The moral aesthetics of simulated suffering in standardized patient performances

Promoting moral imagination in nursing education: Imagining and performing

Moral imagination is a central component of moral agency and person-centred care. Becoming moral agents who can sustain attention on patients and their families through their illness and suffering involves imagining the other, what moral possibilities are available, what choices to make, and how one wants to be. This relationship between moral agency, moral imagination, and personhood can be effaced by a focus on task-driven technical rationality within the multifaceted challenges of contemporary healthcare. Similarly, facilitating students' moral agency can also be obscured by the task-driven technical rationality of teaching. The development of moral agency requires deliberate attention across the trajectory of nursing education. To prepare nursing students for one practice challenge, workplace violence, we developed a multimodal education intervention which included a simulated learning experience (SLE). To enhance the realism and consistency of the educational experience, 11 nursing students were trained as simulated participants (SP). As part of a larger study to examine knowledge acquisition and practice confidence of learners who completed the SLE, we explored the experience of being the SP through interviews and a focus group with the SP students. The SP described how their multiple performances contributed to imagining the situation 'on both sides' prompting empathy, a reconsideration of their moral agency, and the potential to prevent violence in the workplace beyond technical rational techniques, such as verbal de-escalation scripts. The empirical findings from the SP prompted a philosophical exploration into moral imagination. We summarise the multimodal educational intervention and relevant findings, and then, using Johnson's conception of moral imagination and relevant nursing literature, we discuss the significance of the SP embodied experiences and their professional formation. We suggest that SLEs offer a unique avenue to create pedagogical spaces which promote moral imagination, thereby teaching for moral agency and person-centred care.

'Hallucination': Hospital Ecologies in COVID's Epistemic Instability

Historians and ethnographers have described biomedicine as a modernist project that imagines accumulating ever-more stable knowledge over time. This project broke down in heavily hit hospitals at the onset of the COVID-19 pandemic in the U.S., when bureaucratic, physical and knowledge structures collapsed. A combination of terror, a partially characterized disease entity and clinicians' inability to operate without disease models drove them to draw on rapidly changing and contradictory information via social media, changing medical practice minute-to-minute. The result was a unique form of knowing described as "hallucination": a hyperreal, unstable ecology of imagined viral particles distributed in physical spaces, transforming with each text message and tweet. The nature, experience and practice of this ecology sheds light on what happens when instability comes to otherwise stable places.

Compassion or Corruption? Temporalities of Care and Nationhood in Papua New Guinean Nursing Education

Nurse educators in Papua New Guinea (PNG) must prepare students for often demoralizing working conditions. This article analyzes classroom and practical lessons in a PNG Highlands nursing college. A variety of pedagogical practices, including role plays and other simulation technologies, were used to socialize students to imagine patients' relatives while making clinical decisions, and to contemplate their own relatives and ancestors in reflecting on their moral commitments to health care. Such practices generate a mode of medical citizenship shaped by a regime of biocommunicability in which Christianity and education are thought to transform one's capacity to detach from the emotional appeals of kin. These pedagogies link the individual subjectivities of health workers to a persistent, though fragile, vision of the nation in which transgenerational, urban-rural kinship is a synecdoche for nationhood (and its deferral), despite professional counternarratives that cast these kinship ties as a slippery slope toward "corruption." [medical citizenship, temporalities of care, nursing simulation, nationhood, Papua New Guinea].

Implementation and utilization of gynecological teaching associate and male urogenital teaching associate programs: a scoping review

BACKGROUND

Gynecological Teaching Associates (GTAs) and Male Urogenital Teaching Associates (MUTAs) are individuals trained to instruct health professional learners with their own body to conduct accurate, patient-centered breast, pelvic, urogenital, rectal, and/or prostate examinations. Evidence indicates that this results in improvements in technical competence and communication skills, but there is wide variability to how such programs are implemented and engaged within the curriculum. In this scoping review, we mapped evidence regarding (1) how GTA/MUTA programs are utilized with health professional learners, (2) how GTA/MUTA programs are implemented using the Association of Standardized Patient Educators (ASPE) Standards of Best Practice (SOBP) as a framework, and (3) what broad outcomes are addressed in publications.

METHODS

PubMed, ERIC, PsychINFO, CINAHL, and Sociological Abstracts were searched for all publications addressing instruction of physical examinations with a GTA/MUTA and/or administration of GTA/MUTA programs. Studies were charted in tandem until consensus was identified and then charted individually, using an iterative process. The scoping review protocol was registered prospectively.

RESULTS

One hundred and one articles were identified, and nearly all highlighted positive results regarding GTA/MUTA programs. Most studies addressed medical students within the USA and Europe. During instructional sessions, three (SD=1.4) learners worked with each GTA/MUTA and an average of 32 min (SD=17) was allocated per learner. GTAs/MUTA instructed both independently (n=33) and in pairs (n=51). Thirty-eight articles provided detailed information consistent with one or more of the Domains of the ASPE SOBP, with six providing specific information regarding safe work environments.

CONCLUSIONS

While studies demonstrate consistently positive outcomes for learners, there is wide variability in implementation patterns. This variability may impact learning outcomes and impact both physical and psychological safety for GTAs/MUTAs and learners. Terminology used to refer to GTAs/MUTAs is inconsistent and may obscure relevant publications. Additional research is indicated to explore the pedagogical variables that result in positive learning outcomes and examine methods to ensure physical and psychological safety of GTAs/MUTAs and learners.

TRIAL REGISTRATION

https://osf.io/x9w2u/ .

Diversity and inclusion in simulation: addressing ethical and psychological safety concerns when working with simulated participants

Healthcare learners can gain necessary experience working with diverse and priority communities through human simulation. In this context, simulated participants (SPs) may be recruited for specific roles because of their appearance, lived experience or identity. Although one of the benefits of simulation is providing learners with practice where the risk of causing harm to patients in the clinical setting is reduced, simulation shifts the potential harm from real patients to SPs. Negative effects of tokenism, misrepresentation, stereotyping or microaggressions may be amplified when SPs are recruited for personal characteristics or lived experience. Educators have an ethical obligation to promote diversity and inclusion; however, we are also obliged to mitigate harm to SPs. The goals of simulation (fulfilling learning objectives safely, authentically and effectively) and curricular obligations to address diverse and priority communities can be in tension with one another; valuing educational benefits might cause educators to deprioritise safety concerns. We explore this tension using a framework of diversity practices, ethics and values and simulation standards of best practice. Through the lens of healthcare ethics, we draw on the ways clinical research can provide a model for how ethical concerns can be approached in simulation, and suggest strategies to uphold authenticity and safety while representing diverse and priority communities. Our objective is not to provide a conclusive statement about how values should be weighed relative to each other, but to offer a framework to guide the complex process of weighing potential risks and benefits when working with diverse and priority communities.

Performance-based assessment in the 21st century: when the examiner is a machine

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Patient involvement in health professionals' education: a meta-narrative review

More than 100 years ago, Osler inspired educators to consider health professions education (HPE) as intricately reliant on patients. Since that time, patient involvement in HPE has taken on many different meanings. The result is a disparate body of literature that is challenging to search, making it difficult to determine how to continue to build knowledge in the field. To address this problem, we conducted a review of the literature on patient involvement in HPE using a meta-narrative approach. The aim of the review was to synthesize how questions of patient involvement in HPE have been considered across various research traditions and over time. In this paper, we focus on three scholarly communities concerned with various interpretations of patient involvement in HPE-patient as teachers, real patients as standardized patients, and bedside learning. Focus on these three research communities served as a way to draw out various meta-narratives in which patients are thought of in particular ways, specific rationales for involvement are offered, and different research traditions are put to use in the field. Attending to the intersections between these meta-narratives, we focus on the potentially incommensurate ways in which "active" patient engagement is considered within the broader field and the possible implications. We end by reflecting on these tensions and what they might mean for the future of patient involvement, specifically patient involvement as part of future iterations of competency based education.

Using conversation analysis to inform role play and simulated interaction in communications skills training for healthcare professionals: identifying avenues for further development through a scoping review

BACKGROUND

This paper responds to previously published debate in this journal around the use of sociolinguistic methods in communication skills training (CST), which has raised the significant question of how far consultations with simulated patients reflect real clinical encounters. This debate concluded with a suggestion that sociolinguistic methods offer an alternative analytic lens for evaluating CST. We demonstrate here that the utility of sociolinguistic methods in CST is not limited to critique, but also presents an important tool for development and delivery.

METHODS

Following a scoping review of the use of role play and simulated interaction in CST for healthcare professionals, we consider the use of the specific sociolinguistic approach of conversation analysis (CA), which has been applied to the study of health communication in a wide range of settings, as well as to the development of training.

DISCUSSION

Role play and simulated interaction have been criticised by both clinicians and sociolinguists for a lack of authenticity as compared to real life interactions. However they contain a number of aspects which healthcare professionals report finding particularly useful: the need to think on one's feet in real time, as in actual interaction with patients; the ability to receive feedback on the simulation; and the ability to watch and reflect on how others approach the same simulation task in real time. Since sociolinguistic approaches can help to identify inauthenticity in role play and simulation, they can also be used to improve authenticity. Analysis of real-life interactions using sociolinguistic methods, and CA in particular, can identify actual interactional practices that are used by particular patient groups. These practices can then be used to inform the training of actors simulating patients. In addition, the emphasis of CA on talk as joint activity means that proper account can be taken of the way in which simulated interaction is co-constructed between simulator and trainee. We suggest that as well as identifying potential weaknesses in current role play and simulation practice, conversation analysis offers the potential to enhance and develop the authenticity of these training methods.

Students' Learning Experiences from Didactic Teaching Sessions Including Patient Case Examples as Either Text or Video: A Qualitative Study

OBJECTIVES

The aim of this study was to explore medical students' learning experiences from the didactic teaching formats using either text-based patient cases or video-based patient cases with similar content. The authors explored how the two different patient case formats influenced students' perceptions of psychiatric patients and students' reflections on meeting and communicating with psychiatric patients.

METHODS

The authors conducted group interviews with 30 medical students who volunteered to participate in interviews and applied inductive thematic content analysis to the transcribed interviews.

RESULTS

Students taught with text-based patient cases emphasized excitement and drama towards the personal clinical narratives presented by the teachers during the course, but never referred to the patient cases. Authority and boundary setting were regarded as important in managing patients. Students taught with video-based patient cases, in contrast, often referred to the patient cases when highlighting new insights, including the importance of patient perspectives when communicating with patients.

CONCLUSION

The format of patient cases included in teaching may have a substantial impact on students' patient-centeredness. Video-based patient cases are probably more effective than text-based patient cases in fostering patient-centered perspectives in medical students. Teachers sharing stories from their own clinical experiences stimulates both engagement and excitement, but may also provoke unintended stigma and influence an authoritative approach in medical students towards managing patients in clinical psychiatry.

Communication skills training for healthcare professionals working with people who have cancer

BACKGROUND

This is the third update of a review that was originally published in the Cochrane Library in 2002, Issue 2. People with cancer, their families and carers have a high prevalence of psychological stress, which may be minimised by effective communication and support from their attending healthcare professionals (HCPs). Research suggests communication skills do not reliably improve with experience, therefore, considerable effort is dedicated to courses that may improve communication skills for HCPs involved in cancer care. A variety of communication skills training (CST) courses are in practice. We conducted this review to determine whether CST works and which types of CST, if any, are the most effective.

OBJECTIVES

To assess whether communication skills training is effective in changing behaviour of HCPs working in cancer care and in improving HCP well-being, patient health status and satisfaction.

SEARCH METHODS

For this update, we searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 4), MEDLINE via Ovid, Embase via Ovid, PsycInfo and CINAHL up to May 2018. In addition, we searched the US National Library of Medicine Clinical Trial Registry and handsearched the reference lists of relevant articles and conference proceedings for additional studies.

SELECTION CRITERIA

The original review was a narrative review that included randomised controlled trials (RCTs) and controlled before-and-after studies. In updated versions, we limited our criteria to RCTs evaluating CST compared with no CST or other CST in HCPs working in cancer care. Primary outcomes were changes in HCP communication skills measured in interactions with real or simulated people with cancer or both, using objective scales. We excluded studies whose focus was communication skills in encounters related to informed consent for research.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials and extracted data to a pre-designed data collection form. We pooled data using the random-effects method. For continuous data, we used standardised mean differences (SMDs).

MAIN RESULTS

We included 17 RCTs conducted mainly in outpatient settings. Eleven trials compared CST with no CST intervention; three trials compared the effect of a follow-up CST intervention after initial CST training; two trials compared the effect of CST and patient coaching; and one trial compared two types of CST. The types of CST courses evaluated in these trials were diverse. Study participants included oncologists, residents, other doctors, nurses and a mixed team of HCPs. Overall, 1240 HCPs participated (612 doctors including 151 residents, 532 nurses, and 96 mixed HCPs).Ten trials contributed data to the meta-analyses. HCPs in the intervention groups were more likely to use open questions in the post-intervention interviews than the control group (SMD 0.25, 95% CI 0.02 to 0.48; P = 0.03, I² = 62%; 5 studies, 796 participant interviews; very low-certainty evidence); more likely to show empathy towards their patients (SMD 0.18, 95% CI 0.05 to 0.32; P = 0.008, I² = 0%; 6 studies, 844 participant interviews; moderate-certainty evidence), and less likely to give facts only (SMD -0.26, 95% CI -0.51 to -0.01; P = 0.05, I² = 68%; 5 studies, 780 participant interviews; low-certainty evidence). Evidence suggesting no difference between CST and no CST on eliciting patient concerns and providing appropriate information was of a moderate-certainty. There was no evidence of differences in the other HCP communication skills, including clarifying and/or summarising information, and negotiation. Doctors and nurses did not perform differently for any HCP outcomes.There were no differences between the groups with regard to HCP 'burnout' (low-certainty evidence) nor with regard to patient satisfaction or patient perception of the HCPs communication skills (very low-certainty evidence). Out of the 17 included RCTs 15 were considered to be at a low risk of overall bias.

AUTHORS' CONCLUSIONS

Various CST courses appear to be effective in improving HCP communication skills related to supportive skills and to help HCPs to be less likely to give facts only without individualising their responses to the patient's emotions or offering support. We were unable to determine whether the effects of CST are sustained over time, whether consolidation sessions are necessary, and which types of CST programs are most likely to work. We found no evidence to support a beneficial effect of CST on HCP 'burnout', the mental or physical health and satisfaction of people with cancer.

Values and value in simulated participant methodology: A global perspective on contemporary practices

This article has been written for the 40th year of the publication of Medical Teacher. While we celebrate the contribution of simulated participants (SPs) to health professions education through values and value-based learning, we also offer critical reflection on elements of our practice, commencing with language. We argue for the use of the term simulated rather than standardized and acknowledge the dominant role of the SP as patient and the origins of the methodology. These shifts in terms and their implications in practice reflect changes in the conceptualization of SP-based methodology. Recently published standards for those who work with SPs (SP practitioners) are noted as an important milestone in our community's development. We consider contemporary practices addressing the complex notions of values and value in SP-based learning. We simultaneously refer to the work of SPs and SP practitioners. Phases of educational design including identifying learning objectives, scenario design, implementation, feedback and debriefing are used to illustrate methodological shifts. Within each of these phases, there are relational issues that have to date often gone unchecked and are under reported in literature. Finally, using the metaphor of a murmuration, we celebrate contemporary practices of the global SP practitioner community.

Simulated death enhances learner attitudes regarding simulation

Introduction

Despite the widespread use of simulated death in healthcare education, some view it as a controversial learning tool due to potential psychological harm. Others believe that allowing death during simulation enhances participant learning. Sparse data exist in the literature about learner attitudes towards simulated death. Our objective was to establish a link between exposure to simulated death and learner attitudes regarding simulation. Our hypothesis was that exposure to simulated death will positively affect learner attitudes towards simulation.

Methods

Anonymous surveys were distributed to participants of simulations conducted by our department from January 2014 to December 2015. Collected survey data included total number of simulation scenarios, exposure to death and participants' views towards simulation afterwards. Participants also rated the simulation on a Likert scale. We compared demographic and simulation data for participants who experienced simulated death versus participants who did not. Exposure to death and clinical level were included as predictor variables in logistic regressions using the simulator experience variables as outcomes.

Results

250 survey responses were analysed. 64% of participants were attendings. 82% of participants experienced death during simulation. The group that experienced simulated death gave significantly higher ratings (4.77 vs 4.50, p=0.004) and a higher percentage of maximum ratings on the Likert scale (83% vs 59%, p=0.0002). More participants who experienced death thought that simulated death could enhance learning (76% vs 59%, p=0.021). When adjusted for training level, those who experienced death in simulation were nearly twice as likely to think that death can enhance learning (p=0.049) and 133% more likely to give the simulation the highest rating (p=0.036).

Conclusions

Survey participants who experienced simulated death were more likely to think that death can enhance learning and more likely to give the simulation the highest rating, thereby demonstrating that exposure to simulated death positively affects learner attitudes regarding simulation.

Death During Simulation: A Literature Review

INTRODUCTION

One of the goals of simulation is to teach subjects critical skills and knowledge applicable to live encounters, without the risk of harming actual patients. Although simulation education has surged in medical training over the last two decades, several ethically challenging educational methods have arisen. Simulated death has arisen as one of these challenging issues and currently there is no consensus regarding how to best manage this controversial topic in the simulated environment. The goal of this review is to analyze how simulated mortality has been used and discover whether or not this tool is beneficial to learners.

METHODS

In May 2016, the authors performed a literature search on both Pubmed and the Cochrane database using multiple variations of keywords; they then searched bibliographies and related articles.

RESULTS

There were 901 articles acquired in the initial search. The authors eliminated articles that were not relevant to the subject matter. After adding articles from bibliographies and related articles, the authors included the 43 articles cited in this article.

DISCUSSION

As a result, the authors of this article believe that death, when used appropriately in simulation, can be an effective teaching tool and can be used in a responsible manner.

Digital rectal examination skills: first training experiences, the motives and attitudes of standardized patients

BACKGROUND

Physical clinical examination is a core clinical competence of medical doctors. In this regard, digital rectal examination (DRE) plays a central role in the detection of abnormalities of the anus and rectum. However, studies in undergraduate medical students as well as newly graduated doctors show that they are insufficiently prepared for performing DRE. Training units with Standardized Patients (SP) represent one method to deliver DRE skills. As yet, however, it is little known about SPs' attitudes.

METHODS

This is a qualitative study using a grounded theory approach. Interviews were conducted with 4 standardized patients about their experiences before, during and after structured SP training to deliver DRE competencies to medical students. The resulting data were subjected to thematic content analysis.

RESULTS

Results show that SPs do not have any predominant motives for DRE program participation. They participate in the SP training sessions with relatively little prejudice and do not anticipate feeling highly vulnerable within teaching sessions with undergraduate medical students.

CONCLUSIONS

The current study examined SPs' motives, views, expectations and experiences regarding a DRE program during their first SP training experiences. The results enabled us to derive distinct action guidelines for the recruitment, informing and briefing of SPs who are willing to participate in a DRE program.

The 'missing person' in roles-based competency models: a historical, cross-national, contrastive case study

CONTEXT

The use of roles such as medical expert, advocate or communicator to define competencies is currently popular in health professions education. CanMEDS is one framework that has been subject to great uptake across multiple countries and professions. The examination of the historical and cultural choices of names for roles generates insight into the nature and construction of roles. One role that has appeared in and disappeared from roles-based frameworks is that of the 'person'.

METHODS

In order to examine the implications of explicitly including or excluding the role of the 'physician as person' in a competency framework, we conducted a contrastive analysis of the development of frameworks in Canada and the Netherlands. We drew upon critical social science theoretical understandings of the power of language in our analysis.

RESULTS

In Canada, the 'person' role was a late addition to the precursory work that informed CanMEDS, and was then excluded from the final set of CanMEDS role names. In the Netherlands, a 'reflector' role was added in some Dutch schools and programmes when CanMEDS was adopted. This was done in order to explicitly emphasise the importance of the 'person' of the trainee.

CONCLUSIONS

In analysing choices of names for roles, we have the opportunity to see how cultural and historical contexts affect conceptions of the roles of doctors. The taking up and discarding of the 'person' role in Canada and the Netherlands suggest that as medical educators we may need to further consider the ways in which we wish the trainee as a person to be made visible in the curriculum and in assessment tools.

Tracing detached and attached care practices in nursing education

The implementation of skills labs in Danish nursing education can, in itself, be viewed as a complexity. The students are expected to eventually carry out their work in a situated hospital practice, but they learn their professional skills in a different space altogether, detached and removed from the hospitals and practising on plastic dummies. Despite the apparent artificiality of the skills lab, this article will show that it is possible to analyse some of the fundamental aspects of care in nursing by ethnographically following this phenomenon of simulation-based training. These particular aspects of care are not explicated in the curriculum or textbooks; however, they surfaced once this crooked approach to studying care in a simulated practice was applied. The article start from the assertion that detached engagements are not recognized within the field of nursing education as an equal component to attachments. Yet empirical cases from the skills lab and hospitals illustrate how students sometimes felt emotionally attached to plastic dummies and how experienced nurses sometimes practised a degree of detachment in relation to human patients. Detached engagements will therefore be presented as part of care practices of nurses - rendering the ability to detach in engagement with patients a professional skill that students also need to learn. In the analysis to follow, attached and detached engagements are located on an equal plane by integrating both into the same conceptual framework, rather than imposing a priori notions about their dialectic relation. The analysis shows that it is the particular intertwinement of attachment and detachment that gives care its fundamental meaning. In conclusion, the need for a conceptual shift from a strong emphasis on attached engagement to a more balanced analytical approach to care work, as involving both attached and detached engagement within Danish nursing education, is advocated.

Communication skills training for healthcare professionals working with people who have cancer

BACKGROUND

This is an updated version of a review that was originally published in the Cochrane Database of Systematic Reviews in 2004, Issue 2. People with cancer, their families and carers have a high prevalence of psychological stress which may be minimised by effective communication and support from their attending healthcare professionals (HCPs). Research suggests communication skills do not reliably improve with experience, therefore, considerable effort is dedicated to courses that may improve communication skills for HCPs involved in cancer care. A variety of communication skills training (CST) courses have been proposed and are in practice. We conducted this review to determine whether CST works and which types of CST, if any, are the most effective.

OBJECTIVES

To assess whether CST is effective in improving the communication skills of HCPs involved in cancer care, and in improving patient health status and satisfaction.

SEARCH METHODS

We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL) Issue 2, 2012, MEDLINE, EMBASE, PsycInfo and CINAHL to February 2012. The original search was conducted in November 2001. In addition, we handsearched the reference lists of relevant articles and relevant conference proceedings for additional studies.

SELECTION CRITERIA

The original review was a narrative review that included randomised controlled trials (RCTs) and controlled before-and-after studies. In this updated version, we limited our criteria to RCTs evaluating 'CST' compared with 'no CST' or other CST in HCPs working in cancer care. Primary outcomes were changes in HCP communication skills measured in interactions with real and/or simulated patients with cancer, using objective scales. We excluded studies whose focus was communication skills in encounters related to informed consent for research.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials and extracted data to a pre-designed data collection form. We pooled data using the random-effects model and, for continuous data, we used standardised mean differences (SMDs).

MAIN RESULTS

We included 15 RCTs (42 records), conducted mainly in outpatient settings. Eleven studies compared CST with no CST intervention, three studies compared the effect of a follow-up CST intervention after initial CST training, and one study compared two types of CST. The types of CST courses evaluated in these trials were diverse. Study participants included oncologists (six studies), residents (one study) other doctors (one study), nurses (six studies) and a mixed team of HCPs (one study). Overall, 1147 HCPs participated (536 doctors, 522 nurses and 80 mixed HCPs).Ten studies contributed data to the meta-analyses. HCPs in the CST group were statistically significantly more likely to use open questions in the post-intervention interviews than the control group (five studies, 679 participant interviews; P = 0.04, I² = 65%) and more likely to show empathy towards patients (six studies, 727 participant interviews; P = 0.004, I² = 0%); we considered this evidence to be of moderate and high quality, respectively. Doctors and nurses did not perform statistically significantly differently for any HCP outcomes.There were no statistically significant differences in the other HCP communication skills except for the subgroup of participant interviews with simulated patients, where the intervention group was significantly less likely to present 'facts only' compared with the control group (four studies, 344 participant interviews; P = 0.01, I² = 70%).There were no significant differences between the groups with regard to outcomes assessing HCP 'burnout', patient satisfaction or patient perception of the HCPs communication skills. Patients in the control group experienced a greater reduction in mean anxiety scores in a meta-analyses of two studies (169 participant interviews; P = 0.02; I² = 8%); we considered this evidence to be of a very low quality.

AUTHORS' CONCLUSIONS

Various CST courses appear to be effective in improving some types of HCP communication skills related to information gathering and supportive skills. We were unable to determine whether the effects of CST are sustained over time, whether consolidation sessions are necessary, and which types of CST programs are most likely to work. We found no evidence to support a beneficial effect of CST on HCP 'burnout', patients' mental or physical health, and patient satisfaction.