Delivering online communication skills training for radiation therapists

Abstract

Objectives

The aim of this project was to determine whether online communication skills training (CST) could be successfully delivered to radiation therapists (RTs) across Australia by adapting RT Prepare CST. RTs' perspectives on the workshop were evaluated as well as determining changes in their confidence in their skills, perspectives on their communication skills “effectiveness” and perspectives about barriers to communicating effectively with people with cancer after the workshop.

Methods

Nine online CST workshops based on the original RT Prepare were run for 52 RTs (4–8 in each workshop) working in: Illawarra Shoalhaven, New South Wales; Newcastle, New South Wales; and Hobart, Tasmania. Two facilitators delivered the workshops and all RTs participated in role plays with trained actors. RTs completed baseline surveys and workshop evaluations. Descriptive statistics (pre-post matched) and content analysis were used to analyse data.

Results

Forty-seven RTs completed pre-workshop surveys and forty-four of these completed post-workshop surveys. Workshop evaluations indicated participants were satisfied with the workshop. Individual RT confidence in communication techniques and skills were significantly improved after the workshop. RTs' confidence in providing patient emotional care significantly improved after the workshop. RTs highlighted the key skills attained in relation to responding to patient emotions of anxiety, depression, distress and anger. RTs awareness of some sources of support in the treatment environment when providing emotional care to patients was improved after the workshop.

Discussion/conclusion

Online delivery of RT Prepare CST provides a practical, scalable approach to strengthening RTs' capacity to prepare and support people with cancer before treatment.

Graphical abstract

Highlights

• •Online radiation therapy communication skills training (RT Prepare) was feasible.
• •Training was well accepted across metropolitan, regional and rural settings.
• •Role play with trained actors remained effective and engaging in an online format.
• •Confidence improved in communication, emotional cues and psychosocial assessment.
• •Online delivery is cost-effective for embedding communication skills in practice.

Introduction

Radiation therapy is an effective modality in cancer treatment, increasing survival rates and alleviating cancer-related symptoms. However, approximately 50% of people attending radiation therapy experience heightened anxiety and distress prior to treatment planning and treatment commencement [1], [2], [3]. Pre-treatment anxiety can be addressed by providing clear explanations of procedures, side effects, and what treatment feels like [4]. However, information from clinicians and radiation therapists (RTs) can be inconsistent, delayed, and overly technical [5], [6].

Psychosocial needs in cancer care are often unmet [7], [8], and psychological morbidity is frequently under recognised and undertreated [9]. This can worsen outcomes and increase healthcare use [10], [11]. Anxiety and depression may persist from radiation therapy planning to treatment commencement [2], impacting adherence and daily treatment efficiency [12]. Inadequate information may contribute to patients declining beneficial treatment [12]. Whereas timely, tailored information can reduce distress and improve satisfaction [13], [14]. Although radiation therapy educational resources and group interventions exist, many departments rely on general information that does not specifically address preparing for treatment and addressing patient anxiety before and during radiation therapy [15], [16].

The team developed and demonstrated effectiveness of the “RT Prepare intervention” in assisting RTs to prepare patients for planning, treatment, and reduce psychological distress [17]. A key component of ‘RT Prepare’ was communication skills training (CST) specifically developed for radiation therapy. CST was informed by Level 1 evidence and included education for RTs on how to provide patients with procedural and sensory information plus strategies to help RTs manage different patient emotions [18], [19], [20], [21], [22]. The team previously reported RTs positive perspectives and improvement in confidence following face-to-face CST [23].

Following the success of RT Prepare we ran a small number of face-to-face CST workshops in rural New South Wales, Australia. RT Prepare training was effective in improving RTs confidence in discussing psychosocial issues; recognising signs of anxiety/depression; and dealing with anxiety, depression, and distress [24].

The cost-effectiveness evaluation of RT Prepare identified workshop costs were inexpensive compared to other psychosocial interventions [25]. However, the in-person nature of workshops limited scalability and feasibility (due to RT scheduling, facilitator availability and venue requirements). Additionally, COVID-19 pandemic related precautions which occurred prior and during this study limited travel, face-to-face workshop delivery and RT participation, underscoring the need for a delivery solution facilitating CST that remained effective and sustainable.

A systematic review was conducted to determine the effectiveness of online CST for cancer and palliative care healthcare professionals [26]. The review concluded online CST can improve healthcare professionals' communication skills, confidence and knowledge [26]. However, further studies are required and training needs to be implemented into practice. None of the included studies focused on providing online CST for RTs.

The aim of this study was to develop and evaluate online CST workshops for RTs. RT perspectives on the workshop were evaluated, as well as change in confidence in skills, perspectives on communication skills effectiveness and perspectives about barriers to communicating effectively with patients.

Methods

Study design and setting

From June 2022 to June 2023, nine online workshops were conducted with RTs.

Ethics

Approval to conduct the study was granted from Illawarra Shoalhaven Local Health District (P0492_2022/HRE2022-0307), Calvary Mater Newcastle Hospital (AU202302-04/HRE2023-0066) and Royal Hobart Hospital (2022_1034/HRE2022-0605). All clinical sites determined the project was low risk and granted approval as quality improvement, with Curtin University granting reciprocal Human Research Ethics Committee approval.

The Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines were used to ensure appropriate reporting [27].

Participants

RTs working in cancer centres located in two districts in New South Wales and one district in Tasmania, Australia participated. RTs were eligible to participate if they worked in a participating cancer centre and were scheduled to attend a workshop.

RT Prepare communication skills workshops

The online workshops were based on previous RT Prepare face-to-face CST workshops [17], [24], [28], were 5.5–6 h, included scheduled breaks, and each included two facilitators (GH, DY/DN). Length of online workshops was adjusted depending on participant numbers. Facilitators had a range of professional backgrounds (1 each RT, clinical psychologist, radiation oncologist with counselling training). Online workshops focused on: patient experiences of RT; preparing patients for RT; eliciting and responding to patient's emotional cues (anxiety, depression, anger, and distress); and included opportunities to practice skills in an online role play with a trained actor.

The team developed and showed videos of two professional actors simulating an RT communicating with a breast cancer patient experiencing different emotions. Some videos demonstrated good communication skills, while others focused on areas where the RT missed emotional cues and/or did not respond effectively.

Each RT had the opportunity to practice their communication skills with an actor during the workshop. The actor attended the entire workshop to understand what education was covered and observe participants prior to role-plays. The facilitators and actor provided participants with feedback and suggestions at the end of each role play. All workshop attendees were provided a workshop manual, after the workshop was held, which contained the workshop material and RT Prepare resources.

Measures

Quantitative and qualitative data was collected using pre- and post- surveys which had mixed question types, as described here. Pre-workshop surveys collected: demographics, CST experience, perceived need for training (1 item 4-point Likert scale), workplace practices when supporting an emotional patient (1 multiple response item), radiation therapy role perception (10 items 5-point scale), knowledge of verbal and non-verbal emotional cues (4 open-text responses), patient symptom and distress screening practices (1 item with yes/no/sometimes and open text comment), and whether patients were referred for psycho-social support (yes/no).

Pre- and post-workshop surveys assessed: self-rated communication skills (3 items 5-point Likert); communication skills confidence (11 items 3-point Likert scale); level of confidence in communication techniques (5 items 5-point Likert scale); availability of physical, educational and supportive resources (5 items with agree/disagree/don't know answer; 9 items with yes/no/I don't know answers); confidence in various aspects of patient care (3 items 5-point Likert scale); confidence dealing with various patient emotions (4 items 5-point scale); role of the RT in the education and care of emotional patients (8 items 5-point scale; 1 item with yes/no/maybe and open text comment).

The post-workshop survey included additional items assessing: communication strengths, weaknesses, techniques learnt, challenging emotions, and additional support required (5 open-text responses); and confidence in administering symptom and distress screening (1 item 5-point Likert scale). A post-workshop evaluation was also administered with the survey and contained items with a 5-point Likert scale (strongly agree to strongly disagree) asking RTs for their opinion of workshop content and organisation (7 items), role play (9 items), and experience and perception (4 items).

Procedure

A total of nine online whole-day workshops were held in three Australian districts situated in New South Wales (District 1: 4 workshops, District 2: 2 workshops) and Tasmania (District 3: 3 workshops). Centres adjusted scheduling and rostered RTs to enable their participation in a full-day workshop. Each site had 1 or 2 representatives who encouraged RTs to participate in the online workshops and assisted in facilitating their time away from clinical duties and participation in the workshops. Each RT needed access to a computer with a camera and microphone to participate.

RT Prepare workshops ranged in size from 4 to 8 participants. At the commencement of each workshop facilitators discussed technological etiquette including having cameras on, microphone use and the importance of participating in discussions and role plays. Throughout the workshops facilitators tried to keep participants engaged and provide the opportunity for participants to take breaks when required.

Six 1–1.5 h follow-up workshops (2/site) were held approximately 11–16 months later to provide an opportunity to refresh skills, determine how radiation therapists were using skills and the opportunity to gain further feedback from the facilitators about how to improve communication and support people receiving radiation therapy.

Prior to the RT Prepare workshop, attendees were invited to consent to participate in the study and complete a pre-workshop survey (as described above) emailed by their line manager. All workshop attendees were asked to complete a workshop evaluation. Research participants were asked to complete the post-workshop survey (which included the workshop evaluation).

Data analysis

Quantitative

Analysis was completed using IBM SPSS Version 27. Descriptive statistics (counts, percentage proportions, means and standard deviations) were used to present data. Three and five-point Likert scales were collapsed to dichotomous variables (excellent/good vs not; very/somewhat confident vs not; very/somewhat competent vs not; positive vs not; extremely/somewhat confident vs not; disagree vs not; yes vs not; strongly/somewhat agree vs not) to conduct statistical tests of changes in RTs' pre and post workshop responses. Non-parametric statistical tests for paired responses (McNemar's test) were used.

Qualitative

Conventional content analysis was used to analyse short-answer responses [29]. Each question was double coded (GH, MB) to develop categories related to each survey topic and represent the short open text responses provided by participants.

Results

A total of 52 RTs participated in nine RT Prepare workshops. Pre-workshop (n = 47) and post-workshop surveys (n = 44) were completed by RT participants. See Table 1 for participant characteristics.

Table 1.

Baseline characteristics of RT workshop participants.

N = 47	n (%)
Gender
Female	39 (83)
Male	8 (17)
District
1 – Illawarra Shoalhaven (consisting of two linked cancer centres)	19 (40)
2 - Newcastle	16 (34)
3 - Hobart	12 (26)
Work hoursb
Full-time	32 (70)
Part-time	14 (30)
Education
Diploma	2 (4)
Bachelors	41 (87)
Postgraduate	4 (9)
Current area of worka, b
Treatment	20 (44)
Planning/CT	25 (54)
Educator	2 (4)

^aContains missing data.

^bMultiple responses allowed.

The following results are presented by topic, with some topics having both quantitative and qualitative data.

Workshop evaluation

RTs evaluations of the workshop are presented in Table 2. At least 89% of attendees agreed/strongly agreed with each of the items measured. All RTs (100%) agreed/strongly agreed workshops provided practical and relevant information, the actor gave constructive feedback and the size of the group was appropriate.

Table 2.

RTs opinion of various aspects of the workshops.

N = 44	Strongly agree n (%)	Somewhat agree n (%)	Neither agree nor disagree n (%)	Somewhat disagree n (%)	Strongly disagree n (%)	Percentage strongly/ somewhat agreed %
Workshop content and organisation
Provided practical, relevant information	35 (80)	9 (20)	0 (0)	0 (0)	0 (0)	100
The size of the group was appropriate for this type of workshop	36 (82)	8 (18)	0 (0)	0 (0)	0 (0)	100
The content and amount of information provided was appropriate	36 (82)	7 (16)	0 (0)	0 (0)	1 (2)	98
Provided relevant case scenarios	38 (86)	4 (9)	2 (5)	0 (0)	0 (0)	95
Increased my knowledge about communication with patients	32 (73)	10 (23)	1 (2)	1 (2)	0 (0)	95
Helped me to develop knowledge in how to prepare patients for radiotherapy	33 (75)	6 (14)	3 (7)	2 (5)	0 (0)	89
The duration of the workshop was appropriate	35 (80)	4 (9)	3 (7)	1 (2)	1 (2)	89
Role play
The actors gave constructive feedback	40 (91)	4 (9)	0 (0)	0 (0)	0 (0)	100
I had opportunities to practise new ‘lines’ and ‘phrases’	32 (73)	11 (25)	0 (0)	1 (2)	0 (0)	98
The role-plays were believable	39 (89)	4 (9)	1 (2)	0 (0)	0 (0)	98
Giving and receiving feedback was an effective learning experience for me	39 (89)	4 (9)	1 (2)	0 (0)	0 (0)	98
Participating in giving and receiving feedback was an effective learning experience for me	37 (84)	6 (14)	1 (2)	0 (0)	0 (0)	98
I developed skills during the role-plays that I will be able to use in my worka	33 (77)	9 (21)	0 (0)	1 (2)	0 (0)	98
The role-plays felt realistic even though it was online	31 (70)	11 (25)	1 (2)	1 (2)	0 (0)	95
I felt immersed in the virtual environment of the role play	31 (70)	11 (25)	1 (2)	1 (2)	0 (0)	95
The role-plays were safe and non-threatening	37 (84)	4 (9)	2 (5)	1 (2)	0 (0)	93
Experience and perception
Increased confidence in my communication skills	33 (75)	10 (23)	1 (2)	0 (0)	0 (0)	98
Will be of benefit in my job	35 (80)	7 (16)	2 (5)	0 (0)	0 (0)	95
I would recommend the workshop to other radiation therapists	35 (80)	6 (14)	2 (5)	1 (2)	0 (0)	93
I enjoyed participating in this workshop	35 (80)	5 (11)	3 (7)	1 (2)	0 (0)	91

^aContains missing data N = 43.

Fig. 1 shows RTs ratings of various online workshop characteristics. At least 91% of workshop attendees rated all workshop characteristics as excellent/good.

Fig. 1.

RT ratings of online workshop characteristics. Note: N = 43 except for the following items which were N = 42: the actor; ability to actively participate in the workshop; and communicating with other workshop participants. No RTs selected ‘poor’ for any item.

The communication skills workshops received positive feedback which focused on: role play; practising skills; giving and receiving feedback; learning about emotions; learning how to respond to emotional cues; and phrases to use to open conversations:

“Loved it. Fantastic program you have put together brilliantly. Our group was a very experienced crew of RTs and we all got so much out of this!” – RT20.

“Great experience and I am very grateful I had the opportunity to take part in this important part of our profession.” – RT28.

“The roleplay, the actor was incredibly realistic and in touch with our challenges.” – RT22.

Seven participants described the least useful part of the workshops as: difficulty with managing online environment (n = 2), doing role plays online (n = 4), and receiving feedback online and a preference to receive a copy of the education material prior to the workshop (n = 1). Participants also provided feedback on how workshops could be improved: improving audio-visual set-up at their location, modifications to some demonstration videos, having multiple actors for role plays, length of workshops (shorter or longer workshops), more role plays and practising different emotions, and more time for reflection.

Self-assessed communication skills

Before the workshop, most RTs rated their need for communications skills as strong/moderate (79%). Fig. 2 shows only a small increase in RTs' self-assessed communication skills from pre- to post-workshop (not significant).

Fig. 2.

Self-assessed communication skills pre and post workshop.

Perceived effectiveness of communication skills

For all items, most RTs (≥64%) perceived CST had affected them positively (Table 3). The item ‘providing emotional support for patients’ had the highest proportion of RTs who perceived communication skill training had affected them positively (98%).

Table 3.

Self-perceived communication skills effectiveness after the workshop.

N = 42–43	N % rated as positive change for how Communication Skills Training has affected participants and their work
	Post workshop % (n/ N = 44 responses)
Providing emotional support for patients	98 (43/44)
Confidence in dealing with patients	91 (40/44)
Providing support for colleagues	91 (40/44)
Providing information to patients	89 (39/44)
Providing emotional support for patients' carers and significant others	89 (39/44)
Efficiency in dealing with patients	84 (37/44)
Approachability (i.e. the patient's openness to approaching you for information)	80 (35/44)
Job satisfaction	77 (34/44)
Showing respect for patients	68 (30/44)
Personal well-being	66 (29/44)
Work related stress	64 (28/44)

Confidence in communication techniques, skills and providing emotional support

Table 4 depicts RTs' confidence in communication pre- and post-workshops. There was a significant improvement in all five techniques and skills post-workshop, with almost all RTs feeling confident on all items post-workshop. RTs had improved confidence in using the following techniques and skills: using open-ended questions (p < .001; change 23%); using body language and non-verbal cues (p = .008; 21% change); and identifying non-verbal (p < .001; 28% change) and verbal (p = .021; 19% change) cues. The increase in the proportion of RTs who were extremely/somewhat confident was largest for ‘assessing and understanding emotional, psychological, and social needs’ which increased from 53% to 100% post-workshop (p < .001).

Table 4.

RTs confidence in communication techniques, skills and providing patient emotional care.

	N % Confidence with communication techniques
	Pre workshop % (n/ N = 47 responses)	Post workshop % (n/ N = 44 responses)	% change (pre to post)	p value
Assessing and understanding emotional, psychological and social needs	53 (25/47)	100 (44/44)	47	<0.001**
Use of open-ended questions	77 (36/47)	100 (44/44)	23	<0.001**
Use of body language and other non-verbal cues to encourage discussion within a comfortable environment	79 (37/47)	100 (44/44)	21	0.008**
Identifying non-verbal cues in others	70 (33/47)	98 (43/44)	28	<0.001**
Identifying verbal cues in others	79 (37/47)	98 (43/44)	19	0.021*
Anger	40 (19/47)	91 (40/44)	51	<0.001**
Depression	47 (22/47)	93 (41/44)	46	<0.001**
Distress	66 (31/47)	98 (42/43)	32	<0.001**
Anxiety	85 (40/47)	98 (43/44)	13	0.031*
Discussing psycho-social issues with patients	55 (26/47)	93 (41/44)	38	<0.001**
Recognising signs of anxiety/depression	64 (30/47)	96 (42/44)	32	<0.001**
Educating patients on the radiotherapy process	98 (46/47)	100 (44/44)	2	1.000

*p < .05 and **p ≤ .01 significant proportion of RTs extremely/somewhat confident after the workshop compared with baseline (McNemar's test exact 2-sided significance).

RTs had improved confidence after the workshop (Table 4) in dealing with a patient showing signs of: anger (p < .001; 51% change); depression (p < .001; 46% change); distress (p < .001; 32% change); and anxiety (p = .031; 13% change). RTs had improved confidence after the workshop for: discussing psycho-social issues with patients (p < .001; 38% change) and recognising signs of anxiety/depression (p < .001; 32% change).

Development of key skills

Key skills that RTs identified they developed during the workshops included: recognising verbal and non-verbal cues; responding to emotions; silence and active listening; asking open-ended questions; using empathy; and, how to offer support services.

RTs developed skills in relation to each emotion covered in the workshops:

Anxiety: “I developed a better understanding of how to identify anxiety…and how to adapt my communication style to each.” – RT22.

Depression “Sitting in silence, open-ended questions for engagement, how to recognise depression better.” – RT2.

Distress “Silence, clarifying, non-judgement responses, giving space to feel emotions, reassurance, normalising, open-ended questions.” – RT10.

Anger “I have learnt how to communicate and read verbal and non-verbal cues off patients who are angry…” – RT9.

Perceived potential barriers to providing patient emotional care

RTs' perception of commonly perceived barriers to providing emotional support to patients are detailed in Table 5. There was an improvement in the proportion of RTs who no longer perceived these were barriers post-workshop; the change in the proportion of RTs who did not support each barrier (i.e. disagreed) ranged from 2 to 20%.

Table 5.

RTs disagreement with commonly perceived barriers to providing patient emotional support before and after the workshop.

	N % disagreement with commonly perceived work environment barriers
	Pre workshop % (n/ N = 46–47 responses)	Post workshop % (n/ N = 44 responses)	% change (pre to post)	p value
There is no time in the schedule to provide support to emotional patients	57 (27/47)	77 (34/44)	20	0.022⁎
I am too exhausted to provide support to emotional patients	72 (33/46)	91 (40/44)	19	0.021⁎
Increasing treatment complexity has reduced the time available to provide support to emotional patients	40 (19/47)	57 (25/44)	17	0.143
I am too busy at work to provide support to emotional patients	75 (35/47)	84 (37/44)	9	0.344
I often have to prioritise technical demands over support to emotional patients	57 (26/46)	59 (26/44)	2	0.774

^⁎p < 0.05 significant proportion of RTs disagreed after the workshop compared with baseline (McNemar's test exact 2-sided significance).

Sources of support in the treatment environment

The change from baseline to post-workshop in the proportion of RTs' who were aware of various sources of support are shown in Table 6. RTs identified they wanted the following additional supports: follow-up or booster workshops; practice; extra scheduled time with patients; feedback from patients; debriefing opportunities; screening tools to support communication; support from team; information about referral process; and, written information for patients.

Table 6.

RTS awareness of sources of support in the treatment environment when providing emotional care to patients.

	N % aware of each source of support
	Pre workshop % (n/ N = 46–47 responses)	Post workshop % (n/ N = 42–44 responses)	% change (pre to post)	p value
There are educational resources available to me to improve my ability to communicate with emotional patients	41 (19/46)	91 (39/43)	50	<0.001**
There are supportive resources available to me to help me deal with providing support to emotional patients	52 (24/46)	86 (38/44)	34	<0.001**
I have access to patient education materials to help support emotional patients	57 (27/47)	86 (38/44)	29	0.002**
I have enough time to fully communicate with emotional patients	41 (19/46)	59 (26/44)	18	0.049*
I am aware of how to access support services to help an emotional patient	81 (38/47)	96 (42/44)	15	0.039*
I can go to the patient's radiation oncologist for support when I care for an emotional patient	60 (28/47)	71 (31/44)	11	0.344
My team supports me emotionally when I deal with emotional patients	83 (39/47)	93 (39/42)	10	0.453
There are support services I can access to help an emotional patient	92 (43/47)	100 (44/44)	8	0.125
I can go to my manager or supervisor for support when I care for an emotional patient	83 (39/47)	91 (40/44)	8	0.219

*p < .05 and **p ≤ .01 significant proportion of RTs agreed (yes) after the workshop compared with baseline (McNemar's test).

Opinion on the role of the RT

Table 7 shows a significant increase pre- to post-workshop in the proportion of RTs who agreed about two aspects of the RT role: my organisation (e.g. hospital, clinic) values my role in providing symptom and distress screening to our patients (p = .003; 24% change) and administering symptom and distress screening (p = .021; 19% change).

Table 7.

RTs' opinions on the role of the RT prior to and during treatment.

	N % who agreement with the role of the RT
	Pre workshop % (n/ N = 47 responses)	Post workshop % (n/ N = 44 responses)	% change (pre to post)	p value
My organisation (e.g. hospital, clinic) values my role in providing symptom and distress screening to our patients	62 (29/47)	86 (38/44)	24	0.003**
Administering symptom and distress screening	72 (34/47)	91 (40/44)	19	0.021*
Other members of the healthcare team value my role in providing symptom and distress screening to our patients	63 (29/46)	80 (35/44)	17	0.109
My work colleagues (other radiation therapists) value my role in providing symptom and distress screening to our patients	70 (33/47)	84 (37/44)	14	0.180
Discussing psycho-social concerns with patients	85 (40/47)	89 (39/44)	4	1.000
Educating patients on the side effects of radiation treatment	98 (46/47)	96 (42/44)	−2	0.500
Educating patients on the radiation therapy process	100 (47/47)	96 (42/44)	−4	0.500
Referring to other services such as social worker or psychologist	96 (45/47)	91 (40/44)	−5	0.625

*p < .05 and **p ≤ .01 significant proportion of RTs strongly/somewhat agreed after the workshop compared with baseline (McNemar's test).

Perceived role in symptom and distress screening

The proportion of RTs who answered ‘yes’ to the statement ‘it is the role of a radiation therapist to evaluate the results of symptom and distress screening?’ increased slightly from pre- to post-workshop (48% vs 58%, p = .219).

RTs qualitative responses identified perceptions of their role in distress screening: daily patient contact allows for assessment for changes; screening can identify necessary extra supports; helps provide patient-centred care; should be completed by all disciplines in all departments; time constraints; and further training required for junior staff if implemented.

“As RTs we have direct contact with the patient daily and can evaluate changes in behaviour and the need for further support if information is disclosed to us. We can provide support within our scope of practice and then through screening can refer to other health professionals if required.” RT36.

Discussion

Online delivery of RT Prepare CST was feasible, acceptable, and highly valued by RTs across regional and rural sites. These results are similar to previous feedback received on the in-person RT Prepare CST where participants were highly satisfied with the workshops [23] and their confidence in their communication skills was improved [24]. Participants in the current study reported high satisfaction, increased confidence, and perceived improvements in key communication skills, particularly around preparing patients for radiation therapy and managing emotional cues. This study demonstrates that CST designed for RTs can be successfully adapted to an online format without compromising relevance, engagement, or educational value.

Shifts in RTs' confidence were most evident in recognising emotional cues and assessing psychosocial needs, suggesting meaningful learning was gained beyond general self-perceptions. These findings extend previous systematic review findings on online CST [26] and RT Prepare [17] by demonstrating that practice, feedback, and reflection can be preserved in an online environment. Participants consistently reported role-plays were believable and safe, despite virtual delivery. This high acceptability of online role-play suggests experiential CST need not be limited to face-to-face formats, provided psychological safety and skilled facilitation are maintained.

Training and education in radiation therapy remain inconsistently implemented and difficult to scale, particularly outside metropolitan centres, where there has been an increase in services [15]. Online delivery of CST addresses many of the geographic, travel, and staffing barriers that limit access to professional development. This is particularly relevant for regional and rural services, where access to professional development is often constrained by the need to travel for training [30]. Limited access to training and professional development in rural areas has previously been linked to reduced satisfaction, challenges in maintaining skills and rural workforce attrition [30], [31]. Embedding scalable CST into routine practice may support a more sustainable workforce and contribute to improved patient care outcomes across Australia.

The team previously identified that RT Prepare had low ongoing cost relative to other psychosocial interventions [25]. Running online training further reduced costs as there was no requirement for travel. However, organisational requirements for training require leadership support, protected time to complete training and cultural acceptance that communication, patient education and support are core capabilities of RTs that can improve patient outcomes [32].

Improvements to future workshops might include providing online pre-workshop material, providing more opportunities to practice responding to different emotional cues and allowing more time for reflection. Prior directed learning has been reported to ensure learners enter training with a shared baseline understanding and improves skills uptake [33]. Repeated practice, observation, and rehearsal are key mechanisms underpinning communication skills acquisition, particularly for emotionally challenging interactions [34], and mechanisms for training boosters and ongoing debriefing within workplaces are likely important to embed communication skills [35], [36].

Limitations

Study limitations included the use of self-reported outcomes, modest sample size; no long-term follow up to determine skill retention; and no observation of clinical practice to confirm application of skills. Patient outcomes were not included in the current study. However, the effectiveness of RT Prepare in improving patient preparation and reducing psychological distress has been previously demonstrated [24].

Implications for practice

RT Prepare provides an evidence-based approach to patient education which increases RTs confidence in dealing with difficult patient emotions. Online delivery of RT Prepare enabled us to provide CST to RTs in metropolitan, regional and rural radiation therapy centres with improvements in RT confidence. It is more feasible and cost effective for sustained implementation across Australia.

CST focused on preparing patients for radiation therapy and eliciting and responding to emotional cues is beneficial for RTs working clinically. In addition to embedding communication skills into routine practice, departments need to consider providing refresher or booster sessions to support healthcare professionals in further practising and developing their skills. Online RT Prepare could be a practical solution to providing refresher or booster sessions.

Future research

Future research needs to focus on: testing implementation of RT Prepare at scale across multiple jurisdictions, examining long-term retention of skills and the need for follow up or booster training. The training also needs to be adapted and tested for: working with other cancer populations; more complex emotional presentations; assisting healthcare professionals in supporting people with poorer outcomes including people from lower socioeconomic groups, lower health literacy, culturally and linguistically diverse populations, and rural and remote locations. The team are actively engaged in developing resources and training to support RTs in working effectively with First Nations peoples in Australia [37], [38].

Conclusion

Online CST on preparing patients for radiation therapy was successfully conducted across three districts (metropolitan, regional and rural locations) in two states in Australia. Online delivery of RT Prepare CST represents a practical, scalable approach to strengthening RTs' capacity to prepare and support patients at a critical point in their cancer treatment. Further opportunities for providing RTs with CST need to be explored. Embedding CST into routine practice has the potential to improve consistency, confidence, and quality of patient communication across diverse clinical settings.

Credit authorship contribution statement

Georgia K.B. Halkett: Writing – review & editing, Writing – original draft, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Conceptualization. Melissa Berg: Writing – review & editing, Writing – original draft, Formal analysis. Debra York: Writing – review & editing, Methodology. Diana Naehrig: Writing – review & editing, Methodology. Belinda Arnold: Writing – review & editing, Methodology, Funding acquisition, Conceptualization. Bronwyn Hilder: Writing – review & editing, Funding acquisition. Sharon Oultram: Writing – review & editing, Funding acquisition. Joanne Harrison: Writing – review & editing, Funding acquisition. Haryana M. Dhillon: Writing – review & editing, Methodology, Conceptualization.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.