The pilot sites report their findings for end of life care communication skills 22 September 2010 - National End of Life Care Programme This report provides the first round of feedback from a training needs analysis (TNA) pilot project, set up to support the development of communication skills training for all those working in end of life care. It provides some early outcomes and learning from 12 pilot sites around the country, each of which carried out its own local workforce TNA. We hope these initial findings will be useful to other organisations planning to carry out a TNA themselves, or to support the development of EoLC training plans. A series of 'top tips' are summarised in the document. Publication by the National End of Life Programme which became part of NHS Improving Quality in May 2013

1. Communication skills for end of life care
Training for health and social care staff
Talking Needs Action
Training Needs Analysis:
The pilot sites report their findings for
end of life care communication skills

2. Contents
Acknowledgements
Executive summary
1. Introduction
2. Background
3. Taking a needs-based approach
4. Identifying providers
5. The TNA itself
6. Engagement
7. Findings
8. What did the pilot sites get out of the TNA?
9. Getting results
10. Good practice identified through the TNA
11. Next steps for pilots
12. References
2
3
6
8
9
10
10
11
12
15
16
19
21
21
Appendices
i
Tools to support assessment and planning
ii Scope
22
27
Glossary
29
Acknowledgements
With thanks to the 12 pilot sites that have participated in this project and have
shared their findings and experiences with the national programme.
Special thanks to Jill Banks Howe and Linda Nelson at the University of Teesside
for their support in developing the questionnaires for the training needs analysis.
2

3. Executive summary
Purpose and scope of this
report
This report provides the first round of
feedback from a training needs analysis (TNA)
pilot project, set up to support the
development of communication skills training
for all those working in end of life care (EoLC).
It provides some early outcomes and learning
from 12 pilot sites around the country, each of
which carried out its own local workforce
TNA. We hope these initial findings will be
useful to other organisations planning to carry
out a TNA themselves, or to support the
development of EoLC training plans. A series
of ‘top tips’ are summarised in the document.
The report is also aimed at strategic health
authorities, education commissioners and
providers, health and social services
commissioners and service providers, health
and social care staff and their managers.
3
This project has been run by the National End
of Life Care Programme (NEoLCP) in
partnership with Connected©, the national
communication skills training programme for
cancer services.
Context and background
The health and social care EoLC workforce is
employed by a wide range of organisations in
a variety of settings. Competence in
communication underpins all good quality
EoLC. It is essential that health and social care
staff can have open and effective
conversations with people, their families and
carers about death and dying and the issues
surrounding it. This ensures that service users
are well supported, their wishes can be
properly discussed and personal care plans put
in place.
The End of Life Care Strategy1 has identified
communication as one of the four
competence areas that cut across all levels of

4. practice. It recognises the skills that already
exist in the workforce and aims to build on
these to make sure that all staff have the
ability to deliver quality care for everyone.
Training and education are not the only ways
to develop skills. Workplace learning
opportunities through experience, role models
and mentoring are very important. Appraisal
and continuing professional development are
also vital.
There are cost benefits to having a competent
workforce that has timely and appropriate
conversations with people at the end of life:
individuals’ needs will be identified promptly,
resulting in the right care at the right time and
avoiding unnecessary interventions – making
best 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 of
EoLC 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 better
understanding of the workforce engaged in
EoLC, the existing competences and training
currently available. This supports a strategic
approach to workforce development. Wide
partnership engagement has enabled a more
co-ordinated approach and the TNA has
provided a structure for ongoing monitoring
of competences and for evaluating the impact
of training.
The TNA process has had the additional
benefit of raising awareness of EoLC and
identifying enthusiasm for training. It has
supported culture change – getting death and
dying onto the agenda for the whole EoLC
workforce. The pilots have established
structures that facilitate effective
multidisciplinary, multi-agency and
interdisciplinary working across organisational
boundaries. These will support ongoing
workforce development in EoLC as well as
providing a forum for future joint working in
other areas.
Lessons learned – summary of
key good practice tips (full details
in 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.
4

5. 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 an
information base to support development of
training and education that will meet the
needs of their local workforce. It will then be
important to monitor the delivery and uptake
of training and to evaluate its impact on
business objectives, the service user
experience, staff confidence and competence.
The final project report and findings will be
published early in 2011.
5
“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

6. 1. Introduction - Why do a
TNA 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 often
require a complex mix of health and social
care services, which are provided across a
wide range of sectors and organisations
including hospitals, care homes, hospices and
their own homes.
Many people – including clinical and nonclinical staff, family and friends, palliative and
non-palliative staff – provide this care.
However, because it often forms only part of
the non-palliative role, these particular
workers may not be trained in the
identification, delivery and discussion of EoLC.
Workforce competence in communication
underpins all good quality EoLC. While generic
communication skills are important in all
settings, there are particular challenges
involved in communicating with people at the
end of life.
By building on existing workforce skills and
training, we aim to provide health and social
care staff with the skills and confidence they
need to have open and effective conversations
with people, their families and carers about
death and the issues surrounding it. In this
way service users’ wishes can be discussed
and care plans put in place. Good
communication contributes significantly to
quality of care and there is sound evidence to
show that training can improve competence in
communication.
As well as improving service quality there are
inherent cost benefits in developing a
Leeds: St Gemma’s Hospice
"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 unnecessary
interventions and making best use of staff
time. Better communication between staff,
individuals and their carers will improve coordination of services and facilitate best use of
resources. Cost savings could also be made
through improved planning of training
programmes, ensuring that duplication is
avoided. A properly trained workforce is likely
to have higher morale and job satisfaction –
resulting in less staff attrition.
The English health and social care workforce
in EoLC is estimated to be around 2.5 million.
The communication skills pilot project, of
which the TNA is a part, was established to
support development of communication
6

7. competences in this workforce, building on
and enhancing their existing skills. The
NEoLCP is working on this project in
partnership with Connected©, the national
communication skills training programme for
cancer services.
Twelve pilot sites have been set up across the
country2. They were asked to assess existing
workforce competences, then use the results
of their assessment to determine the training
required. Using this needs-based approach,
the first step was for each pilot site to carry
out a TNA.
The purpose of this report is to highlight some
of the early TNA findings and to suggest how
these can be used to develop best practice in
other locations. We hope that it will be useful
to organisations that are planning to carry out
a TNA themselves or to support the
development of their training plans. It
highlights the rationale behind the TNA
project and the processes used, as well as
detailing the key findings from and benefits to
the pilot sites.
This report is relevant to all those with an
interest 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 will
be included in the final project report, which
will be published early in 2011.
7
Lancashire and South Cumbria Cancer Network
"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

8. 2. Background: the three
foundation projects
Three foundation projects have been set up to
progress The National End of Life Care
Strategy’s vision for workforce development.
Communication skills
Twelve pilot sites across England were
established in September 2009. Their aim is to
explore training need, develop local training
for EoLC and so inform good practice for
future 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 competences
Skills for Health and Skills for Care identified
the common core competences and principles
for EoLC, which were published in June
20093. These provide a framework to support
The National End of Life Care strategy,
specifying the principles and competences
that form the common foundation for the
EoLC workforce in health and social care.
A framework of national occupational
standards was subsequently published in
January 20104, which specified the core
standards that underpin the competency
framework. A knowledge set for EoLC is also
available which specifies the learning
outcomes for the five key areas of
competence as identified in the common core
competences, including communication.
The common core competences for
communication skills, their related national
occupational standards and the knowledge
sets have formed the basis of the TNA (see
appendix i for background information).
e-ELCA
A suite of free e-learning sessions launched in
January 2010 by the programme and its
partners includes a core module on
communication skills for EoLC. Workers in
many health and social care agencies are able
to access the resource at www.e-elca.org.uk.
The sessions are intended to support a variety
of learning approaches, including experiential
and face-to-face. The curriculum for
e-learning is also aligned to the common core
competences (see appendix i).
8

9. 3. Taking a needs-based
approach
As well as analysing training needs at an
individual level, the process must consider the
links to both functional and organisational
objectives.
“We have found this project extremely
valuable; the data collected have provided
us with excellent evidence to support our
current communication skills education
provision and have given us significant
insight into how this provision may be
successfully developed for the future end
of life care workforce.”
Sharon de Caestecker, head of
education, LOROS
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.
Why do a TNA?
TNA is the process by which training and
development needs are identified. The
purpose is to outline how organisational
objectives will be realised through the
development of workforce competences.
Once the need is identified, a resource plan
can be agreed and the appropriate training
delivered. Assessment of its impact will then
inform business objectives. This needs-based
approach supports the development of a
competent workforce, avoiding unnecessary
or duplicated training.
Identify the competences
required for the workforce
Training Needs
Analysis
Identify service providers
and assess workforce
competences
Determine business
objectives
Needs-based
approach
Implement
training
Identify current
training and
education
Develop/commission
training
Benchmark against competences
Identify training
need
9
Monitor and evaluate
impact of training
Training resource
plan

10. Dorset Cancer Network
4. Identifying providers
5. The TNA itself
The first step for the pilots was to identify the
health and social care services expected to
deliver EoLC and all local education and
training providers in their area. Dorset
broadened its scope to include nineteen
sectors that may have some contact with
people at the end of life. These included fire
and ambulance services, the police, solicitors
and military bodies.
5.1 Methods
There are a range of data collection methods
available, which include:
• Interviews
• Group discussions
• Focus groups
• Questionnaires and surveys
• Job analysis, including review of job
descriptions.
“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
5.2 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 and
approach that best met local requirements.
The programme worked with Teesside
University, using guidance from NHS
Connecting for Health5,6, and in consultation
with the pilots to develop three separate
questionnaires - for employers, employees and
training providers. These templates could be
modified to reflect local need and ten pilot
sites made some amendments to them.
10

11. The majority of sites used survey
questionnaires as the basis for the TNA but
several supplemented these with focus groups
for particular sectors, eg training providers.
Most questionnaires were completed
independently by individuals – sometimes
following a presentation – while others were
completed by a researcher during telephone
interviews. Questionnaires were delivered to
respondents by hand, sent by post or
electronically and a few sites developed their
own online versions (Plymouth, LOROS,
Dorset).
Most pilots surveyed employer organisations,
employee representatives and training
providers. Essex made the decision to target
only employers and training providers.
Some pilots tailored their approach to specific
staff groups. Leicestershire and Rutland
Hospices (LOROS), for example, targeted
volunteer staff separately and developed a
customised information sheet, while Leeds
tailored its data collection methods for each
staff group.
6. Engagement
“There are a huge number of employing
agencies of various types concerned with
delivering end of life care and one of the
challenges of this study has been to ensure
that we have sufficient responses from a
range of employers to give representative
findings.”
Tonia Dawson, nurse director,
Anglia Cancer Network
Response rates varied between pilots, sectors
and settings. Pilots achieved more responses
by actively marketing the questionnaires
through briefing events, engaging managers
to promote the TNA with their staff and
tailoring their questionnaires or collection
methods to target specific groups. Repeat
mailouts and telephone follow-up of nonresponders also achieved higher rates and
11
East of England
provided an opportunity to complete the
questionnaire by telephone. For example,
Mount Vernon got good results from
employers by repeating emails and carrying
out phone or face-to-face interviews,
achieving 59 percent response rates in primary
care, 35 percent in acute care and 23 percent
in care homes.
In general, response rates were lower from
social care employees. This highlighted the
importance of making language appropriate
and relevant to the sector and of involving
social care partners in the projects from the
outset.
Response rates were higher from training
providers. For example, 66 percent of training
provider questionnaires were returned in
Anglia, 58 percent in Leeds and 54 percent in
Mount Vernon. In Lancashire and South
Cumbria the response rate from training
providers was lower but, by holding a focus
group, they successfully supplemented their
findings with additional qualitative
information.

12. 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 the
challenging 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 more
limited 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 details
The results confirmed that most of the health
and social care workforce is engaged in
delivery of EoLC. For example, 92 percent of
St Luke’s respondents and 52 percent in
Dorset – which surveyed a wider range of
sectors – had conversations with people about
death and dying. This highlights the fact that
many occupations and staff groups have some
engagement with EoLC.
The proportion engaged in EoLC varied
depending on the sector. In Leeds, for
Leicestershire and Rutland Hospices (LOROS)
example, 60 percent of the voluntary staff
and 100 percent of acute sector staff said they
had some involvement, while in Essex 77
percent of nursing, care home and domiciliary
care staff were engaged in this area.
The amount of time staff spent in EoLC
varied, depending on their roles. Anglia found
this ranged between 20 and 100 percent of
staff time overall. Community nursing teams
and critical care workers surveyed in Leeds
spent 20 to 40 percent of their time caring for
people at the end of life. The majority of
critical care workers in Lancashire and South
Cumbria also spent around the same amount
of their time in EoLC, while the majority of
stroke service staff in Lancashire and South
Cumbria reported less than 20 percent
engagement.
The TNA uncovered a frequent
misunderstanding of the term ‘end of life
care’ – with employees not appreciating their
role in delivery of such care and the relevance
of EoLC training to them.
7.2 Training provision – the details
A range of organisations provides
communication skills training: higher
education institutes (HEIs); further education
institutes (FEIs); in-house local service
12

13. providers; hospices and occasionally
independent organisations. Specialist palliative
care staff, working in hospices or the acute
sector, provide most of the communication
skills training for EoLC.
Most pilot sites found a range of local courses
available at basic or basic/intermediate level
for health workers, some of which were
specific to EoLC. Provision of intermediate and
advanced level courses is more limited, with
few opportunities outside the Connected©
training programme for cancer services. There
were, however, some examples of more
extensive provision. For example, LOROS
found that a wide range of communication
skills courses – including some academically
accredited ones – were available to most staff.
Basic communication skills training for social
care workers is generally provided through
induction or NVQ courses. The surveys suggest
that social care staff, particularly those
working for private agencies, may have more
limited access to EoLC communication skills
training than those working in health. In
Essex, however, which is responding to the
shift towards supporting people to die at
home, the important role of domiciliary care
workers has been recognised and plans are in
place to develop specialist domiciliary care
workforce skills.
Most trainers held a teaching qualification and
many had undertaken the Connected©
Advanced Communication Skills Training
(ACST) course. Some of those teaching at
advanced level felt they would benefit from
additional training.
The TNAs suggest that service providers are
not always aware of local training
opportunities for staff and there may be
limited co-ordination in the local planning of
courses with examples of content overlap,
duplication and some gaps. In general, there
appears to be a lack of training co-ordination
across the different sectors and disciplines.
13
“If more people choose to die at home,
domiciliary care agencies have an important
role 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 good
practice. Essex found evidence of collaborative
working between service providers, who
commissioned training from each other.
7.3 Competences – the details
The results show that most health and social
care workers involved in EoLC have received
some basic, generic communication skills
training but may not have received any
training specific to EoLC. In particular, social
care staff were less likely to have received
EoLC communication skills training. Very few
respondents outside the cancer
multidisciplinary teams had advanced training.
Communication is a core skill specified in the
common induction standards for social care

14. and the majority of these respondents had
attended basic courses. The Care Standards
Act 2000 requires 50 percent of care home
staff to be trained to NVQ level 2 or above in
health and social care, which includes a unit
on communication skills. However, care home,
domiciliary staff and employers often
recognised a need for more. Those employed
by private agencies may not have had the
same access to core skills training.
There were some examples of a more skilled
workforce. Essex found many care home staff
had received training specific to EoLC and 57
percent of LOROS employee respondents said
they had received some. Of these, 17 percent
had completed ACST and another 24 percent
had received other training. These courses,
mainly provided by the hospice, included
counselling, palliative care and bereavement.
Most health and social care staff assessed
themselves as competent in EoLC
communication but felt that they would
benefit from additional training. LOROS found
that 50 percent of those who assessed
themselves as competent had received some
relevant training. In Leeds, qualified nurses
working in nursing homes and care officers
working in residential homes felt competent in
discussing advance care planning and
undertaking holistic needs assessments, but
were less confident in supporting bereaved
and distressed relatives. The Leeds TNA
indicated that care workers, especially ancillary
staff, may have overestimated their
competence in some areas owing to a lack of
understanding of the criteria and skill set
required for their role. This would need
further investigation. The difficulty of selfassessing competence was also recognised by
Teesside University and Dorset.
7.4 Training need – the details
The majority of staff felt they had the
opportunity to identify their training needs via
their appraisal with their line manager.
Although most have core competences in
generic communication, relatively few have
had specific training. There was some
variation between settings, with residential
care home staff and domiciliary staff
identifying most training need.
Most sites identified a gap in advanced level
training for EoLC for health and social care
staff who were not eligible for the
Connected© ACST. As well as a need for more
advanced training generally, this highlights the
importance of access to competency-based,
advanced level training for appropriate staff
caring for non-cancer patients.
Many employees felt that they would benefit
from additional tailored training, particularly in
breaking bad news, managing complex needs,
bereavement support, bereavement
counselling, holistic needs assessment,
advance care planning, cognitive behavioural
therapy and informed consent. Most also
recognised the need for ongoing learning and
development.
“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, Teesside
University
14

15. 8. What did the pilot sites
get 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
North East London and South East London Cancer Networks
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.
• 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, multiagency 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 staff
retention and associated cost savings are a
long-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.
15

16. 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 to
each 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.
Greater Manchester and Cheshire Cancer Network
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 contact
information may be difficult and timeconsuming. 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
16

17. acquired from scoping
• Similarly, consider selection of a crosssection 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
• Projections of training needs can be made
through a combination of comprehensive
scoping of health and social care providers,
quantifying the workforce according to staff
groups, 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
17
• 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 the
intended 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 care
providers and to engage with this sector
• Personal approach methods such as
interviews, while more time intensive,
usually provided better responses than more
passive 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

18. 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 overreporting 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 platform
for future working.”
Paula Hine, education and development
manager, St Luke's Hospice
Plymouth: St Luke’s Hospice
18

19. 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
Berkshire East Community Health Services pilot
10. Good practice identified
through the TNA
The TNA results have identified some
important 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 risk
management. Select training that has
evidence of effectiveness, uses recognised
methodologies and offers value for money
• 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 responsibility
and 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 of
all local training and education
• Design training for minimum impact on
continuity of service delivery
• Identify both the cost benefits and the
service benefits of training
• Link workforce development to patient
experience to capture the benefits of
training
• Determine the return on investment by
developing evaluation criteria to assess the
• Provide appropriate support to all those
delivering courses
19

20. • 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 workforce
to training proposals and corporate business
objectives
• Take account of the costs of backfilling staff
absence 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 the
Knowledge 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
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 and
team 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
• Link workforce development to patient
experience in order to capture the benefits
of training.
20

21. 11. Next steps for pilots
The TNA has provided the pilot sites with an
information base to support development of
training and education that will meet the
needs of their local workforce. It will be
important to monitor the delivery and uptake
of training and to evaluate its impact on
business objectives, staff confidence and
competence, and on the user experience.
Please contact the national programme at
info@endoflifecare.nhs.uk for more
information, or if you would like to have
copies of the questionnaires used by the pilot
sites.
Teesside University
12. References
1. National End of Life Care Strategy.
Department of Health, 2008
5. EDT 3 – standard - training needs analysis.
NHS Connecting for Health
2. Developing skills: talking about end of life
care. National End of Life Care
Programme/Connected©, 2010
6. ETD 3 – guidance – training needs analysis.
NHS Connecting for Health
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
7. Care Quality Commission website
http://www.cqc.org.uk/findcareservices.cfm
4. A framework of national occupational
standards to support common core
competences 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
Case studies highlighting the pilot sites' work will be posted on the National End of
Life Care Programme’s website, www.endoflifecareforadults.nhs.uk, as they become
available.
A summary of this report is available from the publications section of the programme’s
website.
21

22. Appendices
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)
Extract
The 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 an
understanding 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 for
Care, 2010)
Extract
National occupational standards (NOS) identified as relevant for ALL health and social care staff
who communicate with people at the end of life.
Assistant level
HSC21
Communicate with and complete records for individuals
Practitioner level
HSC31
Promote effective communication with, for and about individuals
HSC366
Support individuals to represent own needs and wishes at decision-making
forums
HSC368
Present individuals’ needs and preferences
22

23. Advanced practitioner level
HSC41
Use and develop methods and systems to communicate, record and report
CHS48
Communicate significant news to individuals
HSC366
Support individuals to represent own needs and wishes at decision-making
forums
HSC368
Present individuals’ needs and preferences
Download guidance from:
http://www.endoflifecareforadults.nhs.uk/publications/corecompetencesframework
Search tools
Other NOS may be relevant for specific staff roles or settings and a search tool is available at
https://tools.skillsforhealth.org.uk
Additional online tools to support identification and application of NOS are available on the
Skills 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
competences
(key themes)
2.1 Communication
principles
Learning outcomes
2.1.1 Understand the importance of communicating, reporting and
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 be
relationship - roles
communicated by a senior member of staff - however, this should
and 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
23

24. 2.3 Providing
2.3.1 Recognise that more informed individuals are more empowered
accurate and
people
relevant information 2.3.2 Understand that individuals need access to good quality and
comprehensive information, as and when they want it
2.3.3 Have knowledge of local services appropriate for the individual
2.3.4 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 appropriate
to 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 life
family and friends
2.5.2 Understand the need to support and work with family and
friends of the individual
2.5.3 Know how to ensure family members are supported from
diagnosis to the end of the individual’s life and beyond
2.5.4 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 employers
within social care. They are designed to be met within 12 weeks of starting employment.
Standard 3 Communicate effectively
Main areas
Outcomes
1. Importance of
effective
communication in
the work setting
1.1
1.2
1.3
Additional information
Be aware of the different
reasons why people
communicate
Understand how
communication affects
relationships in the work setting
Know why it is important to
observe an individual’s
reactions when communicating
with them
24

25. Main areas
Outcomes
2. Meeting the
communication
and language
needs, wishes
and preferences
of individuals
2.1 Know how to establish an individual’s
communication and language needs,
wishes and preferences
Communication methods
2.2 Understand a range of
include:
communication methods and styles
• non-verbal
that could help meet an individual’s
communication including:
communication needs, wishes and
• eye contact
preferences
• touch
• physical gestures
• body language
• behaviour
• verbal communication
including:
• vocabulary
• linguistic tone
• pitch.
Communication may include
signs, symbols, pictures,
writing, objects of reference,
human and technical aids,
eye contact and touch.
May include a personal audit
3.1 Recognise barriers to effective
of your own written and
communication
communication needs
3.2 Be aware of ways to reduce barriers Eg culture, religion, health
issues, sensory impairment
to effective communication
3.3 Know how to check communication
has been understood to minimise
misunderstandings when
communicating
Services may include:
3.4 Be aware of sources of information
• translation
and support or services to enable
• interpreting services
more effective communication
• speech and language
services
• advocacy services
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 where
information normally considered to
be confidential might need to be
passed on
4.4 Explain how, when and from whom
to seek advice about confidentiality
3. Overcoming
difficulties in
promoting
communication
4. Understand
principles and
practices relating
to confidentiality
Additional information
Link to further details about common induction standards:
http://www.skillsforcare.org.uk/entry_to_social_care/common_induction_standards/common_ind
uction_standards.aspx
25

26. 5. e-ELCA (End of Life Care for All)
Communication skills curriculum
Core competences
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
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
Develop and maintain
communication with people
about difficult and complex
matters or situations related to
EoLC
• “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
Present information in a range
• Face-to-face communication
of formats, including written
• Telephone communication
and verbal, as appropriate to the • Written communication
circumstances
Listen to individuals, their
families and friends about their
concerns related to EoLC, and
provide information and support
•
•
•
•
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
•
•
•
•
•
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
Link to e-ELCA website: http://www.e-elca.org.uk
26

27. Appendix ii: Scope
Pilot
Health care
Social care
Anglia
(EoE)
Acute hospitals (10)
Community hospitals (8) Hospices (6)
GPs (315)
Nursing homes (165) Care homes (625)
Domiciliary agencies (308)
Nursing agencies (138)
East
Berkshire
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)
Nursing care homes (21)
Residential care homes (10)
Domiciliary and Nursing agencies (5)
Local Authority (1)
Learning disabilities team (1)
Essex (EoE)
Acute trusts (3)
Hospices (6)
PCTs (3)
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)
Dorset
Acute Trusts (6)
Mental health/PCT/community services (12)
Hospices (5) GPs (145)
Private hospitals (2)
Nursing & domiciliary agencies (39)
Nursing & registered care homes (123)
Local authorities (10)
Lancs and
South
Cumbria
Stroke network - acute hospitals (7)
Critical Care - acute hospitals (4)
Renal Medicine - acute hospitals (5)
Blackpool Council (10)
Lancashire social care teams (6)
Cumbria social care services
Cumbria social care - independent sector
NHS Acute Hospitals (7)
Social care education providers (2)
Council education providers (2)
Leeds
Acute trust (3 wards)
Community healthcare service (1)
Residential care homes (5)
Nursing care homes (4)
NHS acute trust (1) NHS community trust (1)
Hospices (1) Help the hospices (1)
LOROS
Acute trust (1) PCTs (2)
Community health service (2) Hospice (1)
District/community hospitals (10)
City/county/district councils (10)
Phase 1
Acute hospitals (4) Tertiary centre (1)
Hospices (4) PCT (provider services) (3)
GP practices (20)
Phase 1
Nursing care homes (30) Care care homes (15)
Manchester
Private, independent and voluntary care
organisations (TBC)
Other
Training providers
University (3) Acute trusts (9)
Hospices (3) Local authority (3)
PCT (1) Other (1)
Patients (5)
Patient focus group (1)
Volunteer group (1)
Technical support team (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)
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)
Education providers (9)
East Midlands Deanery
Clinical education centres at hospitals and in-house
providers (TBC)) Universities (4) FEI (20)
Adult education (TBC) Distance learning (TBC)
Phase 1
University (5) Acute trusts (4)
Hospices (3) Local authority (TBC) Other (2)
Phase 2
Phase 2
Phase 2
Nursing care homes (TBC)
Acute Hospitals (10) Hospices (5)
Care care homes (TBC)
PCT (provider services) (5) GP practices (TBC)
University (as phase 1) Acute trusts (10)
Hospices (3) Local authority (TBC)
Mount
Vernon (EoE)
Secondary care teams (31)
Primary care (54) Hospice (3)
Nursing care homes (64) Local authority (11)
Residential care homes (197)
Mental health trusts (8) Prisons (2)
Education/training providers (24)
Plymouth
Acute trust (1) PCTs (2) GP practices (64)
Hospice service (1)
Adult social services (2) Care agencies (12)
Nursing & residential care homes (170)
Charity/volunteer employees (48)
Ambulance services (1)
FEI (5) Universities (1) Local authority (2)
Hospices (1) PCT (1) Other (16)
Teesside
NHS & primary care trusts (16) GPs (192)
Hospices (5)
Nursing homes (7) Social services (33)
Prison services (4) Ambulance trusts (2)
University trainer (2) In-house trainer (3)
Charity trainer (1) Unknown (2)
North East and South East London Cancer Networks used existing data from the Marie Curie
Delivering Choice Programme 2008.
27
28

28. Glossary
Cancer Network
Thirty cancer networks across England co-ordinate the planning,
commissioning and delivery of cancer services
Care Quality Commission
The health and social care regulator for England
Care Standards Act
The Care Standards Act 2000 established a major regulatory
framework for social care
Common induction
Standards for people entering the social care workforce and
standards
those changing roles or employers within social care. Designed to
be met within 12 weeks of starting employment
Competence
A statement describing the behaviour, knowledge and values
expected of workers to fulfil a specific role competently
© (ACST)
Connected
Connected© is the national training programme in advanced
communication skills developed for senior health professionals
working with cancer patients
Continuing Professional
A process to maintain, develop and enhance skills, knowledge
Development (CPD)
and competence in order to improve performance at work
e-ELCA (End of Life Care for A programme providing national, quality assured online training
All)
modules to support health and social care staff working in end of
life care
End of Life Care (EoLC)
All elements of support to people approaching the end of their
lives. It encompasses the management of all symptoms, including
pain, and provides psychological, social, spiritual and practical
support
Knowledge and Skills
The NHS Knowledge and Skills Framework defines and describes
Framework (KSF)
the knowledge and skills that NHS staff need to apply in their
work in order to deliver quality services
Knowledge set for end of
The knowledge set for EoLC describes the minimum key learning
life care
outcomes that are required to deliver on the EoLC competences
within social care
NVQ
National Vocational Qualifications: work-based awards for
National occupational standards that are achieved through
assessment and training
National Occupational
National occupational standards describe performance (the skills),
Standard (NOS)
the performance criteria (what they should achieve) and the
underpinning knowledge required to undertake a particular
function
Palliative care
A comprehensive approach to the physical, social, psychological
and spiritual needs of people with progressive illness
Personal Development Plan A personal development plan sets out the identified learning and
(PDP)
training activities that support staff development, so the job can
be undertaken effectively. This is routinely reviewed during staff
appraisal
Skills for Care
The Sector Skills Council for the UK social care sector
Skills for Health
The Sector Skills Council for the UK health sector
Training needs analysis (TNA) TNA is the process by which training and development needs are
identified
29

29. Crown Copyright 2010
Edited and designed by: www.furnercommunications.co.uk
www.endoflifecareforadults.nhs.uk