Communication Skills Training for Professionals Working with Adolescent Patients with Cancer Based on Participants' Needs: A Pilot

Abstract

Purpose:

We aimed to pilot and evaluate communication skills training (CST) for health care professionals (HCPs) interacting with adolescent patients with cancer and their parents based on participants' needs.

Methods:

We developed and piloted a 2-day CST with physicians and nurses in adolescent oncology. The CST's agenda was determined by the critical incidents reported by the participants. Training consisted of experiential learning based on role-play between HCPs and simulated patients and parents. Whenever suited, short lectures were given on specific communication techniques. Skills were self-assessed by questionnaires before, immediately after, and 6 months after training. We compared the proportion of participants who felt confident in 19 predefined areas of difficult communication before and 6 months after training. Responses to open-ended questions were analyzed qualitatively by thematic analysis.

Results:

Twenty-six physicians and 24 nurses participated in 6 CSTs. The proportion of participants who felt confident increased significantly in 6 of 19 communication items (p < 0.05). Positive feedback outweighed negative in quantity and quality. Predominant themes immediately after training were the training's practical orientation and intensity, and 6 months later, increased self-confidence and applied communication techniques. Participants noted that the effect diminishes with time, and expressed their need for booster trainings.

Conclusion:

The results of CST tailored to the specific needs of HCPs in adolescent oncology were promising. We suggest that similar training opportunities are implemented elsewhere.

Introduction

It is common knowledge that communication with adolescents can be quite difficult, and physicians and nurses working in adolescent oncology need specific communication skills to interact with adolescent patients and their parents.^1,2 In addition to their medical competence, health care professionals (HCPs) must master the challenges of developmentally appropriate communication.^3,4 Professionals often lack competence and confidence in this growing field, despite evidence that supportive communication can be learned with communication skills training (CST).⁵ CST has been established in adult oncology and more recently in pediatric oncology but with no specific focus on adolescents.^6–10 Although mandatory CST is recommended for professionals working with patients with cancer, an online survey distributed to fellows in training through the American Society of Pediatric Hematology/Oncology (ASPHO) reported that 32% have received CST.¹ Furthermore, studies rarely consider adolescents (defined as teenagers aged 13–19 years) as a distinct, developmentally unique group.⁴ Most studies on communicating with adolescents with cancer include either adolescents in samples of pediatric cancer patients,⁶ adolescents in samples of teenagers and young adults diagnosed between 16 and 25 years,^7,8 or adolescents and young adults diagnosed between 15 and 39 years.^9,10

Due to a lack of specific CST for HCPs working with adolescent patients with cancer,^6–10 we developed a concept to pilot such training. There is a long-standing agreement on how to train communication skills.^11,12 A learner-centered approach, the use of role-play and structured feedback, small group size, and trained facilitators are recommended.^13,14 Contrary to the training form, the content of CST in the adolescent cancer setting is more difficult to define. The variety and diversity of topics cannot be addressed in one CST. CST may be addressed as follows:

devoted to a specific theme known for its difficulty (e.g., nonadherence of adolescents with cancer, discussion of fertility preservation),

restricted to themes by defining core functions in a framework (e.g., fostering relationships, exchanging information, responding to emotions, managing uncertainty, making decisions, and enabling patient/family self-management),¹⁵

follow a consensus statement (e.g., breaking bad news, offering end-of-life care, enrolling patients in investigative studies, and disclosing errors, as recommended by the ASPHO Training Committee),¹⁶ or

not have predefined topics but based on the participants' needs and their individual critical incidences of difficult or failed communication.

An additional challenge for developing CST for HCPs working with adolescent patients with cancer is that CST participants are usually either physicians or nurses who have different communication agendas. In a review on the doctor–patient relationship in the adolescent cancer setting, three themes emerged: (1) discrepancies among adolescents, parents, and professionals about the extent of involvement in treatment-related decisions; (2) adolescent desire for appropriate information provision; and (3) adolescents' preferences for how information is delivered, with recognition that these preferences may change with age.⁴ In our preparatory qualitative study on improving communication in adolescent cancer care, nurses' agenda on communication differs substantially from doctors.¹⁷ Care being team based, it is important for physicians and nurses to have an understanding of the other group's perspective. An interprofessional CST can offer a space that fosters such insight.

We provided CST focused on communication between HCPs and adolescent patients with cancer and their families, invited physicians and nurses, and focused on the participants' needs.

In this pilot setting, we evaluated whether HCPs were satisfied with the CST, whether they felt more confident communicating with adolescents after CST, and whether they reported applying the techniques 6 months after CST.

Methods

Setting of training

This new 2-day (16 hours) training program for pediatric oncologists and oncology nurses treating adolescent patients and their parents was piloted by the Swiss Cancer League in Switzerland and in Germany. Ethics committee approval for this quality assessment was not necessary.

Participants

We recruited participants by advertising on the Swiss Cancer League website and offered continuing education credit. Participants had to work with adolescents with cancer regularly. The trainings were subsidized by the Swiss Cancer League.

Content

The last author (A.K.) has been facilitating CST for medical oncologists since the program was introduced.^11,12,14,17 The pilot training for pediatric oncologists and nurses was based on

critical incidence reports (CIRs) of difficult encounters. Participants were asked to remember an occurrence with an adolescent with cancer and/or the parents where communication was difficult or failed, and to write down a verbatim dialog of this encounter (Table 1),¹⁸

findings from focus groups with former adolescent patients, their parents, nurses, and physicians on the elements of good communication,¹⁷

recommendations of the global curriculum of the American and European Societies of Clinical/Medical Oncology, which stipulates that communication training should be conducted by trained facilitators in small groups, be learner centered, and use role-play and structured feedback,¹⁴ and

role-play with simulated patients. The role-play was based on participants' CIRs. Professional actors were trained to interact with HCPs as realistically as possible. After the role-play, structured feedback was given by the participants, the simulated patient, and the facilitator.

Table 1.

Examples of Critical Incidents Reported by Participants

Topic	Excerpt from incident
Breaking bad news	For doctors, giving bad news/For nurses, dealing with patients' emotions after receiving news, is difficult when information is lacking.
Dealing with emotions	Nurse talks about her vacation plans, patient says she no longer will have that opportunity.
Multiperson setting	Patient wants pain killers, mother doesn't want her to receive morphine at this point, nurse is between the two; Father doesn't want his daughter to be told about her bad prognosis although she asks to be informed; the parents want to continue therapy, the 14-year-old daughter doesn't, she understood the information/she understands the implications.
Adolescents' withdrawal	From brushing of teeth to taking medication; pull the covers over his/her head; thrombosis, doesn't want to stay at hospital, what does he need to take with him and do at home.
Different concepts and negotiations	Nurse brings a humidifier to keep mucous membranes from drying out, mother considers this unnecessary.
Noncompliance	No, I'm not doing that analysis/examination

Training was conducted in small, mixed groups of physicians and nurses to promote mutual understanding and to foster team-based thinking.

On day 1, participants completed the precourse assessment and were asked about their personal expectations of the training. The facilitator addressed the goals of the seminar: to reflect on one's own communication style based on CIRs, to try out new communication techniques, and to observe and give feedback respectfully. A brief overview of the results of our study on improving communication in adolescent cancer care¹⁷ was presented and discussed. Each participant provided a CIR involving communication with an adolescent with cancer and his or her family. The CIRs served as “scripts” for role-plays with simulated patients. The professional actors quickly adapted these “scripts” for role-play.¹⁹ Their mandate was limited in terms of duration and intensity, and included debriefing sessions.

On day 2, further CIRs were used for role-plays with simulated patients. Short lectures on topics linked to the CIRs were given based on skills training by Maatouk-Bürmann et al. for patient-centered techniques such as waiting, echoing, mirroring, summarizing, and the NURSE model for dealing with emotions (Naming, Understanding, Respecting, Supporting, Exploring).²⁰ Giving bad news, shared decision making, and discussing transition to palliative care were based on skills training of Back et al.²¹

Evaluation

The evaluation strategy was adapted from Clayton et al. and Fallowfield and Jenkins.^22,23 Participants received a questionnaire, which they filled out in written form immediately preceding, immediately after, and 6 months after the training (Supplementary Table S1).

The questionnaires contained questions on participants' self-assessed confidence, satisfaction with and relevance of the training. Confidence was measured with 19 items at all 3 time points, using 5-point Likert scales from “not at all confident” to “very confident.” The items were based on the evaluation of an experiential workshop in palliative medicine and adapted to the setting of adolescent oncology.²² Due to the adaption, original Cronbach's alpha of 0.965 dropped to 0.871 (before the training), 0.870 (immediately after), and 0.911 (6 months after), which is considered very good internal consistency. Satisfaction was measured immediately after and 6 months after the training with four items with 4-point Likert scales from “strongly disagree” to “strongly agree.” Relevance was measured 6 months after the training with two items that could be answered with yes or no.

The last section of the questionnaires (given directly after the training and 6 months later) consisted of two open-ended questions. Participants were asked to write about positive and negative aspects of the training.

Analysis

Answers by physicians and nurses were pooled. We dichotomized the confidence scales into “not confident” and “confident,” omitting the “neutral” midpoint, and satisfaction scales into “disagree” and “agree,” based on standard analytical methods to reduce the influence of respondents who had no opinion.^24,25 The descriptive results without dichotomization are presented in Supplementary Table S2.

Confidence before the training is presented for participants with and without previous experience with CST. We then compared the percentage of participants in terms of confidence before and 6 months after training. For satisfaction we compared them immediately after and 6 months after training. To do so, we calculated the 95% confidence intervals for the difference and used McNemar's tests of marginal homogeneity. We also checked the confidence ratings immediately after training for consistency with 6-month results. Furthermore, we determined the proportion of participants who reported that the training was relevant. All calculations were done using STATA Version 13; the level of significance was α = 0.05.

The four open-ended questions were analyzed qualitatively with thematic analysis following Braun and Clarke.²⁶ C.S. analyzed the texts generating initial codes and potential themes. These were discussed with the research group. Codes were reconsidered, and new themes discussed regularly throughout the entire process. The analysis was conducted within an essentialist/realist framework, focusing on the explicit meanings in the data.

Results

Response

We conducted 6 CSTs between 2012 and 2015 with a total of 53 participants and 5–15 participants per workshop. Two participants were excluded from the analysis due to their profession (psychologist and social worker). All other participants filled out the questionnaires before training (n = 51), one less did so immediately after training (n = 50), and nine less 6 months later (n = 42). Table 2 includes time, location, and number of participants for each training workshop.

Table 2.

Trainings and Responses

Event	Year	Place	Response before training (n = 51)^a	Response immediately after training (n = 50)	Response 6 months after training (n = 42)
1	2012	Basel	9	9	7
2	2012	Essen	15	15	10
3	2013	Essen	9	8	8
4	2013	Basel	5	5	5
5	2014	Basel	7	7	6
6	2015	Basel	6	6	6

n = 53 participants, 2 were excluded from analysis (1 psychologist and 1 social worker).

Participant characteristics

Participants were between 23 and 58 years old, and three-quarters were women. About half were physicians (n = 26) and half nurses (n = 24). Forty-two percent (n = 21) had attended CST before. Characteristics did not differ between those replying immediately after and 6 months after training (Table 3).

Table 3.

Characteristics of Participants

Characteristics	Response immediately after training (n = 50)	Response 6 months after training (n = 42)
Age at training
Mean (SD)	36.3 (9.2)	36.7 (9.1)
Range	23–58	23–58
Gender
Male	12 (24)	9 (21)
Female	38 (76)	33 (78)
Profession
Physicians	26 (52)	22 (52)
Nurses	24 (48)	20 (47)
Years in adolescent oncology
Mean (SD)	7.6 (6.4)	7.9 (6.6)
Range	0.25–25	0.25–25
Previous experience with CST	21 (42)	18 (42)

Values are numbers (percentages) unless otherwise stated.

CST, communication skills training; SD, standard deviation.

Confidence

Self-assessed confidence before the training was higher in most items for participants with previous CST experience (Supplementary Table S3). Confidence varied between items and points in time (Table 4). Participants felt confident before training in 7 of 19 items and remained confident 6 months after training. These items included disclosing the diagnosis when prognosis is good (item No. 1), psychological counseling (item No. 5), recruiting for clinical studies (item No. 7), obtaining informed consent (item No. 8), discussing side effects and noncompliance (item Nos. 9 and 17), and informing about a complex intervention (item No. 19). The proportion of participants who felt confident increased significantly for six items within 6 months (p < 0.05). These included disclosing the diagnosis when prognosis is bad (item No. 2), mediating between adolescent and parent (item No. 10), considering the viewpoint of the adolescent (item No. 11), getting back into a conversation with adolescents when they withdraw (item No. 13), talking about fertility with male patients (item No. 15), and involving adolescents in decision making about therapeutic options (item No. 18). Confidence was low to medium before training and nonsignificantly better within 6 months for six items. These included disclosing a relapse (item No. 3), changing from curative to palliative treatment (item No. 4), discussing sexuality (item No. 6), dealing with adolescents' decisions to not inform parents about examination results (item No. 12), and talking about fertility with female patients (item No. 16).

Table 4.

Self-Assessed Confidence Before, Immediately After, and 6 Months After the Training

	Variable	n	Before training	Immediately after training	Six months after training	95% CI ^a	p^b
	I feel … when I have to tell an adolescent …	24
1	that he/she has cancer—when prognosis is good.
	Not confident		4 (16.7)	1 (5.3)	1 (4.2)
	Confident		20 (83.3)	18 (94.7)	23 (95.8)	−9.2 to 34.2	0.38
2	that he/she has cancer—when prognosis is bad.	16
	Not confident		10 (62.5)	5 (45.5)	4 (25)
	Confident		6 (37.5)	6 (54.5)	12 (75)	7.5 to 67.5	0.03
3	when he/she has a relapse.	17
	Not confident		10 (58.8)	5 (45.5)	5 (29.4)
	Confident		7 (41.2)	6 (54.5)	12 (70.6)	1.9 to 57	0.06
4	when curative therapy is replaced with palliative therapy.	18
	Not confident		12 (66.7)	7 (53.8)	11 (61.1)
	Confident		6 (33.3)	6 (46.2)	7 (38.9)	−18.7 to 29.8	1
	I am … when I have to talk to an adolescent about …
5	psychological counseling	15
	Not confident		6 (40)	1 (9.1)	1 (6.7)
	Confident		9 (60)	10 (90.9)	14 (93.3)	2.8 to 63.9	0.06
6	about sexuality.	18
	Not confident		9 (50)	2 (15.4)	5 (27.8)
	Confident		9 (50)	11 (84.6)	13 (72.2)	−2.5 to 47	0.13
7	about participating in a clinical trial.	23
	Not confident		1 (4.3)	0 (0)	0 (0)
	Confident		22 (95.7)	19 (100)	23 (100)	−8.3 to 17	1
8	informed consent before beginning a therapy.	18
	Not confident		2 (11.1)	0 (0)	0 (0)
	Confident		16 (88.9)	13 (100)	18 (100)	−9 to 31.2	0.5
9	possible side effects from treatment.	31
	Not confident		0 (0)	0 (0)	1 (3.2)
	Confident		31 (100)	29 (100)	30 (96.8)	−12.7 to 6.2	1
	Particular clinical situations
10	The adolescent and the parents see the need for a therapy differently. When mediating between patient and parents, I feel …	20
	Not confident		9 (45)	0 (0)	2 (10)
	Confident		11 (55)	14 (100)	18 (90)	4.9 to 65.1	0.04
11	The adolescent wants to be solely responsible for a therapy decision. I am … that I that I can adequately take the adolescent's attitude into account in the decision process.	21
	Not confident		11 (52.4)	2 (12.5)	3 (14.3)
	Confident		10 (47.6)	14 (87.5)	18 (85.7)	12.6 to 63.6	0.01
12	The adolescent doesn't want the parents to be informed about the results of an examination. I feel … that I can deal with the patients wish with regard to his/her parents adequately.	17
	Not confident		13 (76.5)	2 (15.4)	9 (52.9)
	Confident		4 (23.5)	11 (84.6)	8 (47.1)	−8.3 to 55.3	0.22
13	An adolescent withdraws more and more. I feel … getting back into a conversation with him/her.	22
	Not confident		17 (77.3)	1 (6.7)	6 (27.3)
	Confident		5 (22.7)	14 (93.3)	16 (72.7)	21.1 to 78.9	0.00
14	Because of hair loss and massive changes to the skin, an adolescent is sad and angry. I feel … addressing and dealing with the sadness and anger.	24
	Not confident		7 (29.2)	1 (4.8)	1 (4.2)
	Confident		17 (70.8)	20 (95.2)	23 (95.8)	0 to 50	0.07
15	The adolescent needs a therapy, which will compromise fertility permanently. I feel … addressing fertility preservation with a male patient.	23
	Not confident		12 (52.2)	7 (41.2)	5 (21.7)
	Confident		11 (47.8)	10 (58.8)	18 (78.3)	7.3 to 53.6	0.02
16	The adolescent needs a therapy, which will compromise fertility permanently. I feel … addressing fertility preservation with a female patient.	26
	Not confident		12 (46.2)	5 (23.8)	5 (19.2)
	Confident		14 (53.8)	16 (76.2)	21 (80.8)	0.3 to 53.5	0.07
17	The adolescent is not taking important medication. I feel … addressing non-compliance.	32
	Not confident		3 (9.4)	1 (3.4)	1 (3.1)
	Confident		29 (90.6)	28 (96.6)	31 (96.9)	−8.9 to 21.4	0.63
18	A decision concerning therapy needs to be taken. I feel … judging the extent the adolescent would like to be involved in decision-making.	16
	Not confident		8 (50)	1 (10)	1 (6.3)
	Confident		8 (50)	9 (90)	15 (93.8)	13.2 to 74.3	0.02
19	The adolescent has to be informed about a complex intervention. I feel … explaining the intervention in developmentally appropriate terms.	21
	Not confident		1 (4.8)	0 (0)	1 (4.8)
	Confident		20 (95.2)	19 (100)	20 (95.2)	−18 to 18	1

95% CIs for difference in the percentage of confident participants between before and 5 months after training.

McNemar's test of marginal homogeneity. Items in bold show a significant increase of confidence.

CI, confidence interval.

The results of 16 of 19 items immediately after the training were consistent with the 6-month results. For two items, the immediate ratings were lower than those observed 6 months later (disclosing the diagnosis when prognosis is bad [item No. 2], talking about fertility with male patients [item No. 15]). For one item, the intermediate rating was higher than that observed 6 months later (dealing with adolescents' decision to not inform parents [item No. 12]).

Satisfaction and relevance

Participants were unanimously satisfied with the training, both immediately after the training and 6 months later (Table 5). They affirmed that the training was efficient, provided them with helpful techniques, and they would recommend it to their colleagues. Within 6 months after the training, 95% (n = 40) of the respondents had applied techniques from the training, and 71% (n = 29) confirmed that some aspects of their practice in adolescent oncology had changed due to the training.

Table 5.

Self-Assessed Satisfaction and Relevance Immediately After and 6 Months After the Training

Variable	n	Immediately after training	Six months after training	95% CI ^a	p^b
The atmosphere during the seminar was pleasant.	50
Disagree		1 (2)	—
Agree		49 (98)	—
Adolescent CST should be compulsory for pediatric physicians and nurses.	50
Disagree		3 (6)	—
Agree		47 (94)	—
It would be appropriate for residents and nurses to pay for the seminar themselves.	48
Disagree		40 (83.3)	—
Agree		8 (16.7)	—
The training was effective.	40
Disagree		0 (0)	0 (0)
Agree		40 (100)	40 (100)	−2.5 to 2.5	1
The training provided me with useful skills.	41
Disagree		0 (0)	0 (0)
Agree		41 (100)	41 (100)	−2.4 to 2.4	1
The training has helped me in discussions with patients and parents.	41
Disagree		0 (0)	1 (2.4)
Agree		41 (100)	40 (97.6)	−9.6 to 4.7	1
I would recommend this training to my colleagues.	41
Disagree		0 (0)	0 (0)
Agree		41 (100)	41 (100)	−2.4 to 2.4	1
Have you applied the communication skills acquired during the training?	42
No		—	2 (4.8)
Yes		—	40 (95.2)
Have any aspects of your practice in pediatric and adolescent oncology changed due to the training?	41
No		—	12 (29.3)
Yes		—	29 (70.7)

95% CIs for difference in the percentage of agreement between immediately after and 5 months after training.

McNemar's test of marginal homogeneity.

Positive and negative aspects

Immediately after training, 45 participants reported what they felt were positive aspects, and 28 reported negative aspects. The predominant positive aspects were the training's practical orientation and many practice opportunities. As one participant wrote “lots of practicing, the very practical orientation (real-life situations); short theory sessions (not too much information at a time).” The dominant negative theme was the training intensity in terms of time and exhaustion.

Six months postseminar, the responses referred to participants' experience when applying what they learned in the training to their work rather than to the workshop itself. Thirty-four participants reported positive aspects and 17 reported negative aspects. The predominant positive themes were more self-confidence and applied communication techniques. Participants reported being more confident talking about “emotional problems with patients” or having “less fear of difficult conversations.” Pauses, talking less, and remaining silent were the communication techniques that were most often reported: “I still find it most impressing how much one can get out of an exaggeratedly (for me) long pause. The long pauses, restraining myself from talking have been my biggest sustainable success!” The predominant negative theme was effect wears off with time: The need for more practice or refresher trainings was expressed repeatedly.

Discussion

The pilot CST based on participants' needs was feasible, satisfied the participants, and increased their self-confidence in specific areas of communication. Recently, Sisk et al. systematically reviewed communication studies in pediatric oncology and evaluated them according to six core functions of communication: fostering healing relationships, exchanging information, responding to emotions, managing uncertainty, making decisions, and enabling patient/family self-management.¹⁵

Our training started with participants' CIRs (Table 1), which did not necessarily cover all six core functions. Nevertheless, the participants' confidence improved in four of these functions: (1) exchanging information, for example, mediating between adolescent and parent; (2) responding to emotions, for example, getting back into a conversation with adolescents when they withdraw; (3) managing uncertainty, for example, talking about fertility with male patients; and (4) making decisions, for example, involving adolescent in decision making about therapeutic options.

Training all six core functions in one workshop is difficult. A focused workshop (e.g., decision making) prioritizes one core function over others. How CST is performed depends on the goal. If the focus is communication about infertility, knowledge and skills must be predetermined. E-learning might be possible with a focus. When based on participants' needs, the focus is not predictable, and face-to-face training is prone to be more favorable.

Feraco et al. reported substantial communication deficits in pediatric oncology, and linked these deficits to absent or insufficient CST, over-reliance on role modeling by seniors, and failure to utilize best practices. The authors advocate dedicated multimodal, small group programs organized around hallmark events such as “giving bad news.”²⁷ “Communication with an adolescent patient with cancer I had difficulties dealing with” could also be a hallmark event. In a pilot seminar, pediatric fellowship trainees were trained by bereaved parent educators and faculty facilitators in small groups using role-play with remarkable success.²⁸ Bereaved parents could be an alternative for actors.

Weintraub et al. reported on the feasibility of implementing a CST in pediatric hematology/oncology fellowships. In a pilot program with 13 pediatric hematology/oncology fellows, 9 completed all 3 years of training with significantly more self-reported comfort in several items such as discussing a new diagnosis, telling a patient he or she is going to die, discussing recurrent disease, communicating a poor prognosis, or responding to anger.²⁹ These results are very similar to our assessment in adolescent oncology. However, it remains difficult to compare the effect of our workshop with CST implemented in a fellowship.

The strengths of our approach are that the CST was focused on both physicians and nurses, and based on participant CIRs. It is inherent to our learner-centered approach that no training is the same. Trainings differ because participants determine the content. The evaluation strategy included the same questions for all participants. It shows that self-confidence in important and difficult situations improved, suggesting that participants provided the relevant CIRs. With this inductive teaching approach, the content is based on the needs and preferences of the participants instead of using a deductive, fixed set of must-haves. In mixed groups of nurses and physicians, the CIRs helped foster understanding of the other professional group's difficulties and promoted team-based, multiperspective thinking. The higher self-confidence ratings before the training of participants with previous CST experience strengthen our results, as the positive training effects are mainly based on beginners who started with low and improved to high ratings.

Limitations of our pilot remain

This is an explorative approach with voluntary, self-enrolling participants. Only a randomized controlled study could potentially prove an effect compared with a control group. When assessing the CST according to Kirkpatrick's four levels of learning evaluation only the first two levels (participants' reaction/course evaluations and self-confidence/evaluation of learning) are reached. In contrast to CST in adult oncology, no study in CST for HCPs interacting with adolescent patients with cancer reaches level 3 (patient interaction/evaluation of reactions) and level 4 (patient survey/evaluation of results).³⁰ Further studies on the effectiveness of CST in the adolescent cancer setting should include Kirkpatrick's levels 3 and 4, like the studies of Reed et al. and Curtis et al.^31,32 We cannot exclude that factors such as more clinical experience of participants may have an influence on the results. Furthermore, the dichotomization of scales allowed us to clearly discern changes in confidence but also reduced the number of replies included in the analysis, similar to the study of Schwenk et al.²⁵ From a statistical point of view, dichotomizing the scales is a valid approach as we used nonparametric tests to determine the effect of the training.³³

Certain topics, including palliative care and sexuality, were not addressed in our CST, and were rated low in terms of confidence by the participants. Future CSTs should include such specific topics additionally. Finally, the financial sustainability of such a training program is unclear. Most of our participants thought that residents and nurses should not have to pay for the training themselves. Costs are an obstacle to implementation that many pediatric oncology program directors share.²⁹

Conclusion

We provide an innovative approach to CST for physicians and nurses interacting with adolescents with cancer. The training focused on adolescent oncology, was interprofessional, and the agenda driven by participants' needs and inputs. The results are promising. Participants were satisfied with the training and considered it to be relevant to their daily work. Pre-existing low confidence in six areas was increased by the workshop and remained high 6 months later.

The results of this pilot suggest that it is worthwhile implementing further training opportunities with a focus on adolescent oncology, an interprofessional setting, and a program based on participant input.

Footnotes

Acknowledgments

We thank the training participants. We also thank the Swiss Cancer League for their support.

Author Disclosure Statement

No competing financial interests exist.

Supplementary Material

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