Child- and family-specific communication skills trainings for healthcare professionals caring for families with parental cancer: A systematic review

Introduction As part of high-quality cancer care, healthcare professionals (HCPs) play a significant role in identifying and addressing specific needs of cancer patients parenting minor children. However, HCPs experience various barriers to adequately support parents with cancer. This systematic review explores current CSTs incorporating child- and family- specific modules for HCPs in oncology. Moreover, outcome measures and effectiveness of trainings are systematically investigated. Methods The systematic review was registered within PROSPERO (registration code: CRD42020139783). Systematic searches were performed in four databases (PubMed, Cinahl, PsycInfo, Web of Science) in 12/2020, including an update in 12/2021 and 08/2022. Quantitative, primary studies fulfilling the pre-defined inclusion criteria were included. Due to the expected heterogeneity a meta-analysis was not conducted. Study selection and quality assessment were conducted by two independent researchers, data extraction by one. Study quality was assessed using an adapted version of the National Institutes of Health quality assessment tool for pre-post studies without control group. Results Nine studies were included in this review following an experimental pre-post design only. Two CSTs were specifically designed to improve communication with cancer patients parenting minor children, the remaining seven incorporated a brief family module only. Seven programs were face-to-face trainings, one an e-learning and one a webinar. Eight studies found at least one statistically significant improvement in communication after training. However, quality of most studies was fair. Conclusion This is the first review exploring specific CSTs for HCPs caring for cancer patients parenting minor children. As only two CSTs focused on parental cancer, evidence on the effectiveness of such CSTs is limited. Existing CSTs should be evaluated properly and include details on content of family modules. Further studies including and evaluating specific CSTs focusing on parental cancer are needed in order to strengthen HCPs’ competencies to meet specific needs of patients parenting minor children.


Introduction
Approximately 14-25% parents with dependent children are diagnosed with cancer [1][2][3] which can have a major impact on the entire family. Cancer patients parenting minor children experience increased levels of stress and anxiety compared to patients without minor children [4,5]. Additional to the burden of the life-limiting disease and its treatment, parents with cancer worry about how to maintain family life and their role as a "good" parent and supporter [6][7][8][9]. Parents often feel insecure if, when and how to communicate with their children about cancer and how to adequately address their children's needs [8,10,11].
Children of parents having cancer experience major challenges in their family routine and increased psychosocial stress [6,12]. Even without knowing, they feel that something serious is going on [13]. Providing age-appropriate information and timely communication about parental cancer can decrease the risk of developing negative psychological and physical consequences in affected children [12,14].
Healthcare professionals (HCPs) have a significant role in identifying patients parenting minor children, their specific needs and-if necessary-initiating supportive, psychosocial care [1,6,8,11]. In order to provide high-quality, patient-centred cancer care, involvement of family and their specific needs is essential [15,16]. Family members are often the primary support for cancer patients [17] and act as caregiver and thus are impacted by cancer as well [18]. As family communication is associated with relationship functioning and adjustment to the cancer diagnosis [18], it is essential for HCPs to provide support to cancer patients and their families on family communication issues, e.g., open communication. In order to identify potential cancer patients parenting minor children, it is key to know about the patient's family status and if applicable to proactively address child-and family specific themes within cancer care. Previous studies show that parents with cancer wish for support and guidance from their HCPs about child-and family-specific aspects, especially on communication with their children [1,9,10,19]. However, current results show that less than 50% of HCPs routinely communicate about child-and family-specific themes with their patients [20]. Barriers of HCPs to include child-and family-specific aspects routinely in cancer care are e.g., lack of specific competencies and knowledge as well as time pressure or structural barriers [8,11,21,22]. Additionally, other studies report that HCPs feel insufficiently trained in providing basic adequate psychosocial support to cancer patients parenting minor children [11,23].
In order to address these major barriers in HCP's communication about child-and familyspecific aspects, adequate trainings are needed to improve communication skills and competencies for HCPs in oncology [10,24].
Over the last decade, various communication skills trainings (CSTs) have been developed and implemented to improve communication skills in oncology. Findings indicate improvements in HCP's communication skills, namely increasing empathy [25], knowledge and self-efficacy [26] or in certain patient-reported outcomes, e.g., patient satisfaction [26].
Considering the described relevance and specific burden of affected parents, CSTs should also address these aspects. However, despite many CSTs being developed for HCPs in oncology in recent years [25][26][27], it remains unclear whether and to what extent child-and familyrelated aspects are addressed in these CSTs and previous reviews on CSTs have not included this topic [25].
To close this gap, this systematic review aims to a.) provide an overview of existing CSTs for HCPs working in oncology addressing child-and parent-specific aspects in cancer care, b.) explore reported outcome measures associated with the CSTs and c.) gather existing evidence of effectiveness of these trainings.

Materials and methods
The systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO, registration code: CRD42020139783) and follows the updated guideline for reporting systematic reviews (PRISMA 2020 statement [28]).

Data sources and search strategy
An electronic literature search was performed in the databases of PubMed, Cinahl, PsycInfo and Web of Science with no limitation regarding the publication year. The search was conducted on December 9 th , 2020, was developed in PubMed and adapted to the other databases. A search update was conducted on December 3 rd , 2021 and on August 12 th 2022. A librarian of the Central Medical Library Hamburg was consulted to review the final search strategy.
The systematic search strategy consisted of a combination of different terms and keywords from the following four domains: (i) communication skills training, (ii) healthcare professional, (iii) oncology, and (iv) parent/family (see Table 1).
Articles on pediatric oncology as well as qualitative studies were excluded. Our primary electronic search strategy was complemented by a hand search, consisting of citation tracking of included articles.

Eligibility criteria and study selection
Due to language restriction of the authors, peer-reviewed publications in English or German were retrieved. We included studies reporting any type of CST with a pre-post design (e.g., single arm intervention studies or studies including a control group) regarding outcomes assessing change of communication competencies, comprising at least one module on child-or parent-specific aspects in cancer care for HCPs caring for adult cancer patients. The applied in-and exclusion criteria are displayed in Table 2. However, despite our extensive search strategy only two studies were identified during the study selection process to focus on child-and parent-specific aspects within their CSTs. Therefore, we decided to broaden the focus of this systematic review and to include studies, which entail a child-and family-specific module within their CST.
To manage and facilitate the selection process, search results were imported into the reference management software EndNote (Version EndNote X9.3.2) and duplicates were removed. One author (WF) conducted the title and abstract screening. All potentially relevant articles according to the defined inclusion and exclusion criteria were included for full text screening. Full texts were independently assessed for eligibility by two reviewers (WF, WG). Disagreement between reviewers was resolved by discussion; where necessary, a third reviewer (LI) was consulted.

Study type and design
Quantitative intervention studies Qualitative studies, observational studies without intervention, studies without a pre-post measurement of outcomes Study is not cancer specific (e.g., mental illness) Dissertations, conference abstracts etc.

Participants
Healthcare professionals (HCPs) working in oncology or with cancer patients (e.g., nurses, physicians) HCPs not working with cancer patients or not having any experience caring for cancer patients HCPs within healthcare educational programmes (e.g., nursing or medical students);

HCPs working in paediatrics
HCPs working in all settings (e.g., outpatient, inpatient)

Interventions
Studies evaluating a communication training or educational program including at least a module on child-, parent-or family-specific themes;

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Education for healthcare professionals caring for families with parental cancer: A systematic review

Data extraction and synthesis
As we were expecting a large heterogeneity of studies including a large variation in participants, outcome measures or type of CST being used, we synthesized findings of the included studies in the form of a narrative review. A data extraction form was developed including the following information: aims/background, study design and methods; details of CST (e.g., development, setting, duration, content, teaching strategies); details on child-and family-specific module; characteristics of participants; CST outcome measures and results. The form was independently pilot tested by two reviewers (WF, WG) with one randomly selected study included in this review. Data extraction of included studies was systematically performed by one reviewer (WF), final results were discussed with two other reviewers (WG, LI). Intervention outcomes and findings were categorized based on Kirkpatrick's framework for training evaluation based on the following levels: 1. Reaction-Participant's satisfaction with the training; 2. Learning-Participant's change of attitudes, increase in knowledge and skills; 3. Behavior-Participant's change in behavior; 4. Results-other improvements in patientoriented healthcare (e.g., participants well-being) [29].

Quality assessment
Methodological quality of included studies was independently assessed by two reviewers (WF, WG) using a slightly modified version of the National Institutes of Health (NIH) quality assessment tool for pre-post studies without control group [30]. This tool was selected as all included studies were quasi-experimental studies with a pre-post design. none including a control group. Study quality could be rated as good, fair or poor. Any disagreement between reviewers was resolved by discussion and, where necessary, a third reviewer (LI) was consulted.

Results
The main literature search identified two studies specifically addressed the subject of cancer patients parenting minor children within their CST and five studies incorporated a brief family module within their CST. The first update added another two studies evaluating a CST for HCPs in oncology, including a brief module on family-specific aspects in cancer care. In total, nine studies were included in this review (Fig 1).

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Education for healthcare professionals caring for families with parental cancer: A systematic review Table 3 gives an overview of included studies. All included studies were published between 2008 and 2021. Five studies were conducted in the North America [31][32][33][34][35], two in Australia [23,36], one in Africa [37] and one in Europe [38]. Included studies used a quasi-experimental design with pre-post measurement only and no studies were identified including a controlgroup.
Detailed description of the CSTs, outcome measurements and results of the included studies are presented in Table 4.

Content and development of the CSTs including a child-or family-specific module
Of the nine studies included, only two included a CST for HCPs specifically addressing the subject of cancer patients parenting minor children [23,38]. The remaining seven studies incorporated a brief family module within their CST. This brief family module often entailed themes e.g., how to communicate with families of cancer patients [31,32,[35][36][37] or how to involve the family in cancer care [33,34]. Detailed information if and in which way the family modules refer to children as relatives in particular or if parental issues were covered was not reported within the studies.
Two studies [31,32] applied the COMSKIL training program [39] and four [33][34][35]37] the original or an adapted version of COMFORT TM SM Communication Curriculum [40], a CST specifically designed for nurses. Three studies developed their own CST program [23,36,38]. The description of the family module differed slightly between studies using the original

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Education for healthcare professionals caring for families with parental cancer: A systematic review

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Education for healthcare professionals caring for families with parental cancer: A systematic review

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Education for healthcare professionals caring for families with parental cancer: A systematic review  c.) After participation nurses were significantly more likely to report taking an active role in 'caring for myself emotionally and spiritually'. (Continued)

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Education for healthcare professionals caring for families with parental cancer: A systematic review

Didactic techniques/materials
All included studies combined various didactic techniques and materials within their training program. Role-play exercises with regular feedback were part of five studies [23,[31][32][33][34], roleplay exercises with simulated patients were incorporated in three studies [23,31,32]. All studies but the study using the e-learning [35] gave some kind of presentation (e.g., power-point introduction on training or overview of communication skills). Discussion rounds were part of the training in four studies [33,34,36,38] and videos e.g., to illustrate key skills or family needs included four studies [31][32][33]35]. Moreover, various studies used written material in form of manuals [23,36], booklets [31,32] or pocket-cards [34]. Five studies reported on professional background of CST facilitators [31-33, 36, 38], which varied greatly between studies (for details see Table 4).

Outcome measurement
Included studies varied considerably in defined outcomes and applied instruments (e.g., number of items, scales, description of adapted instruments). Most instruments have been selfdeveloped without validation (see Table 4 for details). Two studies applied Kirkpatrick's framework [29] for training evaluation, focusing on the first two levels: participant's reaction and learning [31,32]. Participants' satisfaction with the CST was assessed post-training participation. Five studies evaluated satisfaction using quantitative evaluation surveys [31-33, 36, 37] and two qualitative methods (e.g., open-ended questions [35]; focus groups [36]). Some studies assessed overall satisfaction with CST [33,36,37], others assessed satisfaction with individual sessions/ modules [31,32,37,38]. Overall, assessment of participants' satisfaction varied considerably.
Majority of studies (n = 8) included a pre-post participation assessment of self-efficacy and/or perceived confidence in communication competencies [23,[31][32][33][34][36][37][38]. Three studies analyzed change of HCPs' attitudes [23,33,35] (e.g., towards the importance of learned skills [33]), three studies analyzed change of HCPs' self-perceived communication behavior in daily practice [34,35,38] and three observed communication skills assessed through simulated patient assessments (SPAs) [23,31,32] pre-post training participation. Two studies measured change in perceived importance of communication [33,36]. Four studies assessed change of knowledge how to support parents and families [23,35,36,38], e.g., knowledge on palliative care [36] or retrospectively perceived increase of knowledge on supportive needs of parents and families [38]. HCPs' general health (burnout and perceived stress as secondary outcomes) [23] and patient-reported outcomes [34] (adapted version of the patient-family satisfaction with End-of-Live care survey (FEPC), a post-death survey for relatives originally developed by the Natioanl Hospice and Palliatve care Organization in Virginia, USA, however not available) were each reported in one study.

Evaluation of CST following Kirkpatrick's framework for training evaluation
Reaction-Participant's satisfaction with the training. Overall, participants' reaction to CST was predominantly positive. Participants rated the trainings beneficial for applying it to their daily practice [36,38], to increase their confidence [23] and would recommend it to their colleagues [36,38]. Reported suggestions were e.g., increasing group sharing exercises [36] or discussion/ exchange rounds to share their experiences with affected families [33].
Learning-Effects on participant's communication confidence, attitudes and knowledge. Statistically significant improvement on participants' self-reported self-efficacy in communication competencies were found in seven studies [23,31,32,34,[36][37][38] with considerable variation in defined outcomes and applied instruments (see Table 4 for details). One study did not report detailed statistic parameters [37]. Two of the three studies assessing participants' attitudes reported significant improvements over time [23,35]. Only one of the two studies assessing perceived importance of communication found significant improvements over time [36]. Regarding knowledge, three studies reported significant improvements over time [23,35,36], with one study missing clear and detailed statistic parameters [35].
Behavior-Participant's change in behavior. Of the three studies assessing daily communication behavior, only one study reported on significant changes, but did not provide statistic parameters [35]. Semple [23].
Results-other improvements in patient-oriented healthcare. One study assessed participants' general health using the General Health Questionnaire 28 (GHQ), the level of perceived stress (self-administered) and burnout with the Maslach Burnout Inventory (MBI) [23]. There were no significant changes in stress and burnout or level of perceived stress. Significant decrease in the somatic subscale of the GHQ was reported. Regarding the patient-reported outcomes measuring patient-family satisfaction with care no significant differences between pre-and posttraining scores were found [34].
Both studies specifically focusing their CST to provide support for cancer patients parenting minor children found significant changes within the pre-and post training assessment for multiple outcomes [23,38] (see Table 4).

Methodological quality assessment
The methodological quality of included studies was rated as "fair" in six [32][33][34][35][36]38], "poor" in two [31,37] and "good" in only one included study [23] (see Table 3). None of the included studies reported on a sample size calculation, the statistical methods of two studies were of poor reporting quality [31,37], the eligibility criteria for participants were only partly or not described in eight studies [23, 31-33, 35, 38], outcome measures were not or only partly reported in all studies, and only two studies reported on consistent delivery of intervention [23,38].

Discussion
This review aimed to provide an overview of existing CST interventions for HCPs in oncology explicitly addressing child-and parent-specific aspects in adult cancer care. Second, the review aimed to assess reported outcome measures associated with the CST's evaluation. The third aim was to report on CST effectiveness. Since only two studies were identified explicitly reporting on a CST solely focusing on parental cancer, we broadened our focus during the screening process to also include studies reporting on a family-specific module within their CST. Thus, in total, we included nine studies with at least one module on child-or family-specific aspects in communication in cancer care. The seven included studies including a family-specific module did not provide details what is included (e.g., parental-specific aspects during cancer care). Hence, it remains unclear if and to which extend children as relatives of cancer patients are explicitly addressed. Findings of the present work are consistent with previous research identifying a lack of communication skills trainings in oncological care especially for HCPs caring for patients experiencing additional burden and needs [41].
In our included studies, nurses represented a large proportion of participants with six studies including nurses only [23,[31][32][33][34][35] and two studies mainly including nurses [36,38]. This is not surprising as one frequently evaluated CST is the COMFORT curriculum explicitly developed for nurses [40]. As nurses spend a considerable amount of their working time caring for patients, developing a close relationship with their patients and relatives [42], they are often confronted with patient's specific needs and provide emotional support [43]. Additionally, shortage of nursing staff globally and a continuous physically and emotionally draining job [23,44] increase the need to enhance effective communication with patients and their families to reduce stress experience and emotional exhaustion in nursing profession [43,45,46].
Physicians usually are the key contact and person of trust for patients during cancer care [47]. Therefore, they can act as gatekeepers for additional support according to child-and family-related needs. However, in the included studies only few physicians participated.
Studies on child-and parental-related issues report lack of knowledge and specific communication skills as well as perceived limited competence on parental issues in clinicians in cancer care [10,11,21]. This strongly indicates a need for 1) specifically developed training programs for physicians and oncologists incorporating child-and parent-specific aspects or 2) optimization of access to existing interventions to improve participation of physicians, e.g., by including incentives or adapting trainings to their specific needs and working schedule.
Six of the included studies found significant improvements in either self-efficacy and/or confidence, behavior and knowledge for general communication skills, two additional studies for specific communication aspects in parental cancer. This implies that CSTs are a promising approach to improve HCPs communication skills including specific skills on parental cancer and support building a bridge to communicate effectively with affected parents and their families. This implication is supported by previous research, indicating increased self-efficacy, knowledge and skills [48] will in turn improve (a) HCP's communication behavior, (b) HCP's satisfaction with communication and their mental well-being health (e.g., reduced emotional burn-out) [25], and (c) outcomes for patients and their families (e.g., reduced stress and feelings of anxiety, improved satisfaction with care [26,49]). However, findings are not generalizable due to small sample sizes in most studies included in this review and only two included studies applying a specific CST on parental cancer.
The overall methodological quality of included studies was fair to poor. Applied outcome measures varied considerably and psychometric properties of measures were insufficient. However, validated and reliable tools assessing specific communication skills and behavior in child-and family-specific aspects in cancer care are rare [23,38,50]. Hence, there is a need for rigorously developed and psychometrically sound instruments. Moreover, objective simulated patient assessments (SPAs) should be included in future studies as they are the gold standard for evaluation of CSTs [51,52]. Clinical case vignettes, as used in one included study [23], have been found to be comparable to SPAs [52]. However, development of vignettes should be standardized and follow current recommendations [53].

Study limitations
This study has several limitations. First, this systematic review focused on CSTs with a specific module on child-or family specific aspects in cancer care. Though our search strategy was extensive, the articles reviewed may not represent all CSTs with such specific modules in cancer care given the restrictions of search terms used, databases searched and requirements for English-or German-language due to language restrictions of the authors. However, by including a thorough secondary literature search, additional relevant CSTs were included. Second, as included studies varied considerably in e.g., CST content and outcome assessment and tools used, comparison of CSTs and their quality of evidence is difficult and generalizability is impeded. Additionally, based on our quality assessment, only one study with good methodology design was included.

Clinical implications
Overall, implication for future research is to develop a structured and theory-based communication skills intervention for HCPs in oncology to improve family-centered cancer care, specifically when a parent has cancer [38,43]. Future studies should develop specific trainings to enhance HCPs communication skills, knowledge and self-efficacy to address child-and family-specific aspects when a parent has cancer. Also, these studies should provide an evaluation using state of the art methodology (e.g., including a control group thorough outcome assessment with validated, and pilot-tested outcome measurements based on e.g., Kirkpatrick's model of evaluation) [29,50]. Additionally, newly developed interventions should specifically address physicians and oncologists and if possible be adapted to their needs to increase participation of this specific HCP group. Existing studies including a family-specific module should provide further detail on the topic of "family communication", e.g., if minor children are included as family members [29,50].

Conclusion
This systematic review gives an overview of existing CSTs for HCPs on parenthood and cancer. Despite a high need for a specific CST to improve HCP's communication skills regarding parental cancer, only two CSTs focusing on parental cancer were identified, the remaining seven studies only included a brief module on family communication. The quality of evidence for included studies remains insufficient. Due to the lack of specific CSTs and poor or only fair quality of the included studies, further CSTs on aspects of parental cancer should be developed and evaluated rigorously.