of communication skills in healthcare degree programmes (Silverman et al, 1998). However, there is a gap in understanding how Allied Health Professional (AHP) students are taught communication skills, and a need for research that evaluates the student opinion of learning communication skills.
Methods
Design
The research approach taken was action research, which as considered a practical approach to conducting professional inquiry (Waters-Adams, 2006). This can be used when researchers intend to address and change issues in current practice by finding solutions through research (Heale, 2003), and wholly appropriate to use in pedagogic research (Elliot, 1991; Cousin, 2009).
Participants
All students enrolled in the third year of both the Bachelor of Science occupational therapy (n=52) and the Bachelor of Science paramedic practitioner (n=28) courses at a UK university were eligible to participate. Each respective programme lead was eligible to participate; this is the person responsible for overseeing the maintenance of academic standards, ensuring each aspect of the programme is organised and coordinated.
Instruments
In action research, methods are chosen on the basis that they will provide realistic and helpful information about practice under study; action research supports use of multiple-methods to study practice from different perspectives (Waters-Adams, 2006). Hence, a mixed-methods approach was used incorporating document analysis of programme handbooks to inform the questionnaire design (following a format provided by the Australian National University (2009) guide to writing a document analysis), and data was collected through questionnaires with third year OT and PP students and through gaining programme lead feedback.
Questionnaires (Table 1) were designed, comprised of 34 attitudinal scaled-responses under the headings: ‘your programme’; ‘verbal communication skills’; ‘written communication skills’; ‘non-verbal communication skills’ and ‘preparation for placements and practice’. There were two open-ended questions to gain answers in the respondents own words; moreover, there is the valuable possibility of gaining unanticipated responses (Fink, 1995).
| About You (Please delete what does not apply) | |||||
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Please confirm your programme of study: Occupational therapy/Paramedic practitioner |
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How to complete this questionnaire |
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Quick Fire! |
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| Question 1:Your programme | SA | A | DK | D | SK |
| Before starting on this course, I expected to be taught about the communication skills required for practice | |||||
| I was adequately taught about communication skills required for practice during the first year | |||||
| I was adequately taught about communication skills required for practice during the second year | |||||
| I was adequately taught about communication skills required for practice during the third year | |||||
| The programme handbook adequately refers to the teaching and learning of communication skills | |||||
| I am not aware whether communication skills are included within the Programme Learning Outcomes | |||||
| How could your programme improve the provision of teaching communication skills? (Please write your answer here) | |||||
| Question 2. Verbal Communication skills (eg. talking to colleagues/patients, meetings, presentations ) | |||||
| We are taught about verbal communication skills on my programme | |||||
| I understand how my verbal communication skills have been formally assessed on campus | |||||
| I understand how my verbal communication skills have been formally assessed on practice placement | |||||
| I do not need good verbal communication skills as part of being a competent health professional | |||||
| I feel my questioning/interviewing/history-taking skills are competent for practice | |||||
| I feel my presentation skills are competent for practice | |||||
| I do not think my verbal communication has been a skill that I have needed to improve whilst on any of my placements | |||||
| Question 3. Written communication skills (e.g. note-writing, taking histories, recording patient deta ls, reports) | |||||
| We are taught about written communication skills on my programme | |||||
| I understand how my written communication skills have been formally assessed on campus | |||||
| I understand how my written communication skills have been formally assessed on practice placement | |||||
| I do not need good written communication skills as part of being a competent health professional | |||||
| I feel my note-writing and documentation skills are competent for practice | |||||
| Question 4. Non-verbal communication skills (e.g. body language, listening skills, eye-contact) | |||||
| We are taught about non-verbal communication skills on my programme | |||||
| I would welcome the opportunity to receive feedback from my peers about my non-verbal communication skills | |||||
| I would welcome feedback from my mentor/educator about my non-verbal communication skills whilst on placement | |||||
| I do not need good non-verbal communication skills as part of being a competent health professional | |||||
| I feel my listening skills are competent for practice | |||||
| I feel my body-language is appropriate for practice | |||||
| I do not think my non-verbal communication has been a skill that I have needed to improve whilst on any of my placements | |||||
| Question 5. Preparation for placements and practice | |||||
| The taught aspects of my programme have prepared me well for the communication skills I need for practice | |||||
| Before my first placement, I felt prepared for communicating in a clinical setting | |||||
| Before my most recent placement, I felt prepared for communicating in a clinical setting | |||||
| Learning communication skills is important because my ability to communicate effectively is a lifelong skill required for practice | |||||
| I feel confident that I can adapt my communication skills in practice to work with a diverse population | |||||
| Learning communication skills is important to become an effective member of a team | |||||
| I am aware of the professional standards regarding communication skills that I must follow, as outlined by the Health Professions Council | |||||
| I would welcome the opportunity to receive training about communications skills required for practice before I qualify | |||||
Procedure
Ethical approval was granted by the University's Ethics Committee. Ethics protocols were provided to all participants, outlining details such as: the purpose of the study; that their participation was voluntary; that they had a right to withdraw and how confidentiality would be maintained. Consenting OT participants signed a consent form. PP student consent was implied by their completion and return of the questionnaire by email. To ensure confidentiality, questionnaires were assigned a number and did not ask for their names. No abbreviations were used.
Initially, questionnaires were piloted with ten first year OT students. Feedback concerned terminology/language used. Consequently, questions were re-worded for appropriateness, including providing an example of what was meant by verbal, non-verbal and written communication.
The third year OTs were invited to participate following their last lecture in class. Completed questionnaires were placed on a table as each student left the room. Questionnaires were emailed to PPs because ethical approval was not received in time to provide the questionnaire in person, as their last day in class was earlier than the OT cohort. Questionnaires returned by PP students were printed and provided to a colleague to assign an identifying (anonymous) number.
A verbal discussion was held with each programme lead in which the questionnaire and results were explained. The results section was provided to each programme lead, both of whom then provided written feedback in-text, after independently reviewing the questionnaire findings.
Data analysis
Quantitative analysis of the Likert scale questions involved totalling the number of responses in each option and calculating into percentages to create charts/graphs using Excel. A coding frame was developed to analyse the open-ended questions and to search for meaningful patterns in responses (Hague, 1993). This entailed deciding on categories to be used and then allocating the individual responses to these categories in order to find the commonly occurring themes, known as differential analyses (Bowditch and Buono, 1982).
Results
Demographics
A total of 44 (85 % response rate) OT and 11 (39 % response rate) PP third–year students participated in this study. Two OTs did not provide their age or gender and three did not provide their age. Of those OTs who disclosed demographic data, 93 % (n=39) were female, with a mean age of 26.4 years. The majority of PP participants were female (73 %, n=8). PP students had a higher mean age of 28.2 years. Gender and ages of participants were consistent with the demographic profile of the students enrolled on these courses.
Prioritising communication skills
Students were firstly asked to identify and prioritise what they felt were the three most important communication skills required for practice; the majority prioritised listening skills above verbal, non-verbal and written.
Expectations
In terms of pre-course expectations, 64 % (n=7) PPs and 41 % (n=18) OTs strongly agreed and 18 % (n=2) PPs and 46% (n=20) OTs agreed they expected to be taught about the communication skills required for practice. In both groups, the majority agreed they were adequately taught communication skills in the first, second and third years. None strongly disagreed. However, of the OT students, 25 % (n=11) disagreed they were adequately taught in their first year, 16 % (n=7) in their second year and 16 % (n=7) in their third year.
Student recommendations
The second open-ended question asked students how their programme could improve the provision of teaching communication skills; the top suggestion from both groups was for ‘practical sessions’.
Verbal communication skills
As shown in Figure 1, participants mostly agreed when responding to the statement: ‘We are taught about verbal communication skills on my programme’. The majority of all students either strongly agreed or agreed they understood how their verbal skills have been formally assessed in class and on placement. Almost all the students (95 %, n=42 OTs and 100 %, n=11 PPs) strongly disagreed they do not need good verbal communication skills as part of being a competent health professional. In terms of competency for practice, Figures 2 and 3 demonstrate the majority felt their questioning/interviewing/history-taking skills and presentation skills are competent for practice.
Written communication skills
The majority strongly agreed/agreed (77 %, n=34 OT and 100 %, n=11 PP) they are taught written communication skills on their programmes. Many strongly agreed/agreed (89 %, n=39 OT and 82 %, n=9 PP) they understood how their written communication skills have been formally assessed in class; 52 % (n=23) OTs and 64 % (n=7) PPs strongly agreed they understood how they were assessed on placement. Overall, 82 % (n=36) OTs and 82 % (n=9) PPs strongly disagreed they do not need good written communication skills as part of being a competent health professional. In both groups, all students strongly agreed/agreed their note-writing and documentation skills are competent for practice.
Non-verbal communication skills
All of the PPs either strongly agreed/agreed they are taught non-verbal communication skills on their programme. In contrast, while 14 % (n=6) of OT students strongly agreed and 43 % (n=19) agreed, the second largest majority of 20 % (n=9) disagreed.
The majority from both groups strongly agreed that they would welcome the opportunity to receive feedback about their non-verbal communication skills from their peers and their educators/mentors. More similarities were evident, with 86 % OTs (n=38) and 91 % (n=10) PPs strongly disagreeing they do not need good non-verbal communication skills to be a competent health professional. All students strongly agreed/ agreed their listening skills are competent for practice and that their body-language is appropriate for practice.
Preparation for placements and practice
Both groups felt the taught aspects of their programmes prepared them well for the communication skills required for practice, with 73 % (n=32) OTs and 91 % (n=10) PPs strongly agreeing/agreeing. Figure 4 shows many OT and PP students disagreed they felt prepared for communicating in a clinical setting before their first placement, with an evident shift in the majority strongly agreeing/agreeing they felt prepared before their most recent (last) placement.
The majority of all students strongly agreed that learning communication skills is important because the ability to communicate effectively is a lifelong skill required for practice and that learning communication skills is important to become an effective member of a team. Encouragingly, most of the students strongly agreed/agreed they were aware of professional standards regarding communication skills outlined by the HCPC. In relation to receiving training about communication skills required for practice before they qualify, Figure 5 shows the majority would welcome this.
When asked how confident they felt to adapt their communication skills in practice to work with a diverse population, 50 % (n=22) OTs and 73 % (n=8) PPs strongly agreed, 43 % (n=19) OTs and 27 % (n=3) PPs agreed and 7 % (n=3) OTs did not know.
Discussion
There were some differences between OT and PP student opinions regarding their experience of being taught communication skills and their preparation for placement, with many PP students feeling adequately taught and a significant number of OT students disagreeing. Regardless of this finding, all students said they would welcome further communication skills training, and suggested they would like more practical sessions. To meet this need it was suggested a national survey of student opinion is conducted by the professional bodies to inform what aspects of curriculum design require development and subsequent implementation by higher educations institutions (HEIs); the need for further training should also be met and continuously developed by the respective professional bodies and HEIs.
The PP programme lead interpreted the PP student response as feeling adequately taught to indicate student progression over the programme. Reflecting upon the differing OT student response, the OT programme lead questioned: ‘I wonder if without a module titled “communication skills” students feel they haven't been given this?’ Communication skills training is certainly supported as a key feature of undergraduate education in the literature (Chant et al, 2002; BMA, 2004; Hambly et al, 2009; Ryan et al, 2010). Interestingly, however, the College of Occupational Therapy's (COT) pre-registration education standards (2008) do not specify programmes must teach them. Comparatively, the PP curriculum design incorporated the College of Paramedic's (CoP) Curriculum Framework for Ambulance Education (CoP, 2008) that heavily promotes communication skills in its core curriculum content.
By comparing OT and PP students, it is evident there are also similarities in their opinions and experiences. To illustrate, the majority of students ‘strongly agreed’ or ‘agreed’, that they felt confident to adapt their communication in practice to work with a diverse population. Debatably, this conflicts with Lipsitt's (2009) key finding, in which participants felt less proficient communicating with patients/families. To ensure students continue to feel confident and to better prepare for working in multicultural societies, Horton (2009) suggests healthcare programmes should embrace the concept of internationalisation; this would see students dealing with more global and local issues around diversity and working with diverse populations.
In addition to exploring the perspective of PP and OT programme leads, this is the first survey to the researcher's knowledge to compare and document PP and OT student perspectives regarding how they are taught and learn about communication skills. Considering the importance placed upon verbal communication for clinical practice (MARC, 2011), findings show the majority of students identify verbal communication as a skill to be developed. Of significance, the majority also have an expectation to be taught communication skills and prioritise listening as the most important skill required for practice. PP programme lead feedback supports the student opinion, claiming there is greater emphasis upon active listening and verbal interpretation in the PP role. The implication of this for teaching practice is that there has not been curricular emphasis on listening skills (Bondreau et al. 2009). Yet these findings suggest programmes need to incorporate practical development sessions, such as role-play, which can be a valuable feature of their education (Sedgwick and Hall, 2003).
Gender was not deemed to have had a significant effect on the results. However, considering the mean age suggests many students may have been involved in previous study or work prior to starting their course. Therefore, it could be those students who reported feeling adequately prepared for placement and practice might have already developed a range of competent communication skills prior to studying on their chosen programme.
Limitations and recommendations for future research
Issues arising from both rigour and credibility is a major limitation and common critique of action research methodology due to its participatory nature. This action research was deeply embedded within the researcher's HEI, leaving scope for inevitable researcher bias (Waters-Adams, 2006). To improve credibility, a reflective log assists with achieving reflexivity (McGhee et al. 2007). However, due to the nature of action research, it was appropriate the researcher practices at the HEI under study because this allowed for informed identification of a practice issue, with regular access to the practice and participants under study (Koshy, 2005). Subjectivity is therefore understood as inevitable, but also as a strength to addressing a relevant issue.
A significant limitation was the smaller sample size of PPs and the associated lower response rate. Arguably, sufficient data was collected for the purpose of analysis and completion of the research. However, the ability to compare results between PPs and OTs would have been more valid and reliable had sample sizes been similar.
Use of a questionnaire raises some limitations, including:
This is a recognised consequence of using closed questions, in which options offered may not reflect actual opinion (Bryman, 2008). In terms of the open-ended questions, one limitation of analysing this qualitative data is the impossibility of being able to clarify with respondents what their response says or means, leaving the researcher to make judgements without clarificaton (Hague, 1993). Indeed, time limitations meant member-checking results was not conducted, limiting trustworthiness of the results. Ideally, the researcher would have achieved further triangulation through in-depth interviews with students; this could provide rich, meaningful data to further enhance understanding.
This study has highlighted there is scope for further research at a local level to continue developing communication skills training on both programmes. Recommendations for future research include conducting research with a wider group of OT students in order to compare programmes that do and do not have specific modules dedicated to communication-skills training. This would further help to identify whether the findings here are due to differences between the professions, or differences between the programmes, and whether all healthcare programmes need to consider developing a specific interprofessional module dedicated to teaching, developing and assessing communication skills.
Conclusions
Overall, findings show participants would welcome more communication skills training on their programmes. More practical sessions were also suggested as a means to improve the student learning experience. Communication skills are seen as crucial for their own clinical practice. In particular, findings confirm communication skills have a different profile on each programme, and suggest this difference might be due to the PP programme having a communication skills-specific module, whereas the OT programme does not.