Creation of a Training Course Program for Cancer-Patient Group Facilitators and Its Effects

Background: The purpose of this study was to clarify the effects of a facilitator training course focused on teaching beginners facilitator intervention skills. Intervention Method: One-and-a-half-day program combining education, role plays and relaxation. Methods: Participants were 11 participants, and of these 8 gave valid responses to our questionnaire. The scores of the participants on a facilitator intervention skills scale and on a scale of facilitator skills to cope with difficult situations were compared before and after the course, using SPSS16 for windows. In addition, the participants’ impressions before and after the course were analyzed qualitatively and inductively. Results: Seven of the 16 items on the facilitator intervention skills scale and 7 of the 12 items on the facilitator skills to cope with difficult situations improved the participants after the facilitator training. All participants indicated that they could understand the lectures. Their impressions changed from anxiety and enthusiasm to pleasure of learning and discovery of specific problems. Conclusion: The results suggested that the educational method created in this study, with emphasis on role-playing, is useful.


Introduction
In recent years, increasing interest has been paid, both in Japan and overseas, to the psychosocial burden of cancer patients.Studies have been conducted to investigate the effectiveness of psychosocial interventions for reducing the psychological burden of cancer patients and improving their quality of life (QOL) [1]- [7].Group therapy, which was developed in the West as one of the psy-chosocial interventions for improving the QOL of cancer patients [6], is a program consisting of education on stress-coping methods and problem-solving methods, group discussions and progressive muscle relaxation (PMR).The program was modified for the Japanese [4] and its effects were investigated in Japan [1] [2] [6].
Psychosocial group interventions for cancer patients will certainly be further disseminated in the future, but for this to happen, it is first necessary to create a therapeutic environment for providing group interventions.However, at present, there is a lack of human resources with the ability to act as facilitators (having the role of smoothly and effectively leading group discussions in group interventions).Facilitators provide interventions while facing difficulties in dealing with participants having problems, anxiety due to a lack of knowledge, and difficulty overcoming the fear of interventions, etc. [8].Under these circumstances, the facilitator training course program in Japan consists of lectures and role-playing exercises.But the role-playing exercises in the program last for only about 3 and a half hours, and moreover, the program does not focus on facilitator intervention skills [8].Although the level of understanding of lectures and level of anxiety have been reported [8] [9], there have been no systematic reports on facilitators' intervention methods.Therefore, it has been difficult to teach the details of facilitators' intervention methods, and Morita et al. [8] reported that there were a small number of items that reduced anxiety.
Based on the above background, the purpose of this study was to clarify the effects of a facilitator training course focused on teaching beginners facilitator intervention skills.This study is expected to serve as a foundation for finding the direction of facilitator education and for the dissemination of group interventions by clarifying the effects of the facilitator training course focused on facilitator intervention skills in group interventions for cancer patients.

Recruitment of the Study Participants
Posters and leaflets were distributed at the nursing departments in 29 hospitals near a university and within a university to recruit those who wished to participate in the study.In all, 11 persons applied for participation.Improvements in the program were made to incorporate easy-to-use skills.

Creation of a Facilitator Training Program
(Table 1) The explanation provided by the facilitators in the preliminary program was changed so that it could be clearly understood, and exercises of the relaxation method implemented by facilitators in the group therapy were also added, so that the participants would be able to use them immediately [11] [12] [13].In addition, the number of role-playing sessions based on facilitators' difficult-situation scenarios was increased to 5 (two role-playing and two discussion sessions for each scenario), so that an increase in group experience would allow the participants to understand the patients and the facilitators.Furthermore, when role-playing did not work well and remedial measures could not be found in discussions, the lecturers gave them hints for discussion or showed them an example of the facilitation method.

Evaluation Methods
The effects of the program were evaluated along the curriculum as follows.

1) Level of understanding of the lectures
The level of understanding was assessed for each item on a 4-point Likert scale.

2) Changes in attitudes as facilitators 1) Facilitator intervention skills
The scale that we created consisted of 12 items selected using a qualitative study method from the facilitator techniques used in group therapy for cancer patients.Each item was assessed on a 4-point Likert scale, with scores ranging from 0 to 3: e.g., "I have high anxiety" to "I have no anxiety".A scale of facilita-  tor skills to cope with difficult situations consisting of 12 items of difficult situations was also created by reference to representative difficult cases reported by Morita et al., and the level of anxiety was assessed on a 4-point Likert scale with scores ranging from 0 to 3:e.g., "I have high anxiety" to "I have no anxiety".

2) Impressions of the group facilitator training course
The participants were encouraged to freely describe their impressions of roleplaying exercises, what was good or bad, future problems, etc.

Ethical Considerations
This study was conducted with the approval of the Ethics Committee of the School of Heath Sciences, Faculty of Medicine, Tottori University.Researchers explained the purpose of the study verbally and in writing to the participants.

1) Changes in attitudes as facilitators
Scores on each scale before and after the training course were statistically compared by the Wilcoxon test using SPSS16 for windows.The level of significance was set at p < 0.05.
2) Impressions I read free descriptions on days 1 and 2 of the training course again and again, classified the descriptions into categories according to their meaning, gave them category names and counted the number of descriptions for each category.

Characteristics of the Participants
Attributes of the participants There were 11 participants, and of these, the responses of 8 were investigated.The remaining three participants were excluded because they failed to attend the entire one-and-a-half-day training course.Participants in their 20s (n = 3) and 30s (n = 3) were the most common.Nursing practice was the most common occupation (n = 4), followed by nursing students (n = 3).Two participants had previous experience of participating in support groups and 3 had experience of participating in patient groups, but none had previously attended a facilitator training course (Table 2).

Understanding of Lectures
All 8 participants answered that they understood all the lectures (purpose and effects of group therapy for cancer patients, significance of group experience for cancer patients, communication methods, roles and techniques of facilitators, relaxation method, and how to conduct group therapy) (Table 3).

Comparison before and after the Group Facilitator Training Course
1) Facilitation ability Analysis of the participants' facilitation ability before and after the training course revealed that the score on the facilitator intervention skills scale (total score) and that on the facilitator skills to cope with anxious situations (total score) significantly improved after the training (p < 0.05) (Table 4).
In addition, the individual scores for the following items concerning facilitator intervention skills improved significantly: "consider time and distribution of speaking time among individuals", "express participants' feelings in place of them", "encourage participants to reflect on themselves", "show oneself as standing face to face with participants", "participants want to interact with other participants", "participants play the role of facilitator in place of the facilitator", and "the facilitator and sub-facilitator cooperate with each other".Furthermore, the individual scores on the following question items concerning facilitators' ability to cope with difficult situations also improved significantly: "when some participants do not speak at all", "when silence lasts long", "when some participants express dissatisfaction with how to proceed with the group", "when participants often grumble and complain about medical staff", "when participants develop recurrence or metastasis (disease progression)", and "when there is a conflict or difference of opinions among participants".

2) Changes in free descriptions
Based on analysis of the free descriptions, the participants' descriptions on day 1 were categorized as follows: "anxiety about facilitator communication", "acquisition of role-play learning skills", "understanding of the advantages of roleplay learning", "learning from the lecturer's demonstration of facilitation," and "others".The participants' descriptions on day 2 were categorized as follows: "repeated role-playing increases learning", "discovery of specific facilitator strategies", "discovery of problems towards the implementation of facilitation", "use in clinical nursing, etc.", and "others" (Table 5).

Small Number of Participants
The schedule and other information about this course were disseminated to 29 hospitals, inviting attendance, but the actual number of attendees was only 11.
This is probably attributable to the long duration of the course (lecture for one and a half days) and the different design of the course (role-playing on many scenes).Of the 11 participants, 3 were able to attend the course only on one of the two days.Therefore, the number of the study subject was only 8. A high percentage of the participants were unwilling to participate in the role-playing, and it would appear that people tend to avoid participating in training courses that involve much role-playing.I worried about evaluation by others and appearance and I thought I had to do it well, which made me passive at first.I tried to do it without the fear of failure, and I learned a lot.

Day 1
Understanding of the procedures of role-play learning 7 I was able to have a satisfying time.It was good that I could actually watch and learn how the lecturer brought up a subject in the role playing at the end of the course.

Day 1
Understanding of the advantages of role-play learning 10 The situation and casting were real, and I was able to think as if I was actually facing difficulties.

Day 1
Learning from lecturer's demonstration of facilitation 3 I was able to have a satisfying time.It was good that I could actually watch and learn how the lecturer Chujo brought up a subject in the role playing at the end of the course.
Day 1 Others 4 I felt that both the lectures and role playing were beneficial for obtaining a deeper understanding of facilitator intervention skills.
Day 2 Repeated role-playing increases learning 3 We were able to have active discussions in the group on day 2, and this was good for me because I could feel that I learned spontaneously.In addition, I could ask the lecturer about what I did not understand and coping methods, and repeated role-plays of the same situation led me to think.

Extent of Understanding of the Lectures
There have been many reports on the need for lectures on the objectives and significance of group therapy, and the contents of the lectures in this study also covered these items.In the past, explanation about intervention focused on cases where intervention was difficult [9] [10].The present study was unique in that more concrete explanations about the skills of intervention were included in the lectures.When the participants were asked to provide their assessment of the quality of the lectures, all of them answered that they had understood all the topics covered by the lectures, including the lecture on our new attempts.This result is consistent with the results of previously reported studies 8, 9.In regard to the particularly favorable responses in regard to the clarity of the lectures in this study, we could say that this might be attributable to: 1) the small number of participants, which encouraged the participants to ask questions; and 2) the delivery of the lectures while the responses of individual participants were monitored.

Effects on Improvement of the Facilitator Capabilities
Significant improvement was seen not only in the total score on anxiety when facing difficult scenes by facilitators, but also in the scores on various other items of the scales used.This outcome was similar to that reported by Morita [8].This probably indicates that role-playing under the scenario of difficult scenes allowed the participants to devise strategies to deal with the difficulties that they faced.In the present study, questions were also asked about the facilitator's intervention skills, and significant improvement of the facilitators' skills was noted after the training course.This finding suggests that prior concrete explanation about the skills of facilitators enabled the participants to actively utilize such skills during role-playing, resulting in improvement of their skills.

Benefits of Practicing Role-Playing Multiple Times
To the free-answer question asked on the first day, many participants described "anxiety about facilitator communication".Although the participants initially have expressed difficulty in role-playing, repeated role-playing has the advantage of allowing the participants to learn, through comparison, the availability of various ways of dealing with difficulties and the presence of various rationales on the bases of which to choose the appropriate method of handling [14], and it Practice of the educational program of the I Can Cope Program [10] and group therapy for cancer patients: We participated in a workshop on activities in the US (lecture by Catherine Classen on October 11, 2003) [11] and a training course for cancer patient group facilitators in the "I Can Cope Program" in Hiroshima.A one-and-a-half-day program was then designed and implemented by reference to this workshop and training course, aimed at conferring on the participants the ability to facilitate a program known to be effective in patients with recurrent breast cancer on a medium-term basis.
playing sessions based on facilitators' difficult-situation scenarios 70 Practice Role-playing sessions based on facilitators' difficult-situation scenarios 85 Second day Practice Role-playing sessions based on facilitators' difficult-situation scenarios 85 Practice Role-playing sessions based on facilitators' difficult-situation scenarios 85 Practice Role-playing sessions based on facilitators' difficult-situation scenarios 85 Lecture The relaxation method 20 Practice Exercises of the relaxation method 40 Lecture How to conduct group therapy 20 how to let participants know the theme and how to create an atmosphere.It is necessary for facilitators to understand the theme and purpose of the session, and cooperation of the facilitator and sub-facilitator is required.It is important to stay with the patients and think with them.Day 2 Discovery of problems towards the implementation of facilitation 7 Through the facilitator experience, I found future problems such as whether I would successfully stay with the patient from the patient's point of view, eye movements, how to speak and the tone of voice.Day 2 Use in clinical nursing, etc. 2 I would like to utilize what I learnt in the group work for two days in my daily nursing practice.Day 2 Others 4 I became sleepy during the last lecture, because we practiced relaxation before the last lecture.It would have been better to perform the relaxation exercise after the lecture.
also allows the participants to accumulate experience in dealing with practical scenes.Furthermore, participants can deepen their engagement in role-playing and learning as the frequency of role-playing increases.At the same time, participants can also learn various ways of dealing with difficulties through holding discussions with other participants on the basis of their experience with roleplaying.There was a participant who compared what she learned from roleplaying with her own past experience of nursing, and found common features between them, pointing out the possibility of "utilization in clinical nursing, etc."This participant seems to have reached the stage where the knowledge/skill learned from this kind of training course could also be utilized during her practical nursing duties.

Table 3 .
Understanding of lectures.

Table 4 .
The participants' facilitation ability before and after the training course.

Table 5 .
Changes in the free descriptions.