Communication skills for end of life careTraining for health and social care staff

Talking Needs ActionTraining Needs Analysis:The pilot sites report their findings for end of life care communication skills

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Acknowledgements 2Executive summary 31. Introduction 62. Background 83. Taking a needs-based approach 94. Identifying providers 105. The TNA itself 106. Engagement 117. Findings 128. What did the pilot sites get out of the TNA? 159. Getting results 1610. Good practice identified through the TNA 1911. Next steps for pilots 2112. References 21

Appendicesi Tools to support assessment and planning 22ii Scope 27

Glossary 29

Acknowledgements

With thanks to the 12 pilot sites that have participated in this project and haveshared their findings and experiences with the national programme.

Special thanks to Jill Banks Howe and Linda Nelson at the University of Teessidefor their support in developing the questionnaires for the training needs analysis.

Contents

Purpose and scope of thisreport

This report provides the first round offeedback from a training needs analysis (TNA)pilot project, set up to support thedevelopment of communication skills trainingfor all those working in end of life care (EoLC).

It provides some early outcomes and learningfrom 12 pilot sites around the country, each ofwhich carried out its own local workforceTNA. We hope these initial findings will beuseful to other organisations planning to carryout a TNA themselves, or to support thedevelopment of EoLC training plans. A seriesof ‘top tips’ are summarised in the document.

The report is also aimed at strategic healthauthorities, education commissioners andproviders, health and social servicescommissioners and service providers, healthand social care staff and their managers.

This project has been run by the National Endof Life Care Programme (NEoLCP) inpartnership with Connected©, the nationalcommunication skills training programme forcancer services.

Context and background

The health and social care EoLC workforce isemployed by a wide range of organisations ina variety of settings. Competence incommunication underpins all good qualityEoLC. It is essential that health and social carestaff can have open and effectiveconversations with people, their families andcarers about death and dying and the issuessurrounding it. This ensures that service usersare well supported, their wishes can beproperly discussed and personal care plans putin place.

The End of Life Care Strategy1 has identifiedcommunication as one of the fourcompetence areas that cut across all levels of

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Executive summary

practice. It recognises the skills that alreadyexist in the workforce and aims to build onthese to make sure that all staff have theability to deliver quality care for everyone.

Training and education are not the only waysto develop skills. Workplace learningopportunities through experience, role modelsand mentoring are very important. Appraisaland continuing professional development arealso vital.

There are cost benefits to having a competentworkforce that has timely and appropriateconversations with people at the end of life:individuals’ needs will be identified promptly,resulting in the right care at the right time andavoiding unnecessary interventions – makingbest use of staff time and resources.

Key findings

• The majority of health and social care staff are involved in EoLC. Staff time spent working in this area varies, depending on the setting and their role

• Most have received some basic, generic communication skills training

• Most believe they would benefit from further training to address the challenging demands of conversations with people approaching the end of life

• Provision of intermediate and advanced training is limited. There is specific need for more advanced training aimed at staff caring for non-cancer patients

• Social care staff, particularly those working for private organisations, have more limited access to EoLC training than health care staff

• Service providers and staff are not always aware of local training options

• There is often misunderstanding about the term ‘end of life care’. Many staff do not

appreciate their role in its delivery and therefore don’t understand the relevance ofEoLC training

• Co-ordination of training across local areas is often poor, with examples of course duplication and gaps.

Benefits of a TNA

The TNA has provided pilots with a betterunderstanding of the workforce engaged inEoLC, the existing competences and trainingcurrently available. This supports a strategicapproach to workforce development. Widepartnership engagement has enabled a moreco-ordinated approach and the TNA hasprovided a structure for ongoing monitoringof competences and for evaluating the impactof training.

The TNA process has had the additionalbenefit of raising awareness of EoLC andidentifying enthusiasm for training. It hassupported culture change – getting death anddying onto the agenda for the whole EoLCworkforce. The pilots have establishedstructures that facilitate effectivemultidisciplinary, multi-agency andinterdisciplinary working across organisationalboundaries. These will support ongoingworkforce development in EoLC as well asproviding a forum for future joint working inother areas.

Lessons learned – summary ofkey good practice tips (full detailsin report)

For commissioners• Specify the outcomes and quality standards

of education and training that are required for commissioning and risk management. Commission according to identified workforce need, include staff caring for both cancer and non-cancer patients

• Specify the necessary skills, attitudes and training required for the workforce in service agreements and contracts.

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For educators• Align training with workforce need,

accommodate individuals’ requirements, apply adult learning principles, encourage joint working and collaboration.

For service providers• Align workforce development with

corporate business strategies, governance systems, existing frameworks and clinical pathways. Link the cost benefits of a competent workforce to training proposals and embed relevant competences in recruitment/appraisal systems.

For staff managers• Provide opportunities to develop

competences in the workplace through mentoring, example and team support. Ensure person specifications and job descriptions describe the necessary communication competences accurately.

For individual staff• Take personal responsibility for reviewing,

renewing and enhancing the competences, knowledge and skill required for your role in EoLC.

Next steps

The TNA has provided the pilot sites with aninformation base to support development oftraining and education that will meet theneeds of their local workforce. It will then beimportant to monitor the delivery and uptakeof training and to evaluate its impact onbusiness objectives, the service userexperience, staff confidence and competence.

The final project report and findings will bepublished early in 2011.

“We found that the majority of staff within care homes had received little communication skills training and now, recognising that communicating with people at the end of life is a skill gap, are very keen to attend training.”Anil Garcia, project manager, Mount Vernon, Essex

1. Introduction - Why do aTNA and what are its aims?

“Ensuring that health and social care staff at all levels have the necessary knowledge, skills and attitudes related to the care of dying people will be critical to the success of improving end of life care.”End of Life Care Strategy 2008

People approaching the end of life oftenrequire a complex mix of health and socialcare services, which are provided across awide range of sectors and organisationsincluding hospitals, care homes, hospices andtheir own homes.

Many people – including clinical and non-clinical staff, family and friends, palliative andnon-palliative staff – provide this care.However, because it often forms only part ofthe non-palliative role, these particularworkers may not be trained in theidentification, delivery and discussion of EoLC.

Workforce competence in communicationunderpins all good quality EoLC. While genericcommunication skills are important in allsettings, there are particular challengesinvolved in communicating with people at theend of life.

By building on existing workforce skills andtraining, we aim to provide health and socialcare staff with the skills and confidence theyneed to have open and effective conversationswith people, their families and carers aboutdeath and the issues surrounding it. In thisway service users’ wishes can be discussedand care plans put in place. Goodcommunication contributes significantly toquality of care and there is sound evidence toshow that training can improve competence incommunication.

As well as improving service quality there areinherent cost benefits in developing a

"Most staff acknowledged that the communication skills training they had received did not focus specifically on end of life care and felt they would like further training to support them in their role."Sally Coppock, advanced nurse practitioner, St Gemma's Hospice

competent workforce that identifies patients early and is able to initiate timely and appropriate conversations. Needs will be identified promptly, avoiding unnecessaryinterventions and making best use of stafftime. Better communication between staff,individuals and their carers will improve co-ordination of services and facilitate best use ofresources. Cost savings could also be madethrough improved planning of trainingprogrammes, ensuring that duplication isavoided. A properly trained workforce is likelyto have higher morale and job satisfaction –resulting in less staff attrition.

The English health and social care workforcein EoLC is estimated to be around 2.5 million.The communication skills pilot project, ofwhich the TNA is a part, was established tosupport development of communication

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Leeds: St Gemma’s Hospice

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competences in this workforce, building onand enhancing their existing skills. TheNEoLCP is working on this project inpartnership with Connected©, the nationalcommunication skills training programme forcancer services.

Twelve pilot sites have been set up across thecountry2. They were asked to assess existingworkforce competences, then use the resultsof their assessment to determine the trainingrequired. Using this needs-based approach, the first step was for each pilot site to carryout a TNA.

The purpose of this report is to highlight someof the early TNA findings and to suggest howthese can be used to develop best practice inother locations. We hope that it will be usefulto organisations that are planning to carry outa TNA themselves or to support thedevelopment of their training plans. Ithighlights the rationale behind the TNAproject and the processes used, as well asdetailing the key findings from and benefits tothe pilot sites.

This report is relevant to all those with aninterest in EoLC, particularly:• Strategic health authorities’ workforce

development leads• Local education commissioners• Commissioners of local health and social

care services• Education providers including higher

education institutes, further education institutes and specialist education providers

• Local service providers• Health and social care staff and their

managers.

Further analysis of the pilot site findings willbe included in the final project report, whichwill be published early in 2011.

"Staff working in critical care, renal medicine and stroke services initiate and respond to difficult end of life conversations. They need the knowledge and skills to provide support, care and information for this vulnerable group of people and their care givers."Jayne McGurran, senior communication skills development trainer, Lancashire and South Cumbria Cancer Network

Lancashire and South Cumbria Cancer Network

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2. Background: the threefoundation projects

Three foundation projects have been set up toprogress The National End of Life CareStrategy’s vision for workforce development.

Communication skillsTwelve pilot sites across England wereestablished in September 2009. Their aim is toexplore training need, develop local trainingfor EoLC and so inform good practice forfuture training and education.

The pilot sites are:• Berkshire East Community Health Services

• Dorset Cancer Network

• East of England Cancer Networks (Mount Vernon, Anglia, Essex)

• NHS West Essex

• Greater Manchester and Cheshire Cancer Network

• North East London Cancer Network

• South East London Cancer Network

• St Gemma’s Hospice, Leeds

• University of Teesside

• LOROS Hospice (Leicestershire and Rutland)

• St Luke’s Hospice, Plymouth

• Lancashire and South Cumbria Cancer Network.

Common core competencesSkills for Health and Skills for Care identifiedthe common core competences and principlesfor EoLC, which were published in June20093. These provide a framework to supportThe National End of Life Care strategy,specifying the principles and competencesthat form the common foundation for theEoLC workforce in health and social care.

A framework of national occupationalstandards was subsequently published inJanuary 20104, which specified the core

standards that underpin the competencyframework. A knowledge set for EoLC is alsoavailable which specifies the learningoutcomes for the five key areas ofcompetence as identified in the common corecompetences, including communication.

The common core competences forcommunication skills, their related nationaloccupational standards and the knowledgesets have formed the basis of the TNA (seeappendix i for background information).

e-ELCAA suite of free e-learning sessions launched inJanuary 2010 by the programme and itspartners includes a core module oncommunication skills for EoLC. Workers inmany health and social care agencies are ableto access the resource at www.e-elca.org.uk.The sessions are intended to support a varietyof learning approaches, including experientialand face-to-face. The curriculum for e-learning is also aligned to the common corecompetences (see appendix i).

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3. Taking a needs-basedapproach

“We have found this project extremelyvaluable; the data collected have provided us with excellent evidence to support ourcurrent communication skills educationprovision and have given us significant insight into how this provision may besuccessfully developed for the future endof life care workforce.”Sharon de Caestecker, head of education, LOROS

Why do a TNA?TNA is the process by which training anddevelopment needs are identified. Thepurpose is to outline how organisationalobjectives will be realised through the development of workforce competences.

As well as analysing training needs at anindividual level, the process must consider thelinks to both functional and organisationalobjectives.

The TNA process supports:• Development of a training resource plan• Procurement of needs-based education and

training • Planning of associated training activities• Procurement of services provided by a

competent workforce.

Once the need is identified, a resource plancan be agreed and the appropriate trainingdelivered. Assessment of its impact will theninform business objectives. This needs-basedapproach supports the development of acompetent workforce, avoiding unnecessaryor duplicated training.

Identify the competences required for the workforce

Training Needs Analysis

Identify service providers and assess workforce

competences

Benchmark against competences

Identify currenttraining and education

Determine businessobjectives

Monitor and evaluate impact of training

Implement training

Develop/commissiontraining

Training resourceplan

Identify training need

Needs-based approach

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4. Identifying providersThe first step for the pilots was to identify thehealth and social care services expected todeliver EoLC and all local education andtraining providers in their area. Dorsetbroadened its scope to include nineteensectors that may have some contact withpeople at the end of life. These included fireand ambulance services, the police, solicitorsand military bodies.

“The global to specific approach of our scoping proved a useful methodology since it enabled us to get an overall sense of what communication skills training was being provided throughout Dorset, across all sectors.”Annie Raven-Vause, project lead, Dorset

5. The TNA itself5.1 MethodsThere are a range of data collection methodsavailable, which include:• Interviews• Group discussions• Focus groups• Questionnaires and surveys• Job analysis, including review of job

descriptions.

5.2 Objectives• To identify the existing competences in the

EoLC workforce• To identify the current training provision• To match the current skills against the

recommended competences• To identify any shortfall.

5.3 TNA approach Pilot sites selected the objectives andapproach that best met local requirements.The programme worked with TeessideUniversity, using guidance from NHSConnecting for Health5,6, and in consultationwith the pilots to develop three separatequestionnaires - for employers, employees andtraining providers. These templates could bemodified to reflect local need and ten pilotsites made some amendments to them.

Dorset Cancer Network

The majority of sites used surveyquestionnaires as the basis for the TNA butseveral supplemented these with focus groupsfor particular sectors, eg training providers.Most questionnaires were completedindependently by individuals – sometimesfollowing a presentation – while others werecompleted by a researcher during telephoneinterviews. Questionnaires were delivered torespondents by hand, sent by post orelectronically and a few sites developed theirown online versions (Plymouth, LOROS,Dorset).

Most pilots surveyed employer organisations,employee representatives and trainingproviders. Essex made the decision to targetonly employers and training providers.

Some pilots tailored their approach to specificstaff groups. Leicestershire and RutlandHospices (LOROS), for example, targetedvolunteer staff separately and developed acustomised information sheet, while Leedstailored its data collection methods for eachstaff group.

6. Engagement

“There are a huge number of employingagencies of various types concerned withdelivering end of life care and one of thechallenges of this study has been to ensurethat we have sufficient responses from arange of employers to give representativefindings.”Tonia Dawson, nurse director, Anglia Cancer Network

Response rates varied between pilots, sectorsand settings. Pilots achieved more responsesby actively marketing the questionnairesthrough briefing events, engaging managersto promote the TNA with their staff andtailoring their questionnaires or collectionmethods to target specific groups. Repeatmailouts and telephone follow-up of non-responders also achieved higher rates and

provided an opportunity to complete thequestionnaire by telephone. For example,Mount Vernon got good results fromemployers by repeating emails and carryingout phone or face-to-face interviews,achieving 59 percent response rates in primarycare, 35 percent in acute care and 23 percentin care homes.

In general, response rates were lower fromsocial care employees. This highlighted theimportance of making language appropriateand relevant to the sector and of involvingsocial care partners in the projects from theoutset.

Response rates were higher from trainingproviders. For example, 66 percent of trainingprovider questionnaires were returned inAnglia, 58 percent in Leeds and 54 percent inMount Vernon. In Lancashire and SouthCumbria the response rate from trainingproviders was lower but, by holding a focusgroup, they successfully supplemented theirfindings with additional qualitativeinformation.

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East of England

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7. Findings

Main findings

• The majority of health and social care staff are involved in EoLC

• Most have received some basic, generic communication skills training

• Most believe they would benefit from further training to address thechallenging demands of conversations with people approaching the end of life

• Provision of intermediate and advanced training is limited, with a particular need for more advanced training aimed at staff caring for non-cancer patients

• In many areas there is a lack of awareness of available training

• Co-ordination is often poor, with examples of course duplication and some gaps

• Access to EoLC training is generally morelimited for social care staff than health care staff

• Often staff did not appreciate their role in EoLC, or the relevance of specialised training in this area.

7.1 End of life care workforce – the detailsThe results confirmed that most of the healthand social care workforce is engaged indelivery of EoLC. For example, 92 percent ofSt Luke’s respondents and 52 percent inDorset – which surveyed a wider range ofsectors – had conversations with people aboutdeath and dying. This highlights the fact thatmany occupations and staff groups have someengagement with EoLC.

The proportion engaged in EoLC varieddepending on the sector. In Leeds, for

example, 60 percent of the voluntary staff and 100 percent of acute sector staff said theyhad some involvement, while in Essex 77 percent of nursing, care home and domiciliarycare staff were engaged in this area.

The amount of time staff spent in EoLCvaried, depending on their roles. Anglia foundthis ranged between 20 and 100 percent ofstaff time overall. Community nursing teamsand critical care workers surveyed in Leedsspent 20 to 40 percent of their time caring forpeople at the end of life. The majority ofcritical care workers in Lancashire and SouthCumbria also spent around the same amountof their time in EoLC, while the majority ofstroke service staff in Lancashire and SouthCumbria reported less than 20 percentengagement.

The TNA uncovered a frequentmisunderstanding of the term ‘end of lifecare’ – with employees not appreciating theirrole in delivery of such care and the relevanceof EoLC training to them.

7.2 Training provision – the detailsA range of organisations providescommunication skills training: higher education institutes (HEIs); further educationinstitutes (FEIs); in-house local service

Leicestershire and Rutland Hospices (LOROS)

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providers; hospices and occasionallyindependent organisations. Specialist palliativecare staff, working in hospices or the acutesector, provide most of the communicationskills training for EoLC.

Most pilot sites found a range of local coursesavailable at basic or basic/intermediate level for health workers, some of which werespecific to EoLC. Provision of intermediate andadvanced level courses is more limited, withfew opportunities outside the Connected©

training programme for cancer services. Therewere, however, some examples of moreextensive provision. For example, LOROSfound that a wide range of communicationskills courses – including some academicallyaccredited ones – were available to most staff.

Basic communication skills training for socialcare workers is generally provided throughinduction or NVQ courses. The surveys suggestthat social care staff, particularly thoseworking for private agencies, may have morelimited access to EoLC communication skillstraining than those working in health. InEssex, however, which is responding to theshift towards supporting people to die athome, the important role of domiciliary careworkers has been recognised and plans are inplace to develop specialist domiciliary careworkforce skills.

Most trainers held a teaching qualification andmany had undertaken the Connected©

Advanced Communication Skills Training(ACST) course. Some of those teaching atadvanced level felt they would benefit fromadditional training.

The TNAs suggest that service providers arenot always aware of local trainingopportunities for staff and there may belimited co-ordination in the local planning ofcourses with examples of content overlap,duplication and some gaps. In general, thereappears to be a lack of training co-ordinationacross the different sectors and disciplines.

“If more people choose to die at home, domiciliary care agencies have an importantrole to play in end of life care. Targeting these agencies – and ensuring the workforce has the opportunity to develop the skills they need – will contribute to the success of the national strategy.”Carol O’Leary, Macmillan nurse director, Essex Cancer Network

There were, however, some examples of goodpractice. Essex found evidence of collaborativeworking between service providers, whocommissioned training from each other.

7.3 Competences – the detailsThe results show that most health and socialcare workers involved in EoLC have receivedsome basic, generic communication skillstraining but may not have received anytraining specific to EoLC. In particular, socialcare staff were less likely to have receivedEoLC communication skills training. Very fewrespondents outside the cancermultidisciplinary teams had advanced training.

Communication is a core skill specified in thecommon induction standards for social care

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and the majority of these respondents hadattended basic courses. The Care StandardsAct 2000 requires 50 percent of care homestaff to be trained to NVQ level 2 or above inhealth and social care, which includes a uniton communication skills. However, care home,domiciliary staff and employers oftenrecognised a need for more. Those employedby private agencies may not have had thesame access to core skills training.

There were some examples of a more skilledworkforce. Essex found many care home staffhad received training specific to EoLC and 57percent of LOROS employee respondents saidthey had received some. Of these, 17 percenthad completed ACST and another 24 percenthad received other training. These courses,mainly provided by the hospice, includedcounselling, palliative care and bereavement.

Most health and social care staff assessedthemselves as competent in EoLCcommunication but felt that they wouldbenefit from additional training. LOROS foundthat 50 percent of those who assessedthemselves as competent had received somerelevant training. In Leeds, qualified nursesworking in nursing homes and care officersworking in residential homes felt competent indiscussing advance care planning andundertaking holistic needs assessments, butwere less confident in supporting bereavedand distressed relatives. The Leeds TNAindicated that care workers, especially ancillarystaff, may have overestimated theircompetence in some areas owing to a lack ofunderstanding of the criteria and skill setrequired for their role. This would needfurther investigation. The difficulty of self-assessing competence was also recognised byTeesside University and Dorset.

7.4 Training need – the detailsThe majority of staff felt they had theopportunity to identify their training needs viatheir appraisal with their line manager.Although most have core competences ingeneric communication, relatively few havehad specific training. There was somevariation between settings, with residential

care home staff and domiciliary staffidentifying most training need.

Most sites identified a gap in advanced leveltraining for EoLC for health and social carestaff who were not eligible for theConnected© ACST. As well as a need for moreadvanced training generally, this highlights theimportance of access to competency-based,advanced level training for appropriate staffcaring for non-cancer patients.

Many employees felt that they would benefitfrom additional tailored training, particularly inbreaking bad news, managing complex needs,bereavement support, bereavementcounselling, holistic needs assessment,advance care planning, cognitive behaviouraltherapy and informed consent. Most alsorecognised the need for ongoing learning anddevelopment.

“The TNA findings have helped to identify the target audience and required level of communication skills training within our region. We can now utilise this information to develop programmes and workshops to meet these needs, which can only enhance the care currently delivered to individuals at the end of their life.”Linda Nelson, principal lecturer, TeessideUniversity

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7.5 Top tips to improve access to training

• Provide a range of training styles to accommodate a diverse workforce

• Apply adult teaching principles for learning and development that place a level of trust and responsibility on the individual

• Consider timing and venues to facilitate access for all staff groups

• Make information about training widely available

• Use available funding resources to optimise learning opportunities for all

• Take account of high staff turnover and its impact on costs and capacity

• Consider the literacy and language needs of staff with English as a second language.

8. What did the pilot sitesget out of the TNA?

8.1 Benefits for workforce development• A more strategic approach that addresses

the competences required

• A better understanding of the EoLC workforce, its existing competences, the training currently provided and the future training need

• An informed platform on which to base training plans and sound rationale for decision-making

• Resource issues were identified to inform training plans

• Better engagement with stakeholders, improving co-ordination of training

• A structure to monitor workforce competences and evaluate training impact.

8.2 Wider benefits• TNA raises awareness of EoLC,

communication skills and training need

• TNA puts death and dying onto the agenda for the whole EoLC workforce

• New relationships and structures have established effective multidisciplinary, multi-agency and interdisciplinary working across organisational boundaries

• Knowledge gained from this TNA can support development of other EoLC skills, such as advance care planning

• The commitment to staff development has the potential to improve staff morale and the feeling of being valued – better staffretention and associated cost savings are along-term benefit of this

• TNA contributes to the development of a learning culture, enabling faster, more effective implementation of training

• TNA provides an opportunity to address users’ communication needs.

North East London and South East London Cancer Networks

9. Getting results

Top tips for a TNA

1. Allow adequate time for thorough planning and preparation

2. Match the level of enquiry to organisational needs and set a realistic scope and timeframe

3. Consider the use of sampling and making projections based on workforce numbers

4. Involve representatives from all stakeholders in consultation and planning to improve engagement and data quality across sectors

5. Customise questionnaires, using language and terminology specific toeach sector. Keep questions simple and focused, basing them on the core competences and taking into account that literacy and language issues can be barriers

6. If relevant, take advantage of the opportunity to incorporate other EoLC competences in the TNA

7. Pilot questionnaires with all staff groups to reduce incomplete and inaccurate data

8. Use online surveys to easily collate and analyse data but be aware that some staff have limited computer access and IT skills

9. Consider telephone surveys for employers and training organisations. They also help to clarify questions

10. Improve response rates by marketing the TNA beforehand and following up non-responders.

9.1 Preparation• It is difficult to survey such a wide range of

staff groups and organisations. The level of enquiry should identify and reflect organisational needs, with a realistic scope and timeframe agreed beforehand

• Social care, in particular, features large numbers of - often small - providers, which may include private and third sector employers, as well as local authorities. There is often a very mobile workforce. It is important to appreciate that getting contactinformation may be difficult and time-consuming. Databases may be out of date. The Care Quality Commission website7

proved to be a useful source of contact details for all care homes and home care services by local authority region

• Where further investment in training is planned, consider statistical and numerical goals when using questionnaires. The required response rates or the percentage of the workforce surveyed, for example, should be carefully considered in advance

• Consider incorporating other EoLC competences in the TNA if appropriate

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Greater Manchester and Cheshire Cancer Network

• Projections of training needs can be made through a combination of comprehensive scoping of health and social care providers, quantifying the workforce according to staffgroups, and a survey or interviews with a representative sample of the workforce

• Plan how you will communicate results, defining channels and audience

• Delivery and uptake of training must be monitored and evaluated. This should include its impact on business objectives, staff confidence/competence and how this links to the user experience.

9.2 Targeting• Consider customising questionnaires/

approaches for specific staff groups

• Telephone surveys can be useful, especially for employer and training provider organisations. Queries can be addressed more easily and an instant response is received.

9.3 Sampling• It may not be necessary to capture data

from all employees. More meaningful information may be gained by targeting specific staff by group, level or setting, using tailored approaches. Projections can then be made based on workforce data

acquired from scoping

• Similarly, consider selection of a cross-section of care providers and concentrate on a smaller number but with more depth of investigation, using questionnaires, interviews or focus groups as appropriate.

9.4 Engagement• Improved engagement with managers and

organisations can be expected if the TNA has minimal impact on ‘business as usual’

• Targeted marketing and presentations to groups of staff helped to increase response rates. Most sites found that raising awareness and interest in training resulted in a better understanding of local need

• Response rates are improved by good communication; in particular, ensuring people know the ‘format’ for the method (eg interview or group discussion), the time it will take, the purpose of the TNA and theintended use of the data collected

• Involving representatives from all stakeholder groups in consultation and planning is likely to improve engagement across all sectors and achieve higher response rates

• Pilot sites that included social care representation on their planning teams and those that sought support from their regional Skills for Care representatives found it easier to identify social careproviders and to engage with this sector

• Personal approach methods such as interviews, while more time intensive, usually provided better responses than morepassive approaches, such as sending out a questionnaire

• If response rates are low, there is potential for bias and care should be taken in interpretation of the findings.

9.5 Questionnaires• Keep questionnaires simple and be clear

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about the questions that need answering. Keep the focus as narrow as possible

• Use the agreed competences as the basis for the TNA

• The language used in invitation letters and questionnaires is paramount. Terminology and priorities are very different between the health and social care sectors. Take this into account to avoid alienating people

• Literacy and language can be a barrier for some staff attempting to complete questionnaires

• Piloting of questionnaires with a full range of staff groups is essential to reduce incomplete and inaccurate data

• Online questionnaires did not improve response rates but were useful for data analysis and capture

• Not all staff have access to computers in the workplace – particularly in care homes. IT literacy was also found to be an issue for some so consider whether electronic or paper questionnaires are more appropriate

• The pilot schemes found it hard to determine the training levels required by the employees surveyed. Consider incorporating questions on staff role and exposure to EoLC to tackle this.

9.6 Care required• If using questionnaires, it can be difficult to

identify the competences being addressed in training programmes – especially as communication skills training is often embedded within other courses and may not be specific to EoLC

• Self-assessment of competences can be unreliable. The TNA found evidence of over-reporting and under-reporting

• Benchmarking of training against competences does not take account of the quality and effectiveness of the training or value for money.

“The TNA process has improved engagement across a range of organisations and provided a good platformfor future working.”Paula Hine, education and developmentmanager, St Luke's Hospice

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Plymouth: St Luke’s Hospice

10. Good practice identifiedthrough the TNAThe TNA results have identified someimportant ways to improve practice.

10.1 For commissioners• Align workforce development plans with

organisational objectives and strategies

• Incorporate project benefits and expected outcomes into wider project, resource and implementation plans

• Align workforce competences with governance systems around patient safety and risk management

• Specify the outcomes and quality standards that are required for commissioning and riskmanagement. Select training that has evidence of effectiveness, uses recognised methodologies and offers value for money

• Identify both the cost benefits and the service benefits of training

• Determine the return on investment by developing evaluation criteria to assess the

impact on staff confidence/competence. Link workforce development to patient experience

• Specify the necessary skills, attitudes and training required for the workforce in service agreements and contracts

• Oversee the commissioning of training at a sector or regional level and ensure clarity of responsibility for co-ordination of local provision. Aim to provide a comprehensive range of suitable courses with appropriate capacity, avoiding unnecessary duplication

• Commission appropriate communication skills training for staff caring for both cancer and non-cancer patients.

10.2 For educators• Align training with the common core

competences and the identified needs of the local workforce

• Accommodate individual training requirements, in terms of both knowledge and preferred learning style, according to accepted training principles. Apply adult learning approaches that are based on mutual trust, respect, personal responsibilityand experience

• Work collaboratively with other local providers to ensure that the range of training provided is responsive to changing needs, co-ordinated and comprehensive

• Market what is on offer to both health and social care sectors and provide directories ofall local training and education

• Design training for minimum impact on continuity of service delivery

• Link workforce development to patient experience to capture the benefits of training

• Provide appropriate support to all those delivering courses

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Berkshire East Community Health Services pilot

• Encourage joint training across specialities and sectors as this has the potential to reinforce the value of multidisciplinary working

• Consider supplementing the current core generic communication skills training with an introduction to EoLC conversations or scenarios

• Use the e-ELCA (End of Life Care for All) e-learning sessions to supplement generic communication skills programmes for EoLC.

10.3 For service providers• Align workforce development with

corporate business plans and strategies

• Align workforce development with existing frameworks and link to clinical pathways

• Align workforce competences with governance systems around patient safety and risk management

• Link cost benefits of a competent workforceto training proposals and corporate businessobjectives

• Take account of the costs of backfilling staffabsence when planning training and development

• Embed EoLC communication competences in human resources and organisational development plans for recruitment and appraisal

• Align job descriptions and personal specifications for the EoLC workforce to theKnowledge and Skills Framework (KSF) or the Common Induction Standards for communication

• Create good data collection and record keeping systems - they are essential to monitor training and staff competences

• Link workforce development to patient experience in order to capture the benefits of training.

10.4 For staff managers• Align workforce development with

corporate business plans and strategies

• Create good data collection and record keeping systems – they are essential to monitor training and staff competences

• Ensure job descriptions and personal specifications accurately describe communication competences required for the role

• Include communication skills in all health and social care staff appraisals and incorporate into continuing professional development

• Provide the opportunity to develop communication competences in the workplace through mentoring, example andteam support.

10.5 For individual staff• Take personal responsibility for reviewing,

renewing and enhancing the competences, knowledge and skill required for your role in EoLC

• Measure individual role specifications against the common core competences, principles and the underlying national occupational standards to identify the competences required

• Use your appraisal and personal development plans to identify training needs.

"Feedback from some employers was that literacy and language could have been a barrier to completing the TNA forms, particularly for those in more junior roles."Sally Coppock, advanced nurse practitioner, St Gemma's Hospice

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11. Next steps for pilotsThe TNA has provided the pilot sites with aninformation base to support development oftraining and education that will meet theneeds of their local workforce. It will beimportant to monitor the delivery and uptakeof training and to evaluate its impact onbusiness objectives, staff confidence andcompetence, and on the user experience.

Please contact the national programme atinfo@endoflifecare.nhs.uk for moreinformation, or if you would like to havecopies of the questionnaires used by the pilotsites.

12. References1. National End of Life Care Strategy.

Department of Health, 2008

2. Developing skills: talking about end of life care. National End of Life Care Programme/Connected©, 2010

3. Common core competences and principles: a guide for health and social care workers working with adults at the end of life.NEoLCP/DH/Skills for Health/Skills for Care, 2009

4. A framework of national occupational standards to support common corecompetences and principles: a guide for health and social care workers working with adults at end of life. NEoLCP/DH/Skills for Health/Skills for Care, 2010

5. EDT 3 – standard - training needs analysis. NHS Connecting for Health

6. ETD 3 – guidance – training needs analysis. NHS Connecting for Health

7. Care Quality Commission website http://www.cqc.org.uk/findcareservices.cfm

Teesside University

Case studies highlighting the pilot sites' work will be posted on the National End ofLife Care Programme’s website, www.endoflifecareforadults.nhs.uk, as they becomeavailable.

A summary of this report is available from the publications section of the programme’swebsite.

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Appendix i: Tools to support assessment and planning

1. Common core competences and principles: a guide for health and social care workers working with adults at the end of life (NEoLCP/DH/Skills for Health/Skills for Care, 2009)

ExtractThe competences for communication

(a) In relation to EoLC, communicate with a range of people on a range of matters in a form that is appropriate to them and the situation

(b) Develop and maintain communication with people about difficult and complex matters or situations related to EoLC

(c) Present information in a range of formats, including written and verbal, as appropriate to the circumstances

(d) Listen to individuals, their families and friends about their concerns related to the end of life and provide information and support

(e) Work with individuals, their families and friends in a sensitive and flexible manner, demonstrating awareness of the impact of death, dying and bereavement, and recognising that their priorities and ability to communicate may vary over time.

Principle 2

Effective, straightforward, sensitive and open communication between individuals, families,friends and workers underpins all planning and activity. Communication reflects anunderstanding of the significance of each individual’s beliefs and needs.

Link to the guidance:http://www.endoflifecareforadults.nhs.uk/publications/corecompetencesguide

2. A framework of national occupational standards to support common core competences and principles for health and social care workers working with adults at the end of life (NEoLCP/DH/Skills for Health/Skills forCare, 2010)

ExtractNational occupational standards (NOS) identified as relevant for ALL health and social care staffwho communicate with people at the end of life.

Assistant levelHSC21 Communicate with and complete records for individuals

Practitioner levelHSC31 Promote effective communication with, for and about individualsHSC366 Support individuals to represent own needs and wishes at decision-making

forumsHSC368 Present individuals’ needs and preferences

Appendices

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Advanced practitioner levelHSC41 Use and develop methods and systems to communicate, record and reportCHS48 Communicate significant news to individualsHSC366 Support individuals to represent own needs and wishes at decision-making

forumsHSC368 Present individuals’ needs and preferences

Download guidance from:http://www.endoflifecareforadults.nhs.uk/publications/corecompetencesframework

Search toolsOther NOS may be relevant for specific staff roles or settings and a search tool is available athttps://tools.skillsforhealth.org.ukAdditional online tools to support identification and application of NOS are available on theSkills for Health website at www.skillsforhealth.org.uk

3. Knowledge set for end of life care (revised edition, Skills for Care, 2010)

Section 2: Communication EoLC common core Learning outcomescompetences (key themes)

2.1 Communication 2.1.1 Understand the importance of communicating, reporting and principles recording effectively in the care environment

2.1.2 Understand the need for positive and effective communication with the individual who is considering the end of their life

2.1.3 Understand the importance of listening to what an individual is saying to you, to ensure individuals feel valued and fully involved in the decision-making process about their care

2.1.4 Recognise that the individual’s feelings and behaviour will often be linked directly to their illness and the need to communicate about it

2.1.5 Understand that the individual’s body language is often a key indicator in what they are communicating

2.1.6 Understand principles and practices relating to confidentiality 2.2 The professional 2.2.1 Understand that significant news should normally only berelationship - roles communicated by a senior member of staff - however, this shouldand responsibilities not limit your communication with individuals

2.2.2 Be aware of the boundaries of your role, know how to communicate this to others

2.2.3 Know what is an appropriate professional relationship with an individual, based on trust and honesty within the constraints of your job role

2.2.4 Know how to develop a professional working relationship with friends and family members in order to support them

2.2.5 Be aware of other sources of support for individuals. For example,when considering spiritual or pastoral needs, offer to contact a minister or other faith leader if appropriate

2.2.6 Understand your level of responsibility and when to refer to a more appropriate person for information

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2.3 Providing 2.3.1 Recognise that more informed individuals are more empowered accurate and peoplerelevant information 2.3.2 Understand that individuals need access to good quality and

comprehensive information, as and when they want it2.3.3 Have knowledge of local services appropriate for the individual2.3.4 Be aware of how to provide information about services and

support networks that are available to individuals, their families and friends

2.3.5 Know how to offer written (or alternatively formatted) information and ensure it is in a language and format appropriateto the person receiving it

2.4 Recording 2.4.1 Know the importance of recording and communicating any practices significant conversations with an appropriate level of detail

2.4.2 Distinguish between subjective and objective language, fact and opinion

2.4.3 Know what constitutes clear, objective statements in care plans, reports, daily logs, handover reports, etc

2.4.4 Understand the importance of using appropriate language and avoid the use of negative statements and language when describing a person approaching the end of life

2.5 Supporting the 2.5.1 Have an understanding of a person-centred approach to support individual and their and care for individuals who are at the end of lifefamily and friends 2.5.2 Understand the need to support and work with family and

friends of the individual2.5.3 Know how to ensure family members are supported from

diagnosis to the end of the individual’s life and beyond2.5.4 Understand the importance of involving family members in the

decision-making process (within agreed limits or if the care plan names them)

Link to the guidance:http://www.skillsforcare.org.uk/developing_skills/knowledge_sets/end_of_life_care.aspx

4. Common induction standards (Skills for Care, 2005)Standards for people entering the social care workforce and those changing roles or employerswithin social care. They are designed to be met within 12 weeks of starting employment.

Standard 3 Communicate effectively

Main areas Outcomes Additional information

1. Importance of 1.1 Be aware of the different effective reasons why people communication in communicatethe work setting 1.2 Understand how

communication affects relationships in the work setting

1.3 Know why it is important toobserve an individual’sreactions when communicating with them

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Main areas Outcomes Additional information

Link to further details about common induction standards:http://www.skillsforcare.org.uk/entry_to_social_care/common_induction_standards/common_induction_standards.aspx

2. Meeting the communication and language needs, wishes and preferences of individuals

3. Overcoming difficulties in promoting communication

4. Understand principles and practices relating to confidentiality

2.1 Know how to establish an individual’scommunication and language needs, wishes and preferences

2.2 Understand a range of communication methods and styles that could help meet an individual’s communication needs, wishes and preferences

3.1 Recognise barriers to effective communication

3.2 Be aware of ways to reduce barriers to effective communication

3.3 Know how to check communication has been understood to minimise misunderstandings when communicating

3.4 Be aware of sources of information and support or services to enable more effective communication

4.1 Understand what confidentiality means in your work role

4.2 Be aware of ways to maintain confidentiality in day to day communication

4.3 Be aware of situations whereinformation normally considered to be confidential might need to be passed on

4.4 Explain how, when and from whom to seek advice about confidentiality

Communication methodsinclude:• non-verbal

communication including:• eye contact• touch• physical gestures• body language• behaviour

• verbal communication including:• vocabulary• linguistic tone• pitch.

Communication may includesigns, symbols, pictures,writing, objects of reference,human and technical aids,eye contact and touch.May include a personal auditof your own written andcommunication needsEg culture, religion, healthissues, sensory impairment

Services may include:• translation• interpreting services• speech and language

services• advocacy services

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Core competencesIn relation to EoLC,communicate with a range ofpeople on a range of matters ina form that is appropriate tothem and the situation

Develop and maintaincommunication with peopleabout difficult and complexmatters or situations related toEoLC

Present information in a rangeof formats, including writtenand verbal, as appropriate to thecircumstances

Listen to individuals, theirfamilies and friends about theirconcerns related to EoLC, andprovide information and support

Work with individuals, theirfamilies and friends in a sensitiveand flexible manner,demonstrating awareness of theimpact of death, dying andbereavement and recognisingthat their priorities and ability tocommunicate may vary overtime

e-ELCA sessions• Importance of good communication• Principles of communication• Communicating with ill people• Talking with ill people: consider the surrounding

environment• Culture and language in communication• Information giving• Breaking bad news

• “Am I dying?” “How long have I got?” - handling difficult questions

• “Please don’t tell my husband….” - managing collusion• “I don’t believe you, I’m not ready to die!” - managing

denial• “What will it be like?” - talking about the dying process• “Why can’t I stay here?” “I don’t want to stay here” -

when preferred place of care cannot be met• “I’m not lovable anymore....” - discussing intimacy • “Why me?” - discussing spiritual distress• Silence: the withdrawn patient• Distress: the crying patient• Request for organ and tissue donation• Request for euthanasia

• Face-to-face communication• Telephone communication• Written communication

• Understanding and using empathy• Skills that facilitate good communication• Dealing with challenging relatives• Challenging communication with colleagues

• Legal and ethical issues embedded in communication• Things that block good communication• Self-awareness in communication• Communicating with non-English speaking patients• Communicating with people with speech and hearing

difficulties• Communicating with children and young people• Discussing ‘do not attempt CPR’ decisions• Discussing food and fluids

5. e-ELCA (End of Life Care for All)

Communication skills curriculum

Link to e-ELCA website: http://www.e-elca.org.uk

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Pilot

Anglia(EoE)

East Berkshire

Essex (EoE)

Dorset

Lancs and South Cumbria

Leeds

LOROS

Manchester

Mount Vernon (EoE)

Plymouth

Teesside

Social care

Nursing homes (165) Care homes (625) Domiciliary agencies (308)Nursing agencies (138)

Nursing care homes (21)Residential care homes (10)Domiciliary and Nursing agencies (5)Local Authority (1)Learning disabilities team (1)

Private residential care homes (25)Voluntary sector residential homes (3)Private nursing homes (3)Voluntary sector nursing homes (3)Dual registered private homes (4)Dual registered voluntary sector homes (1)Private domiciliary/ home care services ( 3)Local authorities (3)

Nursing & domiciliary agencies (39)Nursing & registered care homes (123)Local authorities (10)

Blackpool Council (10)Lancashire social care teams (6)Cumbria social care services Cumbria social care - independent sector

Residential care homes (5)Nursing care homes (4)

City/county/district councils (10)

Private, independent and voluntary careorganisations (TBC)

Phase 1Nursing care homes (30) Care care homes (15)

Phase 2Nursing care homes (TBC) Care care homes (TBC)

Nursing care homes (64) Local authority (11) Residential care homes (197)

Adult social services (2) Care agencies (12)Nursing & residential care homes (170)

Nursing homes (7) Social services (33)

Health care

Acute hospitals (10) Community hospitals (8) Hospices (6)GPs (315)

Community care nursing teams (2)Community outpatients service (1)Community hospital (1)Hospice (1)Allied health professionals teams (2)Ambulance service (1) Long term conditions team (1)

Acute trusts (3) Hospices (6) PCTs (3)

Acute Trusts (6) Mental health/PCT/community services (12)Hospices (5) GPs (145) Private hospitals (2)

Stroke network - acute hospitals (7)Critical Care - acute hospitals (4)Renal Medicine - acute hospitals (5)

Acute trust (3 wards)Community healthcare service (1)

Acute trust (1) PCTs (2)Community health service (2) Hospice (1)District/community hospitals (10)

Phase 1Acute hospitals (4) Tertiary centre (1)Hospices (4) PCT (provider services) (3)GP practices (20)

Phase 2Acute Hospitals (10) Hospices (5)PCT (provider services) (5) GP practices (TBC)

Secondary care teams (31) Primary care (54) Hospice (3)

Acute trust (1) PCTs (2) GP practices (64)Hospice service (1)

NHS & primary care trusts (16) GPs (192)Hospices (5)

Appendix ii: ScopeTraining providers

University (3) Acute trusts (9)Hospices (3) Local authority (3)PCT (1) Other (1)

University (2)Acute trust (1)Hospices (1)Local authority (social care) (1)PCT (1)Other (1)

University (1)Acute trusts (3)Hospices (3)Local authority (1)PCT (1)

Education providers (9)

NHS Acute Hospitals (7)Social care education providers (2)Council education providers (2)

NHS acute trust (1) NHS community trust (1)Hospices (1) Help the hospices (1)

East Midlands DeaneryClinical education centres at hospitals and in-houseproviders (TBC)) Universities (4) FEI (20)Adult education (TBC) Distance learning (TBC)

Phase 1University (5) Acute trusts (4)Hospices (3) Local authority (TBC) Other (2)

Phase 2University (as phase 1) Acute trusts (10)Hospices (3) Local authority (TBC)

Education/training providers (24)

FEI (5) Universities (1) Local authority (2)Hospices (1) PCT (1) Other (16)

University trainer (2) In-house trainer (3)Charity trainer (1) Unknown (2)

Other

Patients (5)Patient focus group (1)Volunteer group (1)Technical support team (1)

Fire & ambulance (2) Police & coroners (6) Prisons (4)Armed services (1) Accountants & finance (2)Solicitors (7) Religious & faith communities (12)Funeral directors (16) Voluntary sector (186)

Hospice volunteers (TBC)Ambulance service (1)Cancer network (1)

Mental health trusts (8) Prisons (2)

Charity/volunteer employees (48)Ambulance services (1)

Prison services (4) Ambulance trusts (2)

North East and South East London Cancer Networks used existing data from the Marie CurieDelivering Choice Programme 2008.

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Cancer Network

Care Quality CommissionCare Standards Act

Common inductionstandards

Competence

Connected© (ACST)

Continuing Professional Development (CPD)e-ELCA (End of Life Care forAll)

End of Life Care (EoLC)

Knowledge and Skills Framework (KSF)

Knowledge set for end oflife care

NVQ

National Occupational Standard (NOS)

Palliative care

Personal Development Plan(PDP)

Skills for CareSkills for HealthTraining needs analysis (TNA)

Thirty cancer networks across England co-ordinate the planning,commissioning and delivery of cancer servicesThe health and social care regulator for EnglandThe Care Standards Act 2000 established a major regulatoryframework for social care Standards for people entering the social care workforce andthose changing roles or employers within social care. Designed tobe met within 12 weeks of starting employmentA statement describing the behaviour, knowledge and valuesexpected of workers to fulfil a specific role competentlyConnected© is the national training programme in advancedcommunication skills developed for senior health professionalsworking with cancer patientsA process to maintain, develop and enhance skills, knowledgeand competence in order to improve performance at workA programme providing national, quality assured online trainingmodules to support health and social care staff working in end oflife careAll elements of support to people approaching the end of theirlives. It encompasses the management of all symptoms, includingpain, and provides psychological, social, spiritual and practicalsupportThe NHS Knowledge and Skills Framework defines and describesthe knowledge and skills that NHS staff need to apply in theirwork in order to deliver quality servicesThe knowledge set for EoLC describes the minimum key learningoutcomes that are required to deliver on the EoLC competenceswithin social careNational Vocational Qualifications: work-based awards forNational occupational standards that are achieved throughassessment and trainingNational occupational standards describe performance (the skills),the performance criteria (what they should achieve) and theunderpinning knowledge required to undertake a particularfunctionA comprehensive approach to the physical, social, psychologicaland spiritual needs of people with progressive illness A personal development plan sets out the identified learning andtraining activities that support staff development, so the job canbe undertaken effectively. This is routinely reviewed during staffappraisalThe Sector Skills Council for the UK social care sectorThe Sector Skills Council for the UK health sectorTNA is the process by which training and development needs areidentified

Glossary

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