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 Table of Contents  
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 202-208

Addressing violence against doctors: Using ADDIE framework for designing, implementation, and evaluation of the effectiveness of a therapeutic communication skills training module

1 Department of Community Medicine, Deben Mahata Government Medical College and Hospital, Purulia, West Bengal, India
2 Department of Medical Education & Community Medicine, Believers Church Medical College and Hospital, Thiruvalla, Kerala, India

Date of Submission11-Nov-2021
Date of Decision22-Nov-2021
Date of Acceptance23-Nov-2021
Date of Web Publication29-Dec-2021

Correspondence Address:
Dr. Aditi Chaudhuri
Department of Community Medicine, Deben Mahata Government Medical College & Hospital, Purulia, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/amhs.amhs_265_21

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Background and Aim: Lack of formal training and assessment in communication skills in India combined with suboptimal doctor-patient ratio leave them with little time, and therefore, patients dissatisfied with doctor's therapeutic communication and often lead to violence against doctors. There is thus an urgent need for health-care providers and their trainers to be formally and systematically trained and assessed. Materials and Methods: Descriptive study (describing the process of training module development using ADDIE Framework) and an educational intervention study (using the Kirkpatrick model for measuring effectiveness of the training). Module's contents were identified through the literature search followed by content, context, and construct validation by communication and subject experts. Modular 8 hour training was implemented for 50 participants in two batches on two different days. Results: In the immediate postintervention feedback, all participants agreed that the training will be beneficial to them in real life and they expressed confidence in teaching communication skills to their students, particularly in breaking bad news and resolving doctor-patient conflicts in the real life. Effectiveness of intervention is reflected by gain in knowledge scores from 6.84 (at pretraining) to 10.76 (immediate posttraining) and sustained at 10.8 (at 3 months posttraining). The impact of the training on their communication skills is also demonstrated by the skill scores showing incremental increase from 12.4 (at pretraining) to 19.16 (immediate posttraining) and then 21.8 (at 3 months posttraining) which is statistically significant (P < 0.05). Conclusion: The training was effective, accepted well by trainees and has been institutionalised.

Keywords: ADDIE framework, doctor-patient communication, training effectiveness evaluation, training module design, violence against doctors

How to cite this article:
Chaudhuri A, Chacko TV. Addressing violence against doctors: Using ADDIE framework for designing, implementation, and evaluation of the effectiveness of a therapeutic communication skills training module. Arch Med Health Sci 2021;9:202-8

How to cite this URL:
Chaudhuri A, Chacko TV. Addressing violence against doctors: Using ADDIE framework for designing, implementation, and evaluation of the effectiveness of a therapeutic communication skills training module. Arch Med Health Sci [serial online] 2021 [cited 2023 Mar 20];9:202-8. Available from: https://www.amhsjournal.org/text.asp?2021/9/2/202/334016

  Introduction Top

Communication is the process of sharing of information, knowledge, and thoughts between two or more persons which aims to bring a mutual understanding in human relation. The term “communication” has its origin from the Latin word “communicare” which means “to share.” Therapeutic communication is a purposeful form of communication, allowing the health professional and the patient to reach health-related goals through participation in a focused relationship. Barriers to communication may have a negative effect and may lead to stress, frustration, anger, and even resentment. Doctor-patient communication is a major component of the health-care delivery.[1] Terry Canale in his American Academy of Orthopedic Surgeons Vice Presidential Address said “The patient will never care how much you know, until they know how much you care.”[2] From time immemorial doctors have held an unique position of respect and power in the society. Even Hippocrates suggested that doctors may influence patients' health. The principles of patient-centered medicine date back to the ancient Greek school of Cos.[3] However, patient-centered medicine has not always been common practice. For example, in the 1950s to 1970s, most doctors considered it inhumane and detrimental to patients to disclose bad news because of the bleak treatment prospect for cancers.[4],[5] Effective doctor-patient communication can reinforce patients' self-confidence, motivation, and positive view of their health status, which may ultimately influence their health outcomes.

Due to various reasons including commercialization of health care in India, doctors spend very little time for therapeutic communication. This factor along with patients becoming more aware of their rights, reports of dissatisfaction with doctor's service delivery are increasing.[6],[7] The negative repercussion of this in the health-care system often gets reflected in increased reporting of mob violence, destruction of hospital property, and endangering the life of health care staff as well as litigations against doctors.[8],[9],[10] One of the important ways by which this trend can be reversed is by improving the communication skill of the health-care providers by suitable pre and in-service training. It is a fact that this “poverty in therapeutic communication skills” situation in the health-care delivery system is also observed in the medical colleges where the student's role-model teachers are no different in their (lack of) demonstration of communication skills.

In a nutshell, therapeutic communication skill development for medical professionals is the need of the hour and should be included as an important curricular component for medical professionals in both undergraduate and postgraduate levels.[11] Therapeutic communication skill has long been used as a component for assessment in examinations conducted by Royal College, London, United Kingdom. The Medical Council of India has introduced Attitude and Communication (ATCOM) module in its Competency-Based Medical Education (CBME) Curriculum[12] to sensitize the medical students about ATCOM skill. Since communication skill development is now an important component of MBBS curriculum, the need for Medical Teachers to undergo formal training becomes a prerequisite. In response to the above context and focusing on the need to address the rising violence against doctors, the present tailor-made intervention on therapeutic communication skills was undertaken. What this study adds is (1) We used the strategy of leveraging a course of ATCOM training (which is a mandatory Workshop for all Medical Teachers) to address a gap in therapeutic communication skill among teachers that was leading to violence against doctors; (2) We used ADDIE framework for instructional design and training module development which is a systematic process that guides the design, implementation, and evaluation of the effectiveness of a new structured therapeutic communication skill training module to make it relevant to the Indian context and (3) We evaluated effectiveness of the intervention beyond the immediate post training period to capture transfer of knowledge and skills to practice at the workplace.

The primary objective of this study was to develop, implement, and validate a structured module of therapeutic communication skill training and evaluate its effectiveness among medical teachers in government medical colleges in the state of West Bengal. We are describing the process in detail so that in the transition to the new CBME curricular paradigm, other academic leaders who recognize the need for introducing various training modules needed for moulding each of the outcome attributes of the competent Indian Medical Graduate who is caring, compassionate and communicative can be replicated elsewhere outside the local context where this training module was developed.

  Materials and Methods Top

The study uses an interventional study design where a training module on therapeutic communication skill was designed and rolled out for the medical teachers and then the evaluation of effectiveness of the training module was done by comparing the pre- and posttraining knowledge and skills of the participants and also after 3 months through Workplace Based Assessment for capturing transfer of skills learned to the workplace. The study was conducted during August 2018 to July 2019 (12 months) at the apex training institute for medical teachers in the state of West Bengal after obtaining administrative and ethical approvals from the concerned authorities. In this pilot study, 50 medical teachers who were due for the faculty development training at the Institute during the study period were included as the study population in our project. The study was conducted in two phases: (1) Design Phase and (2) Implementation and Evaluation Phase and these are described in details to communicate the process clearly for its replication outside the local context.

Phase 1: Designing a training module on therapeutic communication skill

Approvals from the administration and Institutional ethics committee were obtained at the beginning. Thereafter, the focus was on designing and developing the training module on therapeutic communication skill for medical teachers.[13] The content validity for the Module content was initiated through extensive literature search.[14],[15],[16],[17],[18] This was then made contextual and reinforced by the inputs received from medical teachers to identify the commonly encountered difficult case scenarios in hospitals that trigger conflict/dissatisfaction. The construct validity of the module was initiated by following the steps of ADDIE model framework for training module design.[19]

A-Analyzing the training needs of the medical teachers for deciding the contents

Based on extensive literature review on the various frameworks of therapeutic communication and existing training modules, an initial list of nine topics was identified as needed for the training program. As the next step, a handout containing the topics were distributed among 5 senior medical teachers in the rank of Professors and Associate Professors from different subjects who were representative of the study participants. They were not included in the study. They were asked to discuss among themselves and score the 9 topics according to its importance on a scale of 1–10 (10 = most important and 1 = least important). Their consensus about the “must have” contents under each topic of the training module was used for “marrying content into a communication skill framework” by five experts on communication skill who also formed the team of trainers for the same training program.[19]

D-Designing the learning objectives, delivery methods, activities, and tools

The learning objectives for each session, mode of delivery and activities planned including role-plays, and group discussions were prepared by the team of expert trainers by following Gagne's Nine Events in Instruction. The lecture sessions were kept brief (20–40 min) and interactive. To avoid monotony, two lectures were followed by role-play or video clips for demonstrations. The assessment tools, i.e., pre/posttraining questionnaire and checklists for recording knowledge and skill and feedback forms for recording the reaction of the participants (usefulness and confidence level) were also constructed during this phase. The validated Kalamazoo Checklist for Communication Skill[20] was used for the assessment of skills. The tool contents were constructed after thorough literature search by the investigator and then content validated by the team of experts. The systematic process of lesson planning was guided by Gagne's “Nine Events of Instruction:”[21]

Gaining attention

At the beginning of each session, a case scenario or a video clip helped to gain attention of participants about relevance of session topic.

Informing the learner of the session objective

This was done at the onset to motivate the learners and clarify expectations.

Stimulating recall of prerequisite learning was practiced by sharing relevant experiences of difficult situations in the hospitals by the learners themselves.

Presenting Information

Well-organized contents divided into “digestible chunks” in logical sequence emphasizing points (by stating “here is something new that you can apply”) and done in a variety of ways to cater to different learning styles to optimize learning.

Providing learning guidance

the demonstration of doctor − patient communication (content) was done by the facilitators incorporating it into the Kalamazoo framework Checklist for communication and the learners observed the steps.

Eliciting the performance

The batch of 25 participants was divided into small groups of 5 and each group were assigned a case scenario for role-play guided by the checklist.

Providing feedback

Feedback on the performance was provided by facilitators and peers for improvement in identified items on the checklist.

Assessing the performance

Done as above and served to capture immediate impact of the session.

Enhancing retention and transfer

Encouraging them to reflect on their learning during the session and how they will use the opportunities to practice the skills during their daily interaction with their patients.

D-Developing the module, validating, and pilot testing

The training module was further developed to make it more comprehensive. The Calgary-Cambridge guide was used to make the process of doctor-patient communication more closely aligned with the structure and process skills used in communication skills training. Further enhancement of the training module was done by including patient-centered medicine into both process and content aspects of the medical interview. These modifications were done to resolve any problem which may be associated with teaching and application of communication skills in medical practice. Validation of the training module and assessment tools were done by five subject experts and their inputs were incorporated. Pilot testing of the module was done on 10 medical teachers.

Phase 2: Implementation and evaluation of effectiveness

I-Implementing the modular training as per training design

The Institute being the nodal center for training in the state of West Bengal had approved the training program, the recruitment of participants were comparatively Hassle free. An E-mail was sent to the principals of all medical colleges under Government of West Bengal for nomination of medical teachers. In addition, a well-designed brochure was posted in the institute website which appealed to the emotions of the target participants reminding them of their past encounters of violent situations at hospitals. The response was overwhelming with requests from the large number of willing candidates to get enrolled for the training. The structured training program based on the module was then rolled out for medical teachers as a part of their faculty development program. The 8 hour module-based training was implemented for 50 participants in two batches. The modules were distributed to the participants after eliciting pretest of knowledge and skills using questionnaire and OSCE stations (breaking bad news). Training methods used in the program were brief lectures on therapeutic communication, video recordings of ideal doctor-patient communication, and role-plays on sensitive scenarios.[5],[15],[16]

At the end of each training session, participants were assigned role-play exercises (breaking bad news) and their performance in therapeutic communication was assessed by a validated checklist (during posttraining OSCE). Posttest questionnaire was used for eliciting posttraining gain in knowledge. Participants' reactions on the effectiveness of the module and about their training experience were recorded in structured and validated feedback forms.

E-Evaluating effectiveness of the tailor-made module by eliciting trainee's reactions

The Kirkpatrick model for Training Program Evaluation[22] was used for evaluation at two levels at the end of the training and Level 3 on-the-job after 3 months.

  • Level 1: Recording the reaction of the participants (usefulness and gain in confidence) and facilitators after the training with the help of feedback forms
  • Level 2: Evaluation of gain in knowledge and skill with the help of pre/post training knowledge questionnaire and checklists for communication skill measurement, respectively
  • Level 3: Evaluation of change in behaviors on the job which was assessed after 3 months of the training at their workplace. The workplace-based assessment was done by the same team of evaluators and with the same set of posttest questionnaire to assess the retention of knowledge. The application of skill gained through training was evaluated by the team with the help of Kalamazoo Checklist while the trained medical teachers were interacting with real patients in the hospital wards.

  Results Top

The use of the ADDIE Framework for training module design and its instructional design resulted in the following outputs:

Training needs identified [Refer to [Table 1]]
Table 1: Output from step A of ADDIE: Analysis of training needs

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Module design: Contents finalised [Refer to [Table 2]]
Table 2: Output from step D – Design of ADDIE: Supporting literature

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Instructional design

The following strategies and methods used using Gagne's nine events of instruction described under materials and methods.

Design of the Training Session (8 hour) based on training needs and training outcomes

  • Brief lecturette on therapeutic communication, principles, strategies, and barriers (30 min × 4 sessions)
  • Video Clips of ideal doctor-patient communication (5 min × 2 clips)
  • Explanation with demonstration of the steps of Calgary Cambridge guide, SPIKE framework for breaking bad news, Kalamazoo Checklist for Communication (2 h)
  • Role-plays on therapeutic communication skill in sensitive scenarios (2 h)
  • Group activities for achieving training objectives (1 h)
  • Open house for seeking clarifying questions, concerns and responding to them (30 min)
  • Pre and posttest to capture learning from the module-based training (20 min).

Evaluating effectiveness of the training

This is stated as per levels of Kirkpatrick model.

Kirkpatrick level 1: Trainee reaction, satisfaction

At the end of the training feedback, all participants agreed that the training will be beneficial to them in real life and they expressed confidence in teaching communication skills to their students, breaking bad news and resolving conflicts in real-life therapeutic communication. 43 out of 50 participants reported that the training was very much effective while rest 7 reported it be effective. On the other hand, the 4 out of 5 facilitators agreed that the training was very effective and the remaining single facilitator reported it to be effective.

Kirkpatrick level 2: Effectiveness in terms of measurement of trainee learning

Data analysis was done by IBM.SPSS statistics for Windows. Version 21.0. Armonk,NY: IBM; 2012. Comparison of knowledge and skill scores of all participants at pretraining and posttraining period was done using Student's t-test. Results revealed that knowledge score at pretest was 6.84 (Mean) ± 1.31 standard deviation (SD) and at posttest was 10.76 (Mean) ± 1.5 SD (total marks = 15). Similarly, skill score at pretest was 12.4(Mean) ± 3.08 SD and at posttest was 19.16 (Mean) ± 4.22 SD (total marks = 35). Paired t-test for both knowledge and skill showed that the training was effective (P < 0.00001) in improving the knowledge and skills of the participants [Figure 1] and [Figure 2].
Figure 1: Comparison of pre and post training knowledge scores

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Figure 2: Comparison of pre and post training skill scores

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Kirkpatrick level 3: Change in behavior

The participants were followed up after 3 months to observe their behavior at their workplace. This workplace based assessment was done in two steps. In Step 1, a set of questionnaire was administered to assess the knowledge of the participants. In Step 2, OSCE stations were arranged with real-life patients and each participant were asked to demonstrate their therapeutic communication skill by interacting with the patients. The same checklist for assessment was used as in Kirkpatrick level 2.

The comparison of knowledge scores showed a rise from 6.84 at pretraining to 10.76 immediately after the training and 10.8 after 3 months of training. However, the skill scores showed an incremental increase from 12.4 at pretraining to 19.16 immediately after training and then further up to 21.8 after 3 months posttraining (statistically significant, P < 0.05) [Figure 3] and [Figure 4].
Figure 3: Comparison of knowledge scores at pretraining, posttraining immediate and posttraining 3 mons

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Figure 4: Comparison of skill scores at pretraining, posttraining immediate and posttraining 3 mons

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  Discussion Top

The strategy of ensuring teachers getting trained in critical communication skill in the guise of ATCOM training of the students for therapeutic communication skills is a novel idea in this present research work.

In the present study, sharing the training needs assessment findings with the trainees made them motivated to learn in a systematic way using the modular approach. Other studies by Roter et al. and Lee et al. showed that doctors are capable of learning the theory of good doctor-patient communication as well as practice the relevant skills, and can modify their communication style if there is sufficient motivation, incentive and appropriate training.[4],[23] Among the various models for guiding instructional design for construction of a training module, the ADDIE and the Dick and Carey/Systems Approach models are commonly used. Since we were piloting the process for designing a new training module, we opted for the 5 phase ADDIE model described in detail in this study which we found to “fit the purpose” compared to the Dick and Carey 10 step (identify instructional goals, complete instructional analysis, determine entry behaviors and learner characteristics, write performance objectives, development of assessment material, develop instructional strategies, develop instructional material, conduct formative evaluation, conduct summative evaluation and revise the instruction) model that is more suitable for an ongoing training program.

In our study, after the module was designed, to make each session within the module more effective, we followed Gagne's Nine events in instruction defining the learning objectives for each session, mode of delivery and activities planned including role plays and group discussions prepared by the team of expert trainers. The lecture sessions were kept brief (20–40 min) and interactive. To avoid monotony 2 mini lecturettes were followed by role-play or videoclips for demonstration. According to Chiò et al., communication skills involve both style and content.[24] Repetitive reinforcement was done to practice systematic stepwise teaching of therapeutic communication based on Calgary Cambridge guide and Kalamazoo framework that emphasizes Build a Relationship, Open the Discussion, Gather Information, Understand the Patient's Perspective, Share Information, Reach Agreement (if new/changed plan), Provide Closure. Similarly, Platt and Keating has found out that relationship building is especially important in breaking bad news.[25] Important factors include understanding patients' perspectives, sharing information, and patients' knowledge and expectations.[26] In our module, the strategies of therapeutic communication involve important points like silence, accepting, broad opening, active listening, seeking clarification, making observations, summarizing, and reflecting. Similarly, Diette and Rand found that attentive listening skills, empathy, and use of open-ended questions were some examples of skillful communication.[27] Other studies also indicated that the three important components of doctor − patient communication were creating a good interpersonal relationship, facilitating exchange of information and including patients in decision making.[4],[25] We used the SPIKES framework for “Breaking Bad News” in our training program which was complex and challenging task more to owing to the time constraints in 1 day training and our finding was supported by the Baile et al.[5]

In the present study, at the end of the training, all participants agreed that the training will be beneficial to them in the real life and they expressed confidence in teaching communication skills to their students, breaking bad news and resolving conflicts in real-life therapeutic communication. Review of literatures shows that communication skills training has been found to be effective in improving doctor-patient communication.[28],[29] A large number of studies have proven that effective doctor − patient communication plays a pivotal role in the delivery of health care.[8],[9],[10],[23],[28],[30],[31] A patient-centered approach usually results in better patient as well as doctor satisfaction.[4],[26],[27],[29],[30]

Comparison of knowledge and skill scores of all participants at pretraining and immediate posttraining period was done by using Student's t-test and results revealed that the training was effective (P < 0.00001) in improving the knowledge and skills of the participants. However to our delight, another posttraining assessment done to check sustenance of effectiveness of the program after 3 months at their workplace showed that knowledge scores rose from 6.84 at pretraining to 10.76 immediately after the training and 10.8 after 3 months of training while the skill scores had a comparatively better rise from 12.4 at pretraining to 19.16 immediately after training and then rose up to 21.8 after 3 months posttraining (statistically significant, P < 0.05). Although in the present study, skills score is likely to increase due to practice at workplace, previous studies have observed that communication skill tends to decline over time in doctors as they get overburdened with other aspects of health-care delivery.[32] Thus, reinforcements of the need of therapeutic communication in the form of reflection-on-practice leading to continuing professional development needs to be encouraged. The training module on therapeutic communication for the medical teachers developed in the present study has been adopted by the State Institute of Training (institutionalized) as an on-going process which definitely will have a long-term impact in the development of good doctor − patient relations in the state of West Bengal.


The effectiveness of the training module could have been evaluated by comparing with a control group without training of teaching doctor − patient communication and also the long-term impact in terms of reduction in violence against doctors but could not be undertaken owing to time constraints. The list of medical teachers for enrolling in the training was finalized by the Directorate of Training and the participants could not be selected in balanced proportion from preclinical, para-clinical or clinical departments. The ability to generalize may be limited because of the size of the specific population studied. A Hawthorne effect (awareness that one is being observed and evaluated) could not be ruled out during posttraining evaluation at workplace and may affect behavior of the participants.

Way forward

Since the present study with 50 participants was conducted on a pilot basis, there is further scope of replicating the study with more number of participants using the same process of ADDIE framework for training module design after modifying it according to local context or using a control group or use qualitative research methods to identify and gain insights on why the intervention was effective including the role played by the use of ADDIE Framework and Gagne's Instructional design models. This study also serves as a stimulus for further research on the training on different approaches of doctor-patient communication and evaluating the skills. The long-term impact in terms of reduction in violence against doctors in the state may also be evaluated after few years with a special project tasked with training and evaluation of subsequent batch of medical teachers in the state.

  Conclusion Top

Our use of a structured process guided by the ADDIE framework for training module design and Gagne's nine events of instruction for planning sessions was effective. Demonstration of sustained effectiveness of the training even 3 months on-the-job could convince policy makers and administrators about the need for following such a systematic structured communication skill training on an ongoing basis.

Declaration of participant consent

The authors certify that they have obtained all appropriate participant consent forms. In the form, the participants have given their consent for their images and other clinical information to be reported in the journal. The participants understand that their names and initials will not be published and due efforts will be made to conceal their identity, but, anonymity cannot be guaranteed.


We express our sincere thanks and gratitude to the Director of Medical Education, West Bengal and Director, IHFW, Kolkata, for their support and FAIMER faculty for guidance and all facilitators of the ATCOM training program for their active participation in this educational innovation project.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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