Training in communication skills for healthcare providers in chronic care: a systematic review

Abstract

Objectives

Communication skills training (CST) is essential for healthcare providers in chronic care, enabling patient-centered, empathetic, and effective interactions. This systematic review sought to identify evidence on the effectiveness, content, and teaching methods of CST programs for providers in chronic care. It aimed to identify universal principles and adaptable strategies that help improve communication skills across diverse chronic conditions.

Methods

Five databases (Medline/PubMed, Web of Science, Scopus, PsycINFO, and Cochrane Library) were searched from inception to August 2024. Randomized controlled trials (RCTs) and quasi-experimental studies evaluating the impact of CST programs on healthcare providers in chronic care were included. Study selection was carried out independently by two authors, with discrepancies resolved through discussion or consultation with a third reviewer when needed. The Mixed Method Appraisal Tool was used to assess the methodological quality of the included studies.

Results

Fifty-five studies (15 RCTs, 40 quasi-experimental) were included. Few interventions were developed with patient input (n = 4). Most interventions incorporated role-play with feedback (n = 46), didactics (n = 45), and group work (reflection and discussion) (n = 37), often used in combination. Common training foci included basic communication skills (n = 22), breaking bad news (n = 19), empathy (n = 17), and advance care planning (n = 14). Few interventions used booster training such as coaching, telephone, or email support (n = 8) or online/virtual modules (n = 8). Oncotalk and its adaptations were prevalent. CST programs demonstrated significant improvements in communication outcomes. Communication behaviors significantly improved in most studies (93%, 37/40), with similar improvements in communication self-efficacy and confidence (96%, 26/27), largely sustained at follow-ups. Positive shifts in attitudes and beliefs toward communication were also observed in most studies (80%, 8/10).

Conclusion

CST programs consistently improve providers’ communication skills, self-efficacy, and attitudes. Their adaptability across chronic care contexts underscores their potential for broad implementation. However, standardized approaches and innovative delivery methods are needed to enhance scalability and long-term impact.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-07797-1.

Introduction

Patient-healthcare provider communication is the invisible thread weaving through the fabric of chronic care, where treatment lasts for years and trust is built gradually. This thread binds hope to science, fear to reassurance, and uncertainty to partnership. Navigating the complexities of managing a chronic illness generally involves sensitive conversations about, for example, prognosis, treatment options, enduring lifestyle changes, and palliative care [1]. These challenging conversations make both clinical expertise and advanced communication skills necessary to effectively address patients' emotional, psychological, and informational needs, foster trust, and support shared decision-making (SDM) [2]. However, many studies have shown that providers have a low level of ability to handle these aspects of care effectively. For instance, it was found that many providers lack confidence in initiating conversations about care planning in palliative care [3]. In another study, patients expressed dissatisfaction due to doctors' uncommunicative attitudes or poor communication skills [4]. A systematic review highlighted that patient-provider communication influences chronic illness self-management, indicating that providers need to tailor their communication styles to meet patients' unique needs [5]. Similarly, another study identified both general and unique communication challenges faced by advanced practice providers, emphasizing the need for targeted training in communication skills for chronic care [6]. 

To address these gaps, training in communication skills is advocated as essential for all those working in chronic care and managing patients with chronic diseases, equipping them with the tools for patient-centered, empathetic, and effective communication [7–9]. Communication skills training (CST) programs aim to improve providers' ability to carry out critical and interconnected tasks in chronic care communication, such as breaking bad news [10], showing empathy [11], facilitating SDM [12, 13], motivational interviewing [14], and handling difficult interactions, for example, with patient relatives [15]. However, although CST has been thoroughly studied in specific chronic and serious fields, such as palliative care and oncology [16–19], its application across a wider range of chronic illnesses, such as diabetes and cardiovascular diseases, still remains less studied [5, 20].

It is worth mentioning that chronic diseases share inherent challenges that transcend individual diagnoses, such as multi-morbidity, the need for long-term relationship building, and the need for tailored condition-specific communication strategies [21]. These commonalities highlight the importance of developing CST programs that are not only adaptable to specific conditions but also grounded in universal principles applicable to chronic care. For example, a core communication task, such as breaking bad news, requires universal skills like empathy and clarity, which must be generalized and adapted to the unique demands of different chronic conditions.

Despite these shared challenges, there has been some evidence synthesis about CST programs only for a specific chronic condition (e.g., cancer [22, 23], end-of-life care [24]), and there has been no comprehensive review of the evidence about training interventions for a wide range of these conditions, and at the same time, for all those involved in chronic care delivery. However, such a synthesis will identify universal strategies that can be applied across diseases and highlight how these strategies can be tailored to meet the distinct needs of specific conditions of interest. To bridge the gap between disease-specific CST programs and the broader realities of chronic care, this systematic review aimed to provide a comprehensive view of effective communication interventions across diverse chronic care contexts. Our objectives were to identify and describe existing training interventions relating to their development, content, teaching methods, duration, and outcomes.

Methods

This review was not registered but was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline (Supporting information 1) [25].

Search strategy

We conducted a comprehensive electronic search of five databases (Medline/PubMed, Web of Science, Scopus, PsycINFO, and the Cochrane Library) from their inception through August 2024, restricting results to English-language publications. The search was run using Medical Subject Headings (MeSH) and keywords derived from the initial search. As different databases employ different MeSH terms, the terms were modified to fit each database accordingly. Therefore, variations of the following search terms were used: “communication skills” OR “therapeutic communication” OR “consultation skills” OR “interview skills” OR “empathic communication” OR “patient-physician communication” AND “health provider” OR “health professional” OR “physician” OR “nurse” AND “training” OR “educational intervention” OR “workshop” OR “course” OR “program”. The search terms and strategy are provided in Supporting information 2.

Eligibility criteria

The retrieved documents were exported to the EndNote reference manager and checked for duplicates. The documents that remained were screened according to the following criteria:

Population

The study population included healthcare providers, such as physicians (including residents, fellows, and practicing clinicians), nurses, nurse practitioners, dietitians, and other relevant clinical professionals across diverse chronic and serious care contexts. We excluded undergraduate medical students. Moreover, studies involving radiotherapists and pharmacists, which focus more on the technical aspects of care rather than the clinical aspects, were excluded because they do not align with the context of chronic care.

Types of intervention

We included studies that implemented and evaluated the CST. Studies that addressed only the development of a program without implementation and evaluation were excluded.

Types of outcome measures

In this review, we considered the factors affecting communication behaviors with cancer patients proposed by Parle et al. [26]. Therefore, the outcomes of interest were: provider satisfaction, changes in communication behaviors and skills, confidence in communication and self-efficacy, changes in beliefs and attitudes towards communication skills, and perceived support from peers. We excluded studies that assessed the effect of CST solely on patient outcomes without evaluating the impact on healthcare providers to maintain a clear focus on provider-related outcomes.

Comparator(s)/control

We included both comparative and non-comparative studies. In comparative studies, CST interventions were required to be tested pre- and post-training or versus a non-exposed control group. In non-comparative studies, only post-training outcomes were assessed without a control group.

Types of studies

We included randomized controlled trials (RCTs) and quasi-experimental studies that met the above criteria. Conference abstracts and reviews were excluded from the study.

Data extraction

Two review authors (MP and MT) extracted data independently from the included studies using a data extraction form. Any discrepancies were resolved by discussion until a consensus was reached. Specified data were extracted from each of the studies to compare them: author, country, publication year, study design (quasi-experimental studies, RCTs), characteristics of participants and their number, training development, focus of training, teaching methods, and content, number of facilitators per participant, duration of intervention and follow-up time, measured outcomes, provider satisfaction (training acceptability), and key findings related to providers’ communication behaviors. Before extracting the data, we pilot-tested the data extraction form on two of the included studies to ensure that all the data elements were captured.

Quality appraisal

The methodological quality of the included studies was assessed using the Mixed Method Appraisal Tool (MMAT) [27]. The MMAT is a validated tool for evaluating different types of research designs (qualitative research, quantitative descriptive studies, randomized controlled trials, non-randomized studies, and mixed-methods studies). The MMAT checklist includes two screening questions used in all relevant research designs. For a paper to be eligible for inclusion and additional quality assessment, both screening questions must be answered affirmatively (yes). Once a study passes this initial screening, it is evaluated using five specific criteria tailored to its study design. These criteria assess the methodological rigor, such as the appropriateness of the study design, sampling quality, measurement validity, handling confounders, etc. in different study designs. Based on the number of criteria met, the studies are categorized as high quality (meeting all 5 criteria), moderate quality (3 to 4 criteria), or low quality (0 to 2 criteria).

Two authors performed quality assessment independently (MP and MT), and any lack of consensus was resolved by discussion or by a third author (EN). Because the MMAT guideline do not exclude low-quality studies, the researchers decided to include all of them.

Results

Summarizing the results

The number of studies resulting from the systematic search is shown in Fig. 1, in accordance with the PRISMA guideline. Our initial database search retrieved 3518 studies. After excluding duplicates, 1765 studies underwent title and abstract review. This process left 145 studies for full-text review, and finally, 55 studies were included in the final analysis (Supporting information 3).

Fig. 1.

PRISMA flowchart for study selection

The majority (n = 19, 34.6%) reported studies in the USA, followed by Australia (n = 9, 16.4%), Japan (n = 4, 7.3%), and Denmark (n = 4, 7.3%). A summary of all training and study details can be found in Table 1. The most common study designs were quasi-experimental pre-post studies, without (n = 25) and with (n = 4) control groups (total 52.7%), followed by quasi-experimental post-only studies without control (n = 4). Fifteen (27.3%) papers reported RCTs. Two studies used a mixed-methods design combining pre-posttests with qualitative interviews to evaluate training acceptability and satisfaction. Four studies used retrospective pre-post measurements (no control group), and three studies used prospective longitudinal pre-post measurements (no control group). One study used a combination of designs (RCT for a short program and pre-post without control for a long program) (Table 1).

Table 1.

Characteristics of included studies

Study ID Country	Study design	Participant/ Number	Development	Focus of training	Teaching methods and content	F/P	Duration/Follow-up	Measured outcomes	Provider satisfaction	Key findings
Roter et al. (1998) USA [31]	Pre-posttest, with control group	Internal medicine or family practice in ambulatory care/ n = 15	Own prior work	Patient-centered communication	The initial training provided an overview of literature and baseline study findings. Subsequent sessions focused on practical application through role-playing scenarios with feedback emphasizing specific CS (e.g., informativeness, emotional responsiveness, partnership building). Participants received manuals, transcripts, and readings	-	8-h over 2-day	Changes in doctors’ CS during routine medical visits (pre- and post-audiotape analysis of visits using the RIAS)		Doctors trained in CS used significantly more target skills post-training than their untrained colleagues (esp. more facilitations and open-ended questions)
Cooper and Hassell (2002) UK [32]	Posttest only, no control	Rheumatology specialist registrars /n = 14		Consultation skills tailored to typical scenarios in rheumatology practice	Training included small group discussions, observations of pre-recorded consultations, and simulation exercises (role-play between participants) with peer feedback based on scenarios from within the specialist field. It aimed to define effective communication, analyze real-life consultations, and improve communication techniques using various models	2 to 14	A half-day	Evaluating the workshop in terms of its objectives, enjoyment, and relevance, attitudinal changes through a visual analogue scale, feedback on workshop format, and perceived improvement in skills	Participants enjoyed the workshop and felt the objectives were met. The non-threatening use of small groups, integration of theory and practice, and an informal, interactive approach were well-received. Most found videotaping their consultations threatening	There was a high level of agreement among participants that CS can be taught and learned, and that they acquired new skills
Fujimori et al. (2003) Japan [33]	Pre-posttest, no control	Oncologists/ n = 58	Adapted from previous study (Baile et al.)	BBN and transition to palliative care	Training included a didactic lecture on the impact of communication between patients and oncologists and CS for BBN (1 h), followed by small group discussions and role-playing (participants as patients/providers) with feedback simulating cancer diagnosis, disease recurrence, and switching from aggressive therapy to palliative care, according to the steps of the SPIKES model	2 to 6–7	5 h/ 3 months after workshop	Self-reported confidence in communication with patients, psychological distress, burnout, physicians’ difficulties with communications and patients	Participants reported high satisfaction with all aspects of the workshop. The workshop was perceived as highly relevant to clinical practice	Immediately and 3 months after CST, confidence in communication increased significantly compared to pre-training levels. Burnout worsened 3 months post-CST. A learner-centered approach may require adaptation in Japan's paternalistic culture
Back et al. (2007) USA [34]	Pre- posttest, no control	Medical oncology fellows/ n = 115	Empirical studies of patient preferences; own work	BBN, discussing transitions to palliative care, and empathic communication	The Oncotalk workshop included short overviews and extensive skill practice sessions where participants engaged in role-playing with SPs and received feedback from faculty and peers. The program emphasized attending to the patient agenda, recognizing empathic opportunities, and responding verbally	1 to 5	4-day retreat	Acquisition of CS using audio recordings of SP encounters with the coding schemes of SPIKES, NURSE and a custom-developed 6-step approach		The workshop significantly improved participants' bad news skills and transition skills. This improvement was evident in the number of skills acquired after the workshop compared to before
Sutherland et al. (2007) Australia [19]	Pre-posttest, no control	Cancer clinicians/ n = 93	Consultation with an expert panel of stakeholders, previous literature	BBN to patients and their families	This workshop combined theoretical learning of CS with the practical application of skills when BBN. Participants engaged in group activities, discussions and role-playing exercises (with professional actors) with feedback to enhance their abilities. A strong emphasis was placed on experiential learning through simulated patient interactions. Participants received a workshop booklet summarizing key points	-	4.5-h /before and 6-week post workshop	Beliefs about psychosocial care, self-reported communication confidence and behavior, and satisfaction with the program	A high level of participant satisfaction was observed, particularly with the broad aims of the workshop, the performance of the facilitators, and the role-play sessions	Clinicians' confidence in using communication skills to deliver bad news to patients improved. There was no change in clinicians’ beliefs or practice behavior
Liu et al. (2007) China [35]	Pre-posttest, with control group	Registered nurses in the Cancer hospital/ n = 129	Based on Integrated Communication Skills Training Model (ICSTM) developed by Parle et al	Basic CS in cancer care	Training included cognitive, affective, and behavioral components along with managerial support. The integrated CST program comprised two sections:1) learning in a big group with lectures, video demonstrations, Q&A, video reviews, and a handbook; 2) small group sessions to empower head nurses to create a supportive ward atmosphere for nurses	-	3-day (21-h) over 3 weeks/ before, 1 and 6 months after the training	Self-perceived basic CS, self-efficacy, outcome expectancy beliefs, and self-perceived support		There was continued improvement in the basic CS, self-efficacy, outcome expectancy beliefs, and perceived support in the training group. No significant improvement in the control group
Mjaaland et al. (2009) Norway [36]	Pre-posttest, with control group	General practitioners/ n = 25	Literature review, expert consensus, and pilot testing	Patient-centered communication	Training focused on the GRIP communication model (a cognitive and solution-focused therapy technique) designed to enhance the CS of physicians to better support patients in coping with their health issues. The training consisted of experiential learning through role playing (between participants), case-based discussions, and peer feedback	-	40-h over 8 weeks/ before and after the training	Physician communication behavior (pre- and post-analysis of recorded consultations using the RIAS system)		After training, physicians in the intervention group applied significantly more patient-centered communication compared to the control group
Brown et al. (2010) USA [8]	Pre-posttest, no control	Oncology fellows/ n = 45	Literature review, consensus review meetings, piloting	BBN; SDM on treatment options; responding to patient anger; discussing prognosis and transition to palliative care; and SDM on not-resuscitation	The Comskil training covered 3 modules for the patient-centered CST. Each module was presented using didactic presentations, video demonstrations of ideal communication behaviors, and skills practice sessions using role-play with SPs and video feedback. Participants received a training booklet	-	Day-long	Usefulness of each module, self-rated confidence and self-efficacy, CS usage through video analysis with coding	Participants strongly agreed that they would use newly acquired skills, provide better care after training, and had been prompted to critically evaluate their own CS	Participants’ confidence in handling communication challenges increased significantly pre- and post-training. The training increased the fellows’ overall level of skill usage
Grainger et al. (2010) Australia [37]	Posttest only, no control	Oncology health professionals/ n = 62	Evidence-based guidelines and VCCCP framework	Discussing the transition to palliative care with cancer patients	Workshop involved cognitive, behavioral, and experiential components. It included a presentation, a DVD on effective communication, role-playing with trained actors and feedback, and group discussion activities to share experiences. A workshop pack was provided	1 to 6–10	4.5-h	Satisfaction with the workshop, perceived confidence in communicating about the transition to palliative care	Participants were highly satisfied with the workshop, content, and format, especially with the role-play component	Over 98% said that the workshop had increased confidence in their CS
Langewitz et al. (2010) Switzerland [38]	Pre-posttest, no control	Oncology nurses/ n = 70	Literature review, expert panel	Patient-centered communication, and emotional support	The Swiss Cancer League CST program included communication in oncology and specific skills such as helping patients express feelings and expectations, pausing, summarizing, and responding to emotions through practical exercises like role-play and pre-intervention videos with SPs. Participants were supported via phone calls. A booster seminar was held 6 months later to enhance participants' CS based on their experiences and give feedback (post-intervention video)	-	2.5-day initial seminar and 1.5-day booster with 6 months interval	Changes in communication behavior (pre and post videotapes of interviews with SPs using the RIAS coding system)		After training, there was an increase in appropriate empathic responses, professional reassurance, and optimistic utterances. There was an increase in attention to psychosocial issues by asking more closed and open questions
Goelz et al. (2010) Germany [39]	Posttest only, no control	Oncology physicians/ n = 41	An extended and adapted version of the SPIKES model	CS for the transition from curative to palliative care and the involvement of significant others in the conversation	The COM-ON-p program focused on enhancing CS in oncology. It included didactic sessions, video analysis, role-playing with actors and their feedback, and an individual coaching session (30 min) two weeks after the training. Participants developed personal conclusions, wrote take-home messages, and received personalized support to reinforce learning	2 to 8–9	1.5-day	Workshop acceptance	Participants' evaluation was very positive. While they valued the individualized learning tools, they found the practical experience with actors and feedback most beneficial
Fukui et al. (2010) Japan [40]	Pre-posttest, no control	Oncology nurses/ n = 31	Literature review	BBN; Cultural sensitivity	The SPIKES protocol was adapted to the Japanese medical system and culture. The program included a meeting with educational material on the impact of communication between patients and HCPs and its principles for BBN, followed by small group discussions guided by facilitators and role-playing scenarios with feedback	1–2 to 2–3	1-day (6-h)/ 3 months after the program	Self-rating confidence in communication with patients, perception of the training effectiveness	Almost all nurses were positive about the course's effectiveness. Role-playing exercises and peer feedback were valued	Japanese nurses’ confidence was significantly increased, and it was still present 3 months after the program
Swanson et al. (2011) Scotland [41]	Pre-posttest, no control	Diabetologists, GPs, dietitians, podiatrists, diabetes specialist nurses, and primary care nurses/ n = 81		Basic CS and behavior change training targeted HCPs working in diabetes care	Training included didactic sessions on CS, Socratic questioning, information exchange, behavior change models, MI, goal setting, action/coping planning, relapse prevention techniques, and understanding habits. Interactive activities included small group discussion supported by illustrative video material, worksheet tasks for reflection, role plays, case studies, and feedback	3 to 15	3-day sessions, two weeks apart	Questions evaluating communication and behavior change skills, and provider satisfaction of training	Evaluation of the workshop components was positive. Most found role plays stressful but useful	Participants recorded a significant increase in ‘positive’ communication and behavior change techniques and a decrease in ‘negative’ techniques
Roter et al. (2012) USA [42]	Pre-posttest, no control	Physicians (n = 29) and patients (n = 194)	Literature review, own prior work	Patient-centered communication skills for patients and physicians around cardiovascular health	The LEAPS Framework (Listen, Educate, Assess, Partner, and Support) guided the development of web-based tools with interactive video glossaries (10-s clips) for patients and clinicians, focusing on CS for effective patient-provider interactions	-		Physicians and patients self-reported CS		The training had a positive impact on reported use of patient-centered CS among both physicians (greatest gains in SDM and patient education skills) and patients
Clayton et al. (2012) Australia and New Zealand [43]	Pre-posttest, no control	Palliative medicine trainees / n = 41	Literature review, collaboration with experts of the Oncotalk model	Palliative care consultation; discussing prognosis; dealing with mismatched expectations; planning for death	Workshop integrated didactic sessions on evidence-based communication frameworks with hands-on practice through role-playing and SP interactions with feedback. Small group discussions and reflective exercises, accompanied by course-specific written material, promoted skill development and exploration of emotional factors influencing physicians' communication	1 to 5–6	3-day/ 3 months following the workshop	Satisfaction with and impact of the course, self-rated confidence in CS, attitudes to psychosocial aspects of care, stress and burnout	All participants said the training was useful, and they would recommend it to others Combination of skilled actors and experienced facilitators were found important	Only confidence in CS significantly increased following the workshop and it was sustained at three months
Kelley et al. (2012) USA [16]	Pre-posttest, no control	Geriatrics and palliative medicine fellows/ n = 18	Literature review (Oncotalk used as a model), expert panel	Basic communication skills; BBN; negotiating goals of care; and forgoing life-sustaining treatment	GeriTalk training involved an overview presentation with faculty acting out scenarios, followed by CS practice in small groups with actors and feedback. It concluded with fellows selecting two CS to practice for a month, with a reminder postcard sent later	2 to 5–6	Two 8-h days retreat/ 2 months after the course	Self-assessment of preparedness for specific communication challenges and frequency of skills practice over time, course satisfaction	Overall satisfaction with the course was very high. The balance between brief lectures and small group practice sessions was valued	Compared to before, fellows reported an increase in preparedness for specific communication challenges. Two months later, they reported a high level of sustained skills practice
Nørgaard et al. (2012) Denmark [44]	Pre-posttest, no control	Doctors, nurses, nursing assistants, secretaries, and other staff members in orthopedic department/ n = 181	Literature review (Maguire’s), staff views through focus groups	Patient-centered communication, BBN, communication with patient’s relatives, and intercollegial communication challenges	Training, based on the Calgary-Cambridge Observation Guide, included videotaped scenarios, role-plays, simulated communication sequences, and focus group insights. The theoretical presentation focused on effective interviews and handling difficult conversations. In a follow-up session, participants had plenary discussions and feedback on their CS	-	3-day (8 h each), the third day with a 6-week interval/ 6 months after the training	Perceived self-efficacy in communication with patients and communication with colleagues		The mean score for self-efficacy in communication with both patients and colleagues increased immediately after the training. The effect was still present 6 months after the course
Schell et al. (2013) USA [45]	Pre-posttest, no control	Nephrology fellows/ n = 22	Literature review (Oncotalk used as a model) and adapted for NephroTalk	BBN and helping patients define care goals surrounding end-of-life kidney care	The NephroTalk workshop included an overview presentation with faculty role-play demonstration, followed by small-group skills practice with SPs and peer- and facilitator-led feedback. Skills taught in this training were the use of open-ended questions, the ASK-TELL-ASK model, and responding to emotion using NURSE protocol	1 to 6	4-h (half-day) retreat	Provider satisfaction, perceived preparedness, prior experience in palliative care	All respondents reported they would recommend this training to other fellows	Less than one-third reported prior training. Preparedness significantly increased for all skills (delivering bad news, expressing empathy, and discussing dialysis initiation and withdrawal
Bays et al. (2014) USA [46]	Pre-posttest, no control	Internal medicine residents and fellows, nurse practitioner / n = 145	Literature review (Adapted from Oncotalk)	BBN, expressing empathy, and negotiating goals of care	The CodeTalk workshop included a didactic overview with a demonstration role-play by facilitators, skills practice using SPs or family members, and reflective discussions on the experiences. Each session had a specific topic, such as building rapport, giving bad news, and discussing goals of care and advance directives	-	Eight 4-h sessions (twice per week for a month)	CS (pre and post recordings of interactions with SPs using the SPIKES and NURSE coding system)		Trainees’ scores improved in 8 of 11 of the SPIKES and NURSE-based coded behaviors
Pang et al. (2014) China [17]	Pre-posttest, no control	Physicians and nurses in oncology/ n = 31 in English workshop and n = 18 in Chinese version	SPIKES protocol adapted to the Chinese context	Basic CS and BBN in the Chinese cultural context	Two CST workshops were conducted. The first was led by German trainers and translated, while the second was facilitated by experienced Chinese trainers. The CST program included 5 phases: (a)Introduction, (b) Participants' experiences and defining learning goals, (c)Lectures on SPIKES, (d)Small group role-playing with precise feedback, (5)Summary	1 to 9–10	1.5 days (9-h) each English and Chinese workshop	Perceived self-competence in BBN, and the practicability and organization of the workshops	Both workshops (English and Chinese) received positive evaluations, with the highest ratings given to the role-play components and lectures on SPIKES	Participants reported improvements in their subjective competence in various domains, such as satisfaction with conducting consultations, and confidence in the consultation quality
Nightingale et al. (2016) USA [14]	Pre-posttest, with control group	Family medicine residents/ n = 52	Established literature	Brief motivational counseling to improve diabetes self-management	Training focused on MI techniques in chronic care models and patient-centered communication. It included didactic instruction, role-playing with feedback, and follow-up booster sessions. Participants also received a pocket guide with MI principles and a self-management problem list	-	3-h workshop and three 1-h booster sessions over 6 months	Self-reported knowledge of MI and objective application of MI skills (using an objective measure of open-response questions to behavior change statements)		The training significantly increased residents' use of MI techniques, knowledge of MI, and ability to apply MI skills in practice
Banerjee et al. (2017) USA [28]	Retrospective pre-posttest, no control	Inpatient oncology nurses/ n = 342	Literature review, expert consensus, and pilot testing (adapted from physician Comskil)	Responding empathically to patients; discussing death and EoL goals of care; and responding to challenging interactions with families	The nursing comskil training included three 2-h modules following an introductory lecture. Each module, designed to address specific communication challenges in oncology settings, included a 30–45-min presentation covering rationale, relevant literature, recommended communication strategies, skills, and tasks. Participants were provided with exemplary videos and workbooks. They then engaged in 90-min small group role-playing exercises with SPs. These sessions were co-facilitated and included peer feedback and video analysis	2 to 12	1-day (a total of 6 h)/ 6 months post training	Program evaluation, self-reported self-efficacy, and demonstration of skills (pre- and post- SPAs)	Nurses rated the training favorably. The use of didactic teaching, role plays, and video feedback was highlighted as particularly effective	Nurses reported significant gains in self-efficacy in their ability to communicate with patients in various contexts. They demonstrated significant improvement in several empathic skills, and in clarifying skill
Saslaw et al. (2017) USA [29]	Retrospective pre-posttest, no control	Multispecialty physicians / n = 490	Collaboration with the American Academy on Communication in Healthcare (AACH)	Basic communication skills	Training focused on relationship-centered communication. The program utilized a combination of didactic teaching, role-playing, and feedback sessions. Participants had opportunities to practice their skills in simulated scenarios, which helped translate theoretical knowledge into practical application	2 to 12	7.5-h / 6 weeks after the program	Self-reported self-efficacy, attitudes, and behaviors related to communicating with patients		In 9 out of 10 domains measured, significant changes in self-efficacy, attitudes, and behaviors related to patient communication were observed. No significant change in perceived time management/efficiency during visits
O’Brien et al. (2018) UK [47]	Retrospective pre-posttest, no control	HCPs working with people living with dementia/ n = 45	Literature review, input from experts and service-users, conversation analysis, pilot testing	CST tailored to common scenarios in dementia care	Training focused on the structure of HCP-patient interactions in dementia care, including initiating conversations, making various requests, handling patient responses, and closing discussions. The program combined lectures, video examples, role-playing exercises with SPs and feedback. Participants also completed reflective exercises between sessions	1 to 6–9	2-day with a one-month interval/ one month after the course	Self-rated knowledge and confidence in dementia communication, satisfaction of training, changes in communication behavior using blind-rated assessments of simulated patient encounters	The course received positive feedback from participants, with 95% stating it met their expectations and 98% would recommend it to others. The 2-day duration and reflective exercises were valued	The course improved the knowledge and confidence While there were improvements in some communication behaviors, such as closing interactions, there were no significant changes in behaviors related to making requests or communication tone
Kaur et al. (2019) Australia [48]	Prospective pre-posttest, no control	Oncology nurses working with minorities/ n = 53	Own prior work, literature review, expert panel, pilot testing	Basic CS and cultural competence	This online program included four modules: an introductory module on CS and cultural competence, followed by three modules featuring video-based patient vignettes to illustrate effective culturally competent behaviors	-	2 h /baseline (T0), within 2 weeks (T1) and 3 months (T2) after accessing the site	Program satisfaction, self-rated competence in communication, practices, and attitudes while interacting with minority patients	Participants overwhelmingly found the online training informative, relevant, and useful, and that they would recommend it to others	Results showed a positive impact on nurses' confidence, competence, and practices while interacting with minority patients via an interpreter at T1 and T2
Barbosa et al. (2019) Portugal [49]	Prospective longitudinal pre-posttest, no control	Medical residents/ n = 64	Literature review, own prior work	BBN and responding to patients' cues and concerns	Training was based on a relationship-centered care framework and included a 1-h lecture, three 3-h practical sessions, and individual reflective practice on video-recorded consultations. Small groups of participants used standardized patient interviews and received feedback from actors, peers, and an experienced facilitator	1 to 3–4	10 h/ baseline (T1), 3 days after (T2), and 3 months after (T3)	Relational CS for BBN and responding to patients concerns (T1 with T2 and T3 video-recorded consultations using coding system)		The training improved residents' ability to provide space for patients to express their concerns and emotions. The training led to significant improvements in 7 out of 10 CS for BBN (T2 and T3)
Müller et al. (2019) Germany [12]	1) Pre-posttest, no control 2) Semi-structured interview	Physicians treating asthma/ n = 29		SDM skills, patient-centered communication, and MI techniques	Training included a short introductory talk, videotaped consultations with simulated asthma patients, video analysis in small group settings and individual feedback, short presentations, group discussions, and practical exercises	-	2-day (12-h) on one weekend	Physicians' SDM behaviors from 3 perspectives: Observers (OPTION 5), Physicians (SDM-Q-Doc), and Simulated patients (SDM-Q-9), content analysis of interviews	Most physicians positively appraised the training program. Physicians found SP consultations, including diverse feedback and video analysis, beneficial	Performance in SDM improved following the training when compared with before. The qualitative evaluation revealed that most physicians experienced a change in attitude and behavior after the training
Saeed et al. (2019) USA [50]	Posttest only, no control	Dermatologists/ n = 103		BBN, dealing with unmet expectations, agenda setting, and medication counseling,	This was a simulation and scenario-based workshop. Participants interacted with standardized patient educators and received detailed evaluations, coaching, and structured feedback based on a standardized checklist	-	Not explicitly stated	CS using the Master Interview Rating Scale (MIRS) when interviewing with a SP, perceived usefulness of the workshop	Physicians found this OSCE workshop helpful for practice and feedback, uniformly rating that the workshop met its learning objectives in improving CS	The lowest-rated CS were: allowing the patient to share their narrative thread, summarizing the patient’s history from the provider, and assessing patient understanding
Wolderslund et al. (2021) Denmark [30]	Pre-posttest, no control	HCPs from all clinical departments/ n = 1647	Own prior work	Person-centered communication with patients and their relatives	Program involved a two-day training followed by a four-week practice period. The training included didactic sessions, role-playing (between participants), and peer feedback. Participants were required to video-record their interaction with a patient for review and feedback based on the Calgary-Cambridge Guide during a plenary session	2 to 8	2 + 1-day/ after 24 weeks	Self-efficacy for communication skills		Results showed a significant increase in self-efficacy immediately after the intervention, followed by a slight decrease 24 weeks later
Banerjee et al. (2021) USA [51]	Pre-posttest, no control	HCPs working in thoracic oncology and surgery, or pulmonary medicine/ n = 30	Adapted from the empathic communication module of Nursing Comskil training	Empathy-based, stigma-reducing communication to reduce lung cancer stigma	Training goal was to enhance clinician recognition and responsiveness to lung cancer patients’ empathic opportunities by communicating understanding, alleviating stigma and distress, and providing support. The didactic modular content was followed by experiential role-play exercises with SPs and receiving feedback	-	2.25-h	Module evaluation, self-efficacy for empathic communication	Participants rated the training favorably. More than 90% rated each individual modular component as aiding in learning	Results indicated a significant change in self-efficacy for empathic communication ratings from pre-training to post-training
Cheung et al. (2021) USA [52]	Pre-posttest, no control	Nurses and social workers working in dialysis units / n = 12	Collaboration with key stakeholders and expert facilitation	Active listening, responding to emotion, and exploring goals and values in dialysis settings	Training combined online brief didactic modules (a week before the workshop) with in-person workshop to enhance CS in the dialysis setting. The workshop included interactive didactics, faculty role-play demonstrations, and structured role-play with SPs in small groups and feedback	-	6-h	Self-reported preparedness in advance care planning discussions, attitudes towards communication, usefulness of the workshop	The workshop was rated highly in terms of relevance of content, importance of topic, effectiveness of facilitators, opportunity for interaction, and overall quality	Scores improved in all domains: demonstrating empathic behaviors, responding to emotion and EoL concerns, eliciting family’s concerns at EoL and patient’s goals, and discussing spiritual concerns. Participants rated CS as extremely important to their profession
Frydman et al. (2021) USA [53]	Pre-posttest, no control	Geriatrics and palliative medicine fellows/ n = 17	Adapted from the in-person Geritalk course	Basic communication principles, sharing serious news, eliciting goals of care, and discussing life-sustaining treatment	The virtual Geritalk included: 1. Online asynchronous modules with pre-recorded videos demonstrating CS 2. Synchronous sessions on role play with professional actors focused on deliberate practice of CS and reflective exercises	2 to 6	4-day (10 h)	Self-assessed preparedness for serious illness communication, satisfaction with the course	Overall, satisfaction with the course was high	The virtual Geritalk course was as effective as the in-person version in improving participants' self-reported preparedness for serious illness communication
Iversen et al. (2021) Denmark [54]	Pre-posttest, no control	Doctors, nurses, physiotherapists, and chiropractors in a spine outpatient clinic/ n = 43		Patient-centered communication	Training (Clear-Cut Communication with Patients) was designed to focus on CS based on the Calgary-Cambridge Guide. The first 2 days covered theory, discussion, and role-playing. Participants then practiced new skills in their clinical setting for 4 weeks before returning for a final session dedicated to video review and feedback	-	2 + 1-day	Change in HCPs' communication behavior (audio-recorded consultation assessment using coding system)		HCPs improved their communication behavior in favor of being more patient-centered, with no effect on the length of consultations
Kaczmarek et al. (2021) Australia [55]	1) Pre- posttest, no control 2) Qualitative semi-structured interviews	Podiatrists/ n = 11	Own prior work, expert consensus	MI related behaviors and CS to address diabetes related foot disease (DFD) self-care	Program focused on imagery-based MI for DFD self-care. The first session covered challenges, benefits of a positive approach, MI concepts, video examples, and practical guidance for podiatrists. The second session emphasized hands-on practice through role-playing and feedback to build skills and confidence. Participants received follow-up support and email reminders to reinforce learning	-	Two 4-h sessions separated by 2 weeks /baseline, 2, and 12 weeks after the training	MI-related skills and use of imagery (pre-post analysis of audio-recorded consultations using a tool), participants' experiences with the training	Participants valued the training. They liked the small group and role-play practice. Some felt there was a lot of information in a short time and reported challenges in fitting imagery into their practice	Training significantly improved MI skills, although gains were not sustained long-term (12th week)
Khajeh Azad et al. (2022) Iran [56]	Pre-posttest, no control	Internal medicine residents (n = 50), patients (n = 100)		Empathic communication skills	Training included a tutorial on patient-physician CS, covering nonverbal communication, empathic listening, speaking, and observation skills. It was followed by interactive group discussions and role-playing exercises	-	8-h (2 days)/before and 3 weeks after the training	Residents self-reported empathy, patients’ perceptions of their providers empathy		The results showed a significant improvement in the residents' self-perceived empathy. Patients’ ratings of their providers empathy increased after the training
Patell et al. (2022) USA [57]	Pre-posttest, no control	Internal medicine residents in oncology/ n = 52	Own prior work	Communication skills in palliative care	This online training consisted of a 4-min animated video tutorial modeled around the ask more and summarize technique	-	4 min /6-month follow up	Self-reported acquisition of skills, perceived usefulness, and retention of skills	95% enjoyed the format, and thought the narration and animation was an effective learning tool. A majority (87%) felt the tool would be useful	Results showed a significant increase in skills acquisition, with trainees reporting an increase in the frequency of asking more about patient questions. Almost all continued to report using the skills learnt after 6 months
Rosa et al. (2022) USA [18]	Pre-posttest, no control	Oncology HCPs in geriatrics (n = 11), patients (n = 44)	Literature review, expert consensus, and pilot testing (adapted from Comskil training)	Communication skills for HCPs working with older cancer patients with functional, sensory, or cognitive impairments	The Geriatric Comskil training consisted of three 2-h modules: Geriatrics 101, Cognitive Syndromes, and Shared Decision Making. The training included didactic knowledge, exemplary videos, experiential learning role plays with SPs, and peer/facilitator feedback. Participants received a workbook	-	6-h (1-day)	HCP: module evaluations, self-efficacy, CS uptake (pre-post video-recorded interactions with SPs and comskil coding system), perceived ageism (attitude) Patients: HCPs’ empathy, satisfaction with communication	The program was found to be feasible and acceptable, with participants consistently rating all 3 modules favorably. Role play experience and exemplary video were valued	The training led to: significant improvements in HCPs' self-efficacy in communicating with patients; improvements in HCPs' CS, including agenda setting and overall skill use. Patients reported increased empathy and satisfaction with communication
Ito et al. (2022) Japan [58]	Pre-posttest, no control	Physicians/ n = 48	Adapted from Vital Talk course	BBN, responding to emotions, eliciting goals of care, and discussing life-sustaining treatment	This virtually administered VitalTalk workshop included 2 synchronous role-playing sessions and preceding asynchronous modules (a series of videos of lectures and skill demonstrations)	2 to 12	2-day (3 h per day) with a 1-week interval	Participants satisfaction with the virtual format, self-assessed preparedness in serious illness communication	Learners in Japan were highly satisfied with the virtual format of the VitalTalk workshop, including the educational quality and technical aspects	Participants' self-reported preparedness significantly increased after the workshop
Gil et al. (2023) Spain [59]	Prospective longitudinal pre-posttest, no control	Medical residents/ n = 86	Previous literature, adaptation for the Spanish population, expert consensus	BBN to patients and families while offering psychosocial support	Training on BBN included considering disease and patient context, addressing barriers posed by family, providing information to children of sick parents, and offering psychosocial support. Phase one included lectures and role-playing with professional actors and feedback. In second phase, participants applied skills in their practice and documented their challenges through an online questionnaire. Third phase addressed the most difficult scenarios reported by participants, through role-playing and feedback	3 to 20	16-h in 3 phases: T0:12-h over 2 days, T1: 3 months after T0, T2: 4-h workshop, 6 months after T0	Participants’ beliefs about their competence in caring for patients’ psychosocial aspects, self-confidence in CS, use of learned CS in practice		No differences were found between T0 and T1in participants’ beliefs about their competence and self-confidence. However, after T2 completion, significant improvements were observed in all assessed areas
White et al. (2024) Australia [60]	Retrospective pre-posttest, no control	Clinicians in serious illness/ n = 50	Literature review, collaboration with experts (adapted from Oncotalk)	Goals of patient care (GoPC)-specific communication skills	Training included a didactic presentation on the general principles of GoPC communication (ICE, REMAP, NURSES), pre-readings and instructional videos, simulated patient role-play scenarios with facilitator feedback, and a debriefing session	2 to 5–11	A half-day (4.5-h)/ 2 months after the workshop	Acceptability of the workshop, self-reported confidence in CS	All participants indicated they would recommend the workshop to a colleague Feedback from facilitators/peers, small group sizes, and the use of a trained actor were valued	A mean improvement in confidence in communication skills of 35% was identified following participation, which remained elevated at 2 months
Levinson et al. (1993) USA [61]	Short program: RCT Long program: pre-posttest, no control group	Primary care physicians/n = 31(short program) and n = 20 (long program)		Patient-centered communication	The short program included didactic presentations and case-based discussions on fundamental skills like open-ended questions, psychosocial discussions, information-giving, and active listening. The long program allowed participants to identify their own learning needs and engage in small group discussions and feedback	Long: 1 to 4	Short: 4.5-h Long: 2.5-day/ before and one-month post-program	Changes in CS (pre- and post-audiotapes analysis of the medical visit using the RIAS system)		The short program did not significantly impact CS. However, the longer program led to improvements in open-ended questioning and psychosocial discussions
Jenkins et al. (2002) UK [62]	RCT	Oncology HCPs/ n = 93	Own prior work	Basic CS and addressing psychosocial concerns in oncology care	Training included cognitive, experiential, and behavioral components. Participants worked in small groups with facilitators and patient simulators to encourage discussion and personalized feedback. Filmed consultations were reviewed in depth, allowing participants to reflect on their communication styles and identify areas for improvement	1 to 3–5	3-day residential course/ baseline and 3 months after the training	Subjective (self-reported) and objective (pre- and post-videotape analysis) changes in physicians' communication styles, attitudes and beliefs toward psychosocial issues in care		Intervention group demonstrated improved communication skills (empathy, use of open questions) and positive attitudes towards psychosocial issues
Rubak et al. (2006) Denmark [63]	RCT	General practitioner (GP) in type 2 diabetes care/ n = 65	Established literature	MI counseling to promote behavior change for lifestyle changes and chronic disease management	The course trained GPs in MI techniques to encourage behavior change. It included didactic instruction, group discussions, and role-playing with feedback. Key topics were empowerment, addressing ambivalence, decision-making, self-efficacy, the stage of change model, and reflective listening	1 to 6–12	1.5-day + two 0.5-day meetings during the first year after initial training	GP’s self-reported professional behavior		The GPs trained in MI adhered statistically significantly more to the methods than did the control group. More than 95% of the GPs receiving the course stated that they had used the specific methods in general practice
Brug et al. (2007) Netherlands [64]	RCT	Diabetes care dietitians/ n = 37	Collaboration with experts	Motivational counseling style	Training introduced the principles of MI, followed by practicing MI skills through role-playing and interactive exercises with feedback. A 1-day follow-up workshop discussed initial experiences and refreshed MI knowledge	-	2-day + 1-day follow-up/ baseline, 1 and 6 months after the training	Counseling styles of dietitians (pre- and post-tape-recorded analysis using a coding system)		MI dietitians were more empathetic, reflective, and patient-centered
Butow et al. (2008) Australia [65]	RCT	Oncology doctors /n = 30	Literature review	Eliciting and responding to emotional cues	The CST included a presentation on effective communication principles, a DVD of ideal behaviors in patient interactions, and interactive role-playing with SPs and feedback. Participants received a booklet, DVD, and video recordings for learning and reflection. The training was followed by four 1.5-h monthly video conferences incorporating role-plays of doctor-generated scenarios	1 to 3–6	1.5-day /before, after, 6, and 12 months after the training	Doctor behavior (analysis of video-recorded simulated patient interviews using a coding system), stress, burnout, and acceptability of the training	Feedback from participants indicated high satisfaction with the training and its relevance to their practice	While the intervention group demonstrated an initial increase in empathic communication behaviors, the differences between the intervention and control groups were not sustained at the 6- and 12-month follow-ups
Bonvicini et al. (2008) USA [11]	RCT	Physicians from primary care /n = 155		Basic CS and Empathic communication	Training included 3 workshops: 1) effective communication techniques (4Es: Engage, Empathize, Educate, Enlist), 2) strategies to help patients change behaviors, 3) empathic responsiveness skills. The workshops featured brief presentations, video reviews, role-playing with feedback, and experiential learning activities. Each workshop was complemented by individual coaching sessions and feedback	-	Three 6-h monthly /before and 6 months after the training	Physician expression of empathy during medical encounters (pre- and post- analysis of audiotapes with coding)		Training made a significant difference in physician empathic expression in the physician training group from baseline to follow-up
Liénard et al. (2010) Belgium [66]	RCT	Medical residents/ n = 113	Literature review	Basic communication skills and BBN	The BIC–CST used a learner-centered, skill-focused, practice-oriented approach. It included CS and stress management training, organized in brief presentations and role-play small groups (with an actor), receiving feedback, and two-person and three-person consultations (with a relative). The program followed a 3-phase model of bad news delivery: pre-delivery, delivery, and post-delivery	1 to 7	40-h over 8 months, bimonthly /baseline, and 8-month after baseline	CS (pre- and post-analysis of audiotaped SP consultations)		The trained residents used effective CS more often than the untrained residents: more open questions, open directive questions, and empathy; and less information transmission. The pre-delivery phase was longer for the trained compared with the untrained residents
Fujimori et al. (2014) Japan [67]	RCT	Oncologists/ i = 30	Patient preferences, expert consensus, literature review, and pilot testing	BBN and supporting patients emotionally	Training, based on the SHARE model, was designed to improve the empathic communication and effective behaviors of oncologists. It included an ice-breaking discussion, a 1-h computer-aided didactic lecture with text and video materials, role-playing with SPs, and peer feedback	2 to 4	2-day/ before and after the training	Objective performance of communication skills (pre- and post-video analysis with coding), confidence in communicating with patients		The intervention group demonstrated improved communication skills, including emotional support, setting up a supportive environment and information delivery, with higher perceived confidence in communication
Butow et al. (2015) Australia [15]	RCT	Oncologists from Australian/New Zealand (ANZ) and from Swiss/German/Austrian (SGA)/ n = 62	Own prior work, consensus meetings, literature reviews and pilot testing	SDM about standard treatment and clinical trials	Training focused on 5 main concepts: establishing an SDM framework, organizing information in a clear and logical sequence, fostering understanding (e.g., avoiding jargon), and avoiding coercion. It included the presentation of materials (written and oral), video modeling of ideal behaviors, role-play practice with SPs, and individualized feedback, as well as a follow-up phone call one month later	-	1-day (7-h)/ before, after, and 5 months following the training	Change in SDM behaviors via audiotape analysis with coding, satisfaction with the training, confidence in information provision, stress, and burnout	Doctors strongly endorsed the training, with most finding it very helpful and recommending it to others	In the ANZ cohort, there was a significant increase in behaviors aimed at establishing the SDM framework after the training, while the control group showed a decline in this behavior. No other significant changes in any other SDM behaviors and confidence
Murray et al. (2015) Australia [7]	RCT	Physiotherapists in chronic low back pain care/ n = 24	Literature reviews	Self-determination theory-based communication skills (needs-supportive communication behavior)	Training focused on SDT concepts. Physiotherapists were taught 18 specific SDT-based communication strategies categorized into 5 groups based on the 5A’s framework of behavior change (Ask, Advise, Agree, Assist, Arrange). The training included an overview presentation, video demonstrations, role-playing with feedback, and group discussions. Participants set personal goals and received follow-up support emails	-	8-h (two 4-h separated by 1 week)/ baseline and 16.7 weeks after the training	Physiotherapists’ needs-supportive communication behavior (audiotape analysis by independent raters)		Independent raters' scores showed that trained physiotherapists provided significantly greater support for their patients' psychological needs compared to the control group
Gorniewicz et al. (2017) USA [10]	RCT	Medical residents/ n = 66	Interviews with cancer patients and qualitative analysis, literature reviews, expert consensus	Basic CS and BBN	This brief self-guided training module focused on practical CS, such as pausing and paying attention to patient responses after BBN, addressing feelings, and determining the patient's preparedness to proceed after BBN. Participants learned through video segments (on a CD-ROM or website) from interviews with cancer patients	-	60- minute (A brief CST)/ before and after the training	Changes in communication skills using an OSCE method		Residents who completed the training significantly improved in various areas, such as active listening, addressing patient emotions, and global interview performance
de Figueiredo et al. (2018) Germany [68]	RCT	Oncology physicians/ n = 72	Previous literature, own prior work (Goelz et al.)	Coaching-enhanced patient-centered communication	The ComOn-Coaching training included: 1) A 1.5-day CST workshop, which featured a short presentation and small group role-play activities (with actor patients) with feedback, focusing on CS with the SPIKES model, 2) Coaching sessions, with the intervention group receiving 4 sessions and the control group receiving 1 session. The coaching sessions involved analyzing video recordings of participants' consultations with patients	-	1.5-day plus 4 coaching sessions/ before and after the workshop, and after coaching sessions	Physicians’ communication skills during real consultation (analysis of video recordings by independent raters using the ComOn rating scale)		The group that received 4 coaching sessions showed significantly better CS performance compared to the group that received only 1 coaching session. Individual coaching was shown as an important add-on for CS workshops
Chen et al. (2021) Taiwan [69]	RCT	Advanced practice nurses/ n = 61	Previous literature	Cancer truth-telling and emotional support	This CST, based on the Japanese SHARE model, focused on patient-centered communication and emphasized reassurance and emotional support during truth-telling. The training consisted of a lecture on the SHARE model, role-play with SPs, and comments from facilitators	2 to 4	6-h / before (T0), after (T1), and 2 weeks later (T2)	Self-reported confidence in communication and perceptions of cancer truth-telling		Nurses in the intervention group had more confidence and better perceptions of cancer truth‐telling than nurses in the control at both T1 and T2
Yazdanparast et al. (2021) Iran [70]	RCT	Nurses/ n = 60	Adapted from SPIKES model	BBN	Training included a lecture on communication principles, barriers, and strategies for improvement. It also included Q&A sessions, group discussions, role-playing, and film presentations. Participants reflected on their BBN experiences, analyzed their performances, and learned the appropriate skills	-	Four 2-h in 2 weeks/ before and after the training	Self-reported BBN skills, and participation in BBN		A significant difference was observed in the mean score of nurses' skills and participation in the process of delivering bad news between the intervention and control groups
Fang et al. (2022) Taiwan [71]	RCT	Nephrologists and nephrology nurses/ n = 91		Truth-telling and SDM for end-stage renal disease (ESRD)	This asynchronous online ESRD CST covered theoretical frameworks for truth-telling (SHARE model) and SDM (Three-Talk model), along with video demonstrations of communication with ESRD patients. Both intervention and control groups received basic CST	-	30 min/ before (T0), 2 (T1), and 4 (T2) weeks after the training	Self-reported truth-telling confidence, self-reported SDM ability, and satisfaction with ESRD CST	Over 95.6% of participants were satisfied with the online ESRD CST, and over 91.1% of participants were willing to recommend it to others	Overall, the study found that the online ESRD CST enhanced only short-term truth-telling confidence (T1), but its effectiveness on SDM ability was not observed clearly

F/P Facilitator per participants, CS Communication skills, BBN Breaking bad news, CST Communication skills training, SP Simulated patient, SDM Shared decision-making, VCCCP Victorian cancer clinicians communication program, EoL End-of-life, HCP Healthcare providers, MI Motivational interviewing, SPAs Standardized patient assessments, OSCE Objective structured clinical examination, RIAS Roter interaction analysis system, RCT Randomized controlled trial, BIC-CST Belgian interuniversity curriculum- communication skills training, SDT Self-determination theory

The sample size of studies varied from 11 to 194 participants. The sample sizes of the three studies were much larger than these, including 342 [28], 490 [29], and 1647 [30]. These studies were hospital-wide initiatives with mandatory participation for all healthcare providers in two of them.

Seventy-eight percent of interventions focused on teaching one provider group (n = 43): most often doctors (n = 19), junior doctors (i.e., residents, registrars, trainees, fellows, n = 14), nurses (n = 8), dietitians (n = 1), and physiotherapists (n = 1). Multidisciplinary groups were taught in 12 (22%) programs. Half of the studies (n = 28, 50.9%) were in oncology care contexts. Other contexts included palliative and geriatric care, diabetes and cardiovascular disease care, musculoskeletal and orthopedic care, rheumatology, nephrology, pulmonary care, and dermatology (see Table 1).

Developing training

Information on how the intervention was developed was available for 46 (83.6%) of the identified training interventions. This most commonly included reference to previous literature and literature reviews (n = 30), particularly training interventions reported by others (n = 12). Integration of provider or expert views was also common (n = 20). Some authors referred to their own prior work (n = 11). Four reported including patient views and preferences in their development. The reports on development strategies varied considerably, from single sentences to complete documents describing training development. For 9 (16.4%) interventions, no information regarding training development was reported (see Table 1).

Training content

The main focus of the identified training interventions was:

• Basic communication skills and patient-centered communication (n = 22)

• Breaking bad news (n = 19)

• Empathy and emotional support (n = 17)

• Advance care planning, including discussing the transition to palliative care, discussing death, and negotiating goals of care (n = 14)

• Shared decision-making (SDM), including SDM about treatment options, and SDM about not resuscitating (n = 7)

• Training related to specific conditions or patient populations, including communication skills to address diabetes-related foot disease self-care, skills tailored to common scenarios in dementia care, communicating with older patients with functional and cognitive impairment, end-stage renal disease truth-telling, cancer truth-telling, consultation skills tailored to typical scenarios in rheumatology care, and lung cancer stigma-reducing communication (n = 7)

• Communication skills based on specific communication techniques or theories, including motivational interviewing technique, relapse prevention technique, coaching, and self-determination theory-based communication skills (n = 7)

• Challenging interactions with families (n = 5)

• Cultural sensitivity and competency (n = 3)

• Prognostic communication, including discussing prognosis and dealing with mismatched expectations (n = 2)

• Communication with colleagues (n = 1) (see Table 1).

Teaching methods

The most common teaching methods reported were role play with facilitator/peer feedback (n = 46), didactics (i.e., lectures, presentations; n = 45), and group work (i.e., small group discussion, reflection, and discussion; n = 37) (see Table 1). Some also used video-based learning (video demonstrations of ideal communication behaviors (n = 15), video review and analysis (n = 12)), self-reflective practices (n = 15), instructional materials (i.e., manuals, workbooks, booklets, and pocket guides of workshops; n = 11), and e-learning (n = 7). A few used coaching [11, 39, 50, 68], telephone, or email support [7, 15, 38, 55] as part of the training. Among training programs, Oncotalk (now widely known as Vitaltalk), designed for communicating with cancer patients, and its adapted versions for other chronic conditions or cultural needs emerged as a prevalent training program, followed by the Comskil training program (oncologist Comskil, nursing Comskil, and geriatric Comskil).

Facilitator to participant ratio

Out of the 55 included studies, 27 reported data on the number of facilitators per participant, with ratios ranging from 0.5 (2 facilitators for 4 participants) to 0.08 (1 facilitator for 12 participants) (see Table 1).

Duration and follow-up

Course duration ranged from 4 min [57] to 8 months [66]. This included 5 interventions with a total training time of 2.25 h or less, 7 lasting 4–5 h (almost a half-day), 15 lasting 6–8 h, 6 lasting 9–12 h, 15 lasting 13–24 h, and 5 lasting 25 h and more. Information on duration was unclear for two interventions [42, 50]. In total, 25 (45.5%) of the included studies had follow-up time, which ranged from 3 days to 12 months after the training.

Outcomes measured and findings

Provider communication knowledge and skills outcomes were the most frequently measured across studies.

Objective changes in provider communication knowledge and skills (observed behaviors through video/audio recordings and/or direct observations using coding systems) were assessed in 26 studies, while subjective (self-reported) changes were assessed in 14 studies, totaling 40 studies. Additionally, training acceptability and satisfaction were assessed in 29 studies, self-efficacy and perceived confidence in communication skills in 22 studies, and attitudes and beliefs towards communication skills and their importance in practice in 9 studies. Five studies measured perceived preparedness for specific communication challenges [16, 45, 52, 53, 58], and one study measured self-perceived support [35]. (Table 1).

Studies measuring changes in communication skills showed that training led to significant improvements. However, the studies by Sutherland et al. [19], Fang et al. [71], and Levinson and Roter [61] (the short program version) reported no change in communication skills after training. Additionally, the studies by Kaczmarek et al. [55] and Butow et al. (2008) [65] found that positive changes in communication skills were not sustained at follow-ups (3 to 12 months).

Among studies measuring training acceptability and satisfaction (n = 29), participants generally reported high satisfaction with the workshops, courses, and their content and format. The most beneficial aspects of training programs reported were role-play exercises and simulated consultations [12, 17–19, 28, 32, 37, 40, 41, 55], individual feedback from trained actors, peers, and facilitators [12, 19, 39, 40, 43, 52, 60], didactic methods with a balance between brief lectures and small group sessions [16–18, 28, 32, 58], and video feedback with reflective exercises [12, 28, 32, 47]. However, some participants perceived videotaping their consultations as threatening, and some felt that a substantial amount of information was given to them in a relatively short time [32, 41, 55, 60]. Beyond these reports, qualitative insights from Muller et al. [12] and Kaczmarek et al. [55] deepened these findings, showing that while providers valued interactive elements like role-play, implementation barriers emerged regarding such as: clinical integration (e.g., imagery was hard to use with real patients [55]), training logistics (time constraints, artificial simulation environments [12]), and sustainability needs (requests for extended training, real-patient scenarios, and mentoring [12, 55]).

Studies measuring perceived confidence in communication and self-efficacy demonstrated that confidence increased significantly after training [8, 17, 18, 37, 51, 67], and this improvement was sustained at follow-ups [19, 28, 29, 33, 35, 40, 43, 44, 47, 48, 59, 60, 69]. Additionally, while the studies by Fang et al. and Wolderslund et al. showed initial improvements in confidence, these gains decreased at follow-up [30, 71]. In contrast, the study by Butow et al. reported no improvement in confidence after training [15]. Five studies measured perceived preparedness in communication skills and demonstrated that perceived preparedness increased after training [16, 45, 52, 53, 58].

Ten studies assessed changes in attitudes, beliefs, and perceptions related to communication skills training for providers. The majority of these studies (8 out of 10) indicated a strong positive shift in perceptions and beliefs about communication skills and the importance of effective communication across various medical specialties [12, 29, 32, 35, 48, 52, 62, 69]. However, the studies by Sutherland et al. and Clayton et al. reported no significant changes in participantsؙ psychosocial beliefs after communication skills training [19, 43].

Quality assessment

Among the quantitative nonrandomized (quasi-experimental) studies (n = 40), thirty-three were considered to have moderate quality. The two main methodological risks of bias in these studies were related to the handling of confounders in most cases, followed by the completeness of outcome data (Table 2). However, all quantitative nonrandomized studies met the criterion for 'during the study period, the intervention was administered (or exposure occurred) as intended', indicating that the implementation of the interventions was carried out as planned across these studies. Among the quantitative randomized controlled trials (RCTs) (n = 15), twelve were considered to have moderate quality. The main methodological risk of bias for RCTs was related to the lack of blinding of outcome assessors to the intervention provided (Table 3). All fifteen RCTs met the criterion for 'randomization was appropriately performed'.

Table 2.

Risk of bias for each quantitative nonrandomized (quasi-experimental) study assessed by Mixed Methods Appraisal Tool

Studies	Criteria							Study quality
	1*	2*	3*	4*	5*	6*	7*
Levinson et al. (1993) [61]	Y	Y	Y	C	Y	C	Y	Moderate
Roter et al. (1998) [31]	Y	Y	Y	Y	Y	N	Y	Moderate
Cooper and Hassell (2002) [32]	Y	Y	Y	Y	Y	C	Y	Moderate
Fujimori et al. (2003) [33]	Y	Y	Y	Y	Y	C	Y	Moderate
Back et al. (2007) [34]	Y	Y	Y	Y	Y	N	Y	Moderate
Sutherland et al. (2007) [19]	Y	Y	N	Y	N	N	Y	Low
Liu et al. (2007) [35]	Y	Y	Y	Y	Y	C	Y	Moderate
Mjaaland et al. (2009) [36]	Y	Y	Y	Y	N	N	Y	Moderate
Brown et al. (2010) [8]	Y	Y	Y	Y	C	C	Y	Moderate
Grainger et al. (2010) [37]	Y	Y	Y	Y	Y	N	Y	Moderate
Langewitz et al. (2010) [38]	Y	Y	Y	Y	C	N	Y	Moderate
Goelz et al. (2010) [39]	Y	Y	N	C	Y	C	Y	Low
Fukui et al. (2010) [40]	Y	Y	Y	Y	Y	N	Y	Moderate
Swanson et al. (2011) [41]	Y	Y	Y	Y	N	C	Y	Moderate
Roter et al. (2012) [42]	Y	Y	Y	C	C	Y	Y	Moderate
Clayton et al. (2012) [43]	Y	Y	Y	Y	Y	N	Y	Moderate
Kelley et al. (2012) [16]	Y	Y	Y	Y	Y	N	Y	Moderate
Nørgaard et al. (2012) [44]	Y	Y	Y	C	Y	Y	Y	Moderate
Schell et al. (2013) [45]	Y	Y	Y	Y	Y	N	Y	Moderate
Bays et al. (2014) [46]	Y	Y	Y	Y	N	Y	Y	Moderate
Pang et al. (2014) [17]	Y	Y	Y	Y	N	C	Y	Moderate
Nightingale et al. (2016) [14]	Y	Y	Y	Y	N	N	Y	Moderate
Banerjee et al. (2017) [28]	Y	Y	N	Y	Y	N	Y	Moderate
Saslaw et al. (2017) [28]	Y	Y	Y	Y	Y	Y	Y	High
O’Brien et al. (2018) [47]	Y	Y	N	Y	Y	N	Y	Moderate
Kaur et al. (2019) [48]	Y	Y	Y	Y	N	C	Y	Moderate
Barbosa et al. (2019) [49]	Y	Y	N	Y	N	C	Y	Low
Müller et al. (2019) [12]	Y	Y	N	Y	N	N	Y	Low
Saeed et al. (2019) [50]	Y	Y	Y	Y	Y	N	Y	Moderate
Wolderslund et al. (2021) [30]	Y	Y	Y	Y	Y	Y	Y	High
Banerjee et al. (2021) [51]	Y	Y	Y	Y	Y	C	Y	Moderate
Cheung et al. (2021) [52]	Y	Y	N	Y	N	C	Y	Low
Frydman et al. (2021) [53]	Y	Y	Y	Y	N	C	Y	Moderate
Iversen et al. (2021) [54]	Y	Y	Y	Y	N	Y	Y	Moderate
Kaczmarek et al. (2021) [55]	Y	Y	Y	Y	Y	C	Y	Moderate
Khajeh Azad et al. (2022) [56]	Y	Y	Y	Y	C	C	Y	Moderate
Patell et al. (2022) [57]	Y	Y	Y	Y	N	C	Y	Moderate
Rosa et al. (2022) [18]	Y	Y	Y	Y	Y	C	Y	Moderate
Ito et al. (2022) [58]	Y	Y	Y	Y	Y	C	Y	Moderate
Gil et al. (2023) [59]	Y	Y	Y	Y	N	C	Y	Moderate
White et al. (2024) [60]	Y	Y	Y	Y	N	Y	Y	Moderate

^*Y = Yes, N = No, C = Can’t tell

1* Are there clear research questions?

2* Do the collected data allow to address the research questions?

3* Are the participants representative of the target population?

4* Are measurements appropriate regarding both the outcome and intervention (or exposure)?

5* Are there complete outcome data?

6* Are the confounders accounted for in the design and analysis?

7* During the study period, is the intervention administered (or exposure occurred) as intended?

Table 3.

Risk of bias for each quantitative randomized controlled trial (RCT) assessed by Mixed Methods Appraisal Tool

Studies	Criteria							Study quality
	1*	2*	3*	4*	5*	6*	7*
Levinson et al. (1993) [61]	Y	Y	Y	Y	N	N	Y	Moderate
Jenkins et al. (2002) [62]	Y	Y	Y	Y	Y	C	Y	Moderate
Rubak et al. (2006) [63]	Y	Y	Y	Y	Y	C	Y	Moderate
Brug et al. (2007) [64]	Y	Y	Y	Y	Y	Y	Y	High
Butow et al. (2008) [65]	Y	Y	Y	Y	N	C	Y	Moderate
Bonvicini et al. (2008) [11]	Y	Y	Y	Y	Y	Y	Y	High
Lienard et al. (2010)	Y	Y	Y	N	Y	C	Y	Moderate
Fujimori et al. (2014) [67]	Y	Y	Y	Y	Y	C	Y	Moderate
Butow et al. (2015) [15]	Y	Y	Y	C	Y	N	Y	Moderate
Murray et al. (2015) [7]	Y	Y	Y	C	Y	Y	Y	Moderate
Gorniewicz et al. (2017) [10]	Y	Y	Y	Y	Y	Y	C	Moderate
de Figueiredo et al. (2018) [68]	Y	Y	Y	Y	Y	C	Y	Moderate
Chen et al. (2021) [69]	Y	Y	Y	Y	Y	C	Y	Moderate
Yazdanparast et al. (2021) [70]	Y	Y	Y	Y	Y	C	Y	Moderate
Fang et al. (2022) [71]	Y	Y	Y	Y	N	C	N	Low

^*Y = Yes, N = No, C = Can’t tell

1* Are there clear research questions?

2* Do the collected data allow to address the research questions?

3* Is randomization appropriately performed?

4* Are the groups comparable at baseline?

5* Are there complete outcome data?

6* Are outcome assessors blinded to the intervention provided?

7* Did the participants adhere to the assigned intervention?

Discussion

This systematic review analyzed 55 studies on the content, teaching methods, and effectiveness of CST programs for healthcare providers in chronic and serious illness care. A wide range of CST interventions were identified. Consistent with Brighton et al.'s (2017) findings in end-of-life care [23], our analysis also showed that these interventions were predominantly developed from established literature (e.g., published research, clinical guidelines, theoretical frameworks), with only a few incorporating direct patient input. This represents a significant limitation in intervention development, particularly as patient-centered communication is both a core competency in healthcare and a demonstrated predictor of intervention effectiveness. To address this, CST programs should integrate patient partners through co-design methodologies from their inception, as supported by established frameworks for developing complex interventions [72, 73]. Such an approach would ensure training programs are not only theoretically sound but also authentically responsive to patient priorities and lived experiences [72].

When examining the training programs' content, it became clear that the emphasis was largely on patient-centered communication and basic communication skills. A considerable number of studies, nearly half, focused primarily on these areas. Moreover, these skills were present in the remaining studies' programs, either as core components or as supplementary elements. These findings, in line with previous reviews [4, 74], highlight the crucial role of patient-focused communication in chronic care and the importance of integrating it into routine practice. Furthermore, the most frequently addressed issues and communication challenges in the reviewed studies included breaking bad news, demonstrating empathy and emotional support, and discussing advance care planning with patients. These findings reflect the sensitive nature of chronic care, where providers must deal with emotionally charged conversations while supporting patients on long-term illness trajectories [75, 76]. Additionally, SDM skills were frequently addressed in the studies [8, 12, 15, 16, 53, 58, 71], suggesting the importance of recognizing patient autonomy and engaging in collaborative care for chronic conditions.

Another point worth mentioning is that a small subset of included studies (7/55) incorporated disease-specific scenarios (e.g., rheumatology consultations [32], dementia care [47], cancer truth-telling [69]) or population-specific adaptations (e.g., communicating with older patients with functional and sensory/cognitive impairments [18]). These programs applied basic communication skills to clinically tailored contexts. This suggests that while a general CST framework remains broadly applicable, integrating tailored scenarios may enhance provider engagement and perceived relevance by demonstrating tangible applications of communication skills in clinical practice. However, the limited number of such studies precludes definitive conclusions about their efficacy. Further research should explore modular designs that preserve core skill-building while allowing optional adaptation to specific clinical needs, a balance that could optimize both standardization and real-world applicability.

Several studies have incorporated evidence-based communication techniques, such as motivational interviewing [12, 14, 41, 55, 63, 64], relapse prevention [41], coaching [11, 39, 50, 68], and self-determination theory [7]. This reflects increasing attention to evidence-based approaches to communication and an effort to ground CST in established theoretical frameworks and strengthen its potential to stimulate meaningful behavior change in patients.

The teaching methods used in these studies combined cognitive, behavioral, and experiential learning components, which are effective for skill acquisition and retention [77]. The most common method in the included studies, role-playing with feedback, focuses on behavioral learning. Didactic presentations and lectures, the second most common method, provide a cognitive foundation. Likewise, group work, including discussions and reflective exercises, was the third most common method and introduces an experiential component. More than three-quarters of the included studies used a combination of these methods, typically starting with a short lecture, followed by practical exercises and group discussions. Using this multimodal approach, we can enhance learning through cognitive understanding, behavioral practice, and reflective integration. This underscores the value of a multifaceted teaching strategy in CST, particularly in chronic care contexts [78].

Among the training programs identified, Oncotalk/Vitaltalk—a CST framework that integrates evidence-based teaching methods, including role-play, didactic presentations, and reflective feedback—emerged as a prevalent program across chronic care contexts [16, 30, 34, 35, 43–46, 53, 58, 60]. Initially created for oncology, it has since been tailored for specialties like palliative care [43, 46, 58], nephrology [45], and geriatrics [16, 53], demonstrating its versatility in responding to communication challenges common in chronic illness care (e.g., facilitating SDM, breaking bad news, and practicing empathy) [79]. Nonetheless, our review showed disparities in the availability of structured, evidence-supported CST programs for conditions like diabetes [41], where providers contend with challenges of similar complexity, like ongoing lifestyle modifications, stigma, and chronic complications’ management. Diabetes interventions mostly focus on patient-centered approaches like motivational interviewing and behavior change models [14, 41, 55, 63, 64], with limited importance given to structured CST for providers. Addressing this gap, modifying Oncotalk’s framework—for example, repurposing the SDM module for glycemic control goals and the breaking bad news module for chronic complications, customizing empathy training to handle diabetes-related distress or stigma, and incorporating diabetes-specific scenarios—could effectively tackle the distinct communication difficulties in diabetes care. Utilizing established frameworks such as Oncotalk, the field can emphasize efficiency and scalability while maintaining fidelity to evidence-based standards [79].

The substantial variability seen in training duration across included studies—ranging from brief, single-session interventions to long-term programs spanning months—highlights a significant issue in standardizing CST for chronic care contexts. Programs that assessed perceived self-confidence, self-efficacy, and preparedness were predominantly short-term (≤ 8 h) [7, 8, 14, 15, 17, 18, 28, 29, 31, 39, 40, 52, 55, 58, 69]. In contrast, programs that assessed changes in communication behavior were typically longer (≥ 9 h) [11, 12, 16, 34–36, 38, 41, 46, 47, 49, 54, 59, 61–68]. This distinction suggests that shorter programs successfully enhance providers' confidence and self-efficacy, while longer programs more effectively target measurable behavior change in complex communication tasks. Although the lack of behavior-change assessments in shorter programs precludes definitive conclusions, their benefits for confidence-building remain clear. Longer programs, by contrast, provide extended opportunities for skill mastery, behavioral rehearsal, and deeper engagement with challenging scenarios (e.g., breaking bad news, managing patient ambivalence) [4]. Together, these duration-outcome relationships align with established innovation-adoption frameworks. The progression from short-term confidence gains to long-term behavior change mirrors the stages of adoption outlined in Diffusion Theory, including awareness, practice, and maintenance [80]. At the same time, the attenuation effects observed in some studies underscore the need for reinforcement strategies from Health Behavior Change models [81]. This theoretical lens reinforces our practical recommendation: program length and design must be intentionally matched to goals—shorter interventions for confidence-building and longer programs for behavioral change—to address the multifaceted demands of chronic care communication [80, 82].

The consistently high levels of provider satisfaction with CST programs, as observed in the included studies [8, 12, 15–19, 28, 32, 33, 37, 39–41, 43, 45, 47, 48, 50–53, 55, 57, 58, 60, 65, 71], highlight their value and relevance for healthcare providers, irrespective of the length of the programs, the content of the programs or the teaching methods used in the programs. This consistent positive feedback is probably because CST programs resonate highly with providers and may reveal a shift in their attitudes toward the importance of communication skills and training for developing these skills.

The findings on changes in communication behaviors and communication self-efficacy/self-confidence were overwhelmingly positive, with most studies reporting significant improvements after training. This means that CST programs can effectively boost both the practical skills and psychological readiness of healthcare providers to handle complex communication difficulties in chronic and serious care contexts. However, some studies reported limited or no significant changes, highlighting the importance of program duration and design. For example, in studies by Sutherland et al., Fang et al., and Levinson and Roter, very brief training interventions yielded no change in communication behaviors, as previous research has indicated that shorter programs may not be as effective, particularly in the context of complex chronic care [83]. Additionally, Kaczmarek et al. and Butow et al. (2008) reported that the initial enhancement in communication behaviors did not persist at the time of follow-up assessment, thus suggesting that there is a need to have long-term encouragement and reinforcement strategies to sustain the learned skills [55, 65]. For communication self-efficacy and confidence, most studies reported significant and sustained improvements. However, Fang et al. and Wolderslund et al. found that initial confidence gains can wane over time [30, 71], while Butow et al. (2015) found no positive change in confidence [15]. These inconsistencies suggest that factors such as ongoing practice, feedback opportunities, reinforcement strategies (e.g., refresher courses), and organizational support may help sustain providers' confidence and enable effective communication with patients [15, 30, 55, 65, 71].

Although the studies reviewed showed consistent improvements in communication skills through both objective and self-reported measures, a blended evaluation approach combining objective measures (e.g., video-recorded consultations) with self-reports offers a more complete insight into the effectiveness of training. Objective measures provide evidence of skill acquisition, whereas self-reports provide insights into providers' perceptions [71]. The limitations of single-method evaluations, such as the resource intensity of objective measures or biases inherent in self-reports, may be met by blended methods [84]. However, it is important to distinguish this blended approach from separate assessments of communication self-efficacy, which focus on providers' psychological readiness rather than their observed behaviors. Future research should utilize blended methods to increase the rigor and validity of assessment and to capture the practical and psychological dimensions of communication skills development.

Regarding changes in attitudes and beliefs toward communication skills, the studies included, although limited in number, offer insights. Positive changes in the attitude and beliefs of providers on the importance of communication skills [12, 29, 32, 35, 48, 52, 62, 69] were observed. This finding highlights how CST programs can help providers appreciate and understand effective communication. However, studies like those by Sutherland et al. [19] and Clayton et al. [43] reported no significant changes in psychosocial beliefs after training. This suggests that attitudinal changes might be influenced by specific contexts or individual factors. Since current studies haven't focused much on attitudes and beliefs, future research should dive deeper into these aspects. It could give us a better understanding of the cultural factors influencing communication behaviors. Furthermore, future research efforts should examine the identification of specific program elements that bring about positive changes in attitudes and beliefs.

Conventional, in-person teaching methods were used by most of the included studies, but a few explored more innovative approaches. For example, one study combined an online brief didactic module a week before an in-person workshop, which fits with the flipped classroom model [52]. The development of essential skills in healthcare providers is fostered by this approach, especially in adapting to hybrid teaching models [85]. Eight studies also implemented online or virtual modules, including web-based tools with interactive video libraries, asynchronous and synchronous sessions, and videoconferencing [10, 42, 48, 53, 57, 58, 65, 71]. These studies give us insights into alternative ways to deliver CST, which might help overcome barriers like limited resources, time constraints, and geographic challenges [86]. However, the limited number of these studies emphasizes the need for further research to evaluate their effectiveness, feasibility, and applicability in chronic care contexts.

To guide future research, we summarize in Table 4 key evidence-based considerations for CST intervention design, highlighting priority areas where innovation could address identified gaps.

Table 4.

Key considerations for future CST interventions

Focus area	Key finding	Implication for future work
Development process	Most interventions were developed from literature and expert input, with only a few incorporating direct patient involvement in the design process	Involve patient partners as co-designers from inception to ensure interventions reflect patient priorities and real-world needs
Focus of training	◦ Basic communication skills were primary in half of programs and present in all others. Among advanced skills, breaking bad news was most common, followed by empathy, advance care planning, and SDM ◦ Few programs included disease-specific adaptations (e.g., dementia)	1. Modular program design: ◦ Core: Standardize training in basic/patient-centered communication skills ◦ Advanced: Integrate optional skill modules (e.g., breaking bad news, SDM) 2. Tailored adaptations: Develop disease/population-specific add-ons (e.g., geriatrics, oncology) to balance relevance with core competency retention 3. Comparative research: Evaluate efficacy of generic vs. contextualized training approaches
Teaching methods	Multimodal approaches (didactic lectures, role-playing with feedback, and group discussions/reflections) were most common, with > 75% of studies combining these methods	1. Standardize multimodal frameworks: ◦ Combine: brief didactics (cognitive), structured role-playing (behavioral), and guided reflection (experiential) ◦ Ensure hybrid/digital programs retain this triad 2. Optimize delivery formats: ◦ Compare in-person, hybrid (e.g., flipped classroom), and fully virtual models for efficacy/cost 3. Scale accessible training: ◦ Leverage asynchronous tools (e.g., video libraries) for low-resource settings 4. Enhance feedback quality: ◦ Standardize metrics (e.g., for role-play feedback)
Program Duration	◦ Program duration varied from ultra-brief (4 min) to longitudinal (8 months), with nearly half (27/55) lasting ≤ 8 h ◦ Programs assessed self-confidence were predominantly short-term (≤ 8 h), while programs assessed changes in communication behavior were typically longer (≥ 9 h)	Match program length and design to goals: ◦ Short-term training (≤ 8 h) for confidence/self-efficacy gains ◦ Extended programs (≥ 9 h) for behavior change
Effectiveness of training	◦ High provider satisfaction ◦ Significant improvements in observed communication skills ◦ Self-confidence improvements in most studies ◦ Short programs often fail behavior change ◦ Gains decay without reinforcement ◦ Attitudinal shifts observed, but inconsistently	1. Design for skill sustainability: ◦ Extended training for sustained behavior change ◦ Incorporate structured reinforcement strategies (e.g., coaching, quarterly refreshers) grounded in Health Behavior Change models 2. Study attitudinal drivers: ◦ Identify cultural/program factors influencing beliefs
Evaluation methods of training	Communication skills were evaluated using: ◦ Objective measures (65%): Video/audio recordings or direct observations analyzed with coding systems ◦ Subjective measures (35%): Validated self-report questionnaires	1. Standardize blended evaluation approaches: ◦ Pair video assessments (objective measures) with validated self-reports 2. Differentiate targets: ◦ Separate metrics for observed behavior vs. self-efficacy 3. Reduce resource barriers: ◦ Develop efficient tools (e.g., abbreviated video-rating rubrics)

Strengths and limitations

The broad scope is a strength of this systematic review, which covers CST programs in various chronic care settings. By examining CST programs beyond the specific kind of disease, this review identified common challenges and effective strategies applicable to chronic care in general. This demonstrates how well the core CST principles and educational strategies can be tailored and customized to meet the specific needs of various chronic conditions. It also provides valuable perspectives for designing and executing successful CST programs for a range of chronic diseases. However, this broad scope may present challenges, e.g., heterogeneity in disease-specific communication needs. This may complicate the direct comparisons. Additionally, the findings may be less detailed than those of disease-specific reviews.

One limitation of this review is that many of the included studies lacked robust designs (e.g., non-randomized trials and the absence of control groups), which weakened the evidence base for CST’s effectiveness. Furthermore, more than half were conducted in high-income countries. This issue raises concerns regarding the generalizability of the findings to settings with limited resources or different cultural contexts, such as those with a more paternalistic model of patient-physician communication. Additionally, we limited the review to studies published in English, which may have excluded relevant research from non-English-speaking countries.

Conclusion

This systematic review integrated and analyzed data on the content, teaching methods, and effectiveness of CST programs for healthcare providers in chronic care settings. Our findings demonstrated that CST consistently improves providers’ communication skills, self-efficacy, and attitudes toward communication and achieves high levels of provider satisfaction. The generalizability of CST programs across specialties is highlighted by shared training foci—such as breaking bad news, demonstrating empathy, and facilitating advance care planning— and common teaching methods like role-playing with feedback. At the same time, CST’s ability to adjust to disease-specific requirements guarantees its relevance in diverse chronic care contexts, ranging from diabetes self-management discussions to conversations about oncology prognoses. However, differences in program duration, follow-up assessments, and methodological rigor across studies highlight the importance of creating standardized frameworks to improve training design and evaluation.

To improve the rigor and validity of future findings, research should focus more on using blended evaluation methods. This approach combines objective behavioral assessments with self-reported measures. Additionally, a deeper exploration of providers’ attitudes and beliefs is critical to understanding how CST fosters lasting cultural shifts toward patient-centered care. Innovations in delivery, such as virtual simulations or AI-driven feedback, could further enhance accessibility and scalability, particularly in resource-limited settings [57].

CST is ultimately revealed to be a multifaceted, evidence-driven intervention that links medical professionals’ expertise with empathetic communication. By equipping providers to handle the complex, emotionally charged conversations inherent in chronic care, CST not only enhances provider competencies but also establishes a foundation for more empathetic, patient-centered healthcare systems [8].

Authors' contributions

MP conceptualized the study. MP and EN outlined the research proposal, aims, and questions. MP and MT performed the review. MP, MT, and MM drafted the manuscript. All authors edited and approved the final version of the manuscript.

Funding

The authors received no specific funding for this work.

Data availability

All data generated or analyzed during this study are included in this published article [Supporting information 3].

Declarations

Ethics approval and consent to participate

Ethical approval for the study was obtained from the medical research ethics committee of the Tehran University of Medical Sciences (IR.TUMS.EMRI.REC.1401.047).

Consent for publication

Na.

Competing interests

The authors declare no competing interests.