Training interventions for healthcare providers offering group-based patient education. A scoping review.

OBJECTIVES
To provide overview of research on training interventions for healthcare providers aimed at promoting competencies in delivering group-based patient education.


METHODS
A systematic literature search identified relevant studies. Data was extracted on training details, study design, outcomes and experiences. Results were summarized and qualitative data analyzed using content analysis.


RESULTS
Twenty-seven studies exploring various training interventions were included. Ten studies used qualitative methods, eight quantitative and nine mixed methods. Use of a comparison group, validated instruments and follow-up measures was rare. Healthcare providers' reactions to training were mostly positive. Several studies indicated positive short-term effects on self-efficacy and knowledge. Results on observed skills and patient outcomes were inconclusive. Results on healthcare providers' experience of delivery of group-based patient education following training were categorized into 1) Benefits of training interventions, 2) Barriers to implementation and 3) Delivery support.


CONCLUSIONS
Further evaluation of training for healthcare providers delivering group-based patient education is needed before conclusions on training efficacy can be drawn. The results indicate an expanding research field still in maturation.


PRACTICE IMPLICATIONS
Efficacy studies evaluating theoretically grounded training with clear attention on group facilitation and follow-up support are needed. Inclusion of validated instruments and long-term outcomes is encouraged.


Introduction
Chronic conditions are a leading cause of disability and death worldwide [1,2]. Self-management, which is essential for people affected, refers to the individual's ability to manage symptoms, treatment, physical and psychosocial consequences and lifestyle changes that follow a chronic condition [1]. Healthcare providers (HCPs) play a key role in providing self-management support with patient education (PE) [3,4]. Patient education is the process of influencing patient behavior and generating the changes in knowledge, attitudes and skills needed to maintain or improve health [5]. Self-management support may include providing information, emotional support and assistance in lifestyle changes [6]. Patient education can be delivered individually and/or in a group and the formats have their different strengths. Group-based PE allows patients to develop self-efficacy in self-management by learning with and from each other [7,8]. Effectiveness and costeffectiveness of group-based programs on patient outcomes has been established for several conditions [4,9,10].
Healthcare providers' education competencies have been defined as "integration of professionalism, teaching, and empowering in the co-creation of knowledge and skills to achieve behavioral change" [11]. To provide effective PE in groups, HCPs also need to handle the added complexity of the group element and manage the group as a whole [12]; HCPs must balance didactic, experiential and interactive elements in a way that facilitates sharing of knowledge and experiences, and tailor content to suit group member needs [13]. Succeeding with this may require changes in mindset, knowledge and skills.
Observations of and reports by HCPs indicate lack of training in group-based PE, specifically in the theory behind PE and skills related to group enablement and self-management support such as goal setting [14][15][16][17][18]. Healthcare providers' unmet learning needs and lack of competence is concerning since it may lead to PE being disseminated with sub-optimal quality, thus compromising effectiveness [14,16].
Several recent reviews have studied the outcome of training to promote PE competencies on HCPs' knowledge, confidence, skills or performance when providing PE in practice. They suggest that important training elements include a clear theoretical framework, experiential learning with feedback, reflection, interactivity and follow-up [19][20][21]. Those reviews explore training in PE without specific attention to the group format. Given the importance of skills in group-based PE, dissemination of research on grouptargeted training is warranted. The aim of this study is to give an overview of training for HCPs in providing PE in groups and the potential impact on HCPs competencies.
The following questions are addressed: 1. What study designs, outcomes and measures are described? 2. What kinds of training interventions are described? 3. What outcomes and experiences are associated with participating in the training?

Methods
Preliminary searches indicated a limited number of relevant studies and a scoping review method was therefore chosen to draw evidence from different study designs, beneficial in an emerging field [22]. This review was guided by a five-stage framework [22].

Stage 1
A study group was assembled and initial research questions defined. The group consisted of seven PE researchers and two HCPs experienced in group-based PE and in training HCPs.

Stage 2
A systematic search was conducted by a medical research librarian. The following electronic databases were searched: MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), ERIC (Ovid), AMED (Ovid), CINAHL (EBSCO), SveMed + and Cochrane Library (Wiley). Searches included subject headings and text words with synonyms for 1) HCPs, 2) training, 3) PE, 4) professional competence and 5) group. Studies were included if they: involved training in group-based PE, described training aimed at HCPs, reported outcomes associated with HCPs' competencies, were published between January 2000 and February 2019, were in English, Danish, Norwegian or Swedish and reported primary research (see Appendix A in Supplementary material). Some criteria were adjusted during the early screening process. First, training in recovery-oriented approaches was excluded since recent reviews exist [23,24]. Second, studies where the PE was defined as therapy were excluded as this was considered beyond the scope of this review. Lastly, studies describing tools for groupbased programs, but not training in using them, were excluded. After eliminating duplicates, we removed obviously irrelevant studies based on titles.

Stage 3
Two authors independently screened the remaining abstracts. Full-text articles were screened independently by two authors. Disagreement was resolved by a discussion between authors. To identify as many relevant studies as possible, a snowballing search was performed by searching reference lists and references citing the included studies. At this point we included studies published after our original search timeframe. If titles were considered relevant the abstract was read and when found relevant, two authors independently screened the full-text.

Stage 4
Following data was extracted: 1) characteristics of the training (aim, theoretical background, key content, training methods, duration and trainers), 2) HCPs' characteristics and setting, 3) Patient population and type of PE and 4) Study design, methods, sample size and key results.

Stage 5
Key study results were summarized. To map the impact of training we used the four-level model of Kirkpatrick (1996), widely used for appraisal of evidence of training [25]. Hence, the outcomes were categorized as: 1) reactions to training; 2) learning (acquired attitudes, knowledge and/or skills) and 3) behavior (ability to apply knowledge and skills in practice), and 4) results (patient outcomes). To document results from qualitative studies in greater detail, a category on "experiences of delivery" was included containing HCPs' (participating in training) experiences of group-based PE. This data was analyzed by two authors with an inductive conventional content analysis approach [26]. They read the results sections of the relevant qualitative studies and identified preliminary themes. Preliminary themes were discussed, adjusted and finally broad themes were agreed upon by the research group. The quality of the included studies was assessed independently by two authors using the Mixed methods appraisal tool (MMAT) [27]. Disagreements were resolved in discussion between the two authors.

Screening process
The search identified 9681 records, 6560 of which were unique. Removal of irrelevant titles left 3941 records. Abstract screening eliminated all but 242 studies, of which 82 were only available in abstract form. Of the remaining 160 studies, 146 were excluded, most frequently because: 1) the training did not involve group format, 2) not primary research or 3) HCPs outcomes not included. Snowballing gave 13 additional studies, resulting in 27 studies being included in the review. The selection process is shown in Fig. 1.

Methodological quality
All the qualitative studies were found to be of high methodological quality. The quantitative studies were mostly of high quality but a few omitted relevant information. The quality of the mixed methods studies was varied; several were unclear about methodological aspects related to the qualitative and/or quantitative approach. Quality assessment results are provided in Appendix A in Supplementary material.
The training involved different methods with lectures and group discussions most commonly mentioned. Sixteen studies reported experiential learning with role-play [31][32][33][37][38][39][41][42][43][47][48][49][51][52][53][54] and three experiential learning with patients under supervision [31,36,38]. Thirteen studies reported training in application of different forms of educational tools such as dialogue or reflection prompts [29,32,34,35,39,40,42,46,49,[51][52][53][54]. Five studies used educational tools as a key feature of the training [29,39,40,51,52]. Also, twelve studies specified a component on group facilitation [   Aim: Improve competencies in delivery of a group-based program ("Self-management of osteoarthritis and low back pain through activity and skills"; SOLAS) Background & content: Overview of program, education content for each week, self-determination theory-based communicaiton strategies, exercises and their mode of delivery, practicalities of program delivery. Based on a face-to-face training program (see [42]) Training methods: e-learning (based on a collaborative learning environment and gamification principles) with lectures, peer role modeling, self-reflections (including knowledge assessments), experiential learning with feedback Duration: HCPs were encouraged to complete the training over a 4-week period Trainers: Trainers within the e-learning program not clearly reported Physiotherapists; primary care setting People with osteoarthritis or low back pain; group-based self-management program (6 sessions) Keogh; 2018 [42] Aim: Improve competencies in delivery of a group-based program (SOLAS) Background & content: Training in the content and delivery of SOLAS, training in 9 self-determination theory based communication strategies (e.g. offer meaningful rationale for the behavior, provide opportunity for input and choice to patients; use support and encouragement rather than pressurizing behavior; collaborative goal setting, action planning and problem solving; provide positive, information-rich feedback)  Training interventions had different aims. Most trainings provided some information on PE framework such as cognitive behavioral approach, psychoeducation, empowerment, self-determination theory or person-centeredness. Most interventions included components about conditions, self-management and/or goal setting and behavior change. Four studies [32,34,37,54] explored interventions aiming to improve HCPs' skills in both group-based and individual PE.

Target group and setting
The studies included different HCP populations. Thirteen comprised interprofessional training, of which two also included people with chronic illness experience [37,44]. Amongst singleprofession interventions, six involved physiotherapists [30,34,42,43,48,54] and two concerned nurses [38,49]. HCPs were recruited from various settings, mostly outpatient settings. Three studies targeted inpatient psychiatric settings [38,45,49]. The HCPs were generally experienced professionals. However, 14 of the studies did not specify prior group-based training or work experience. Among studies providing such information, nine reported little or no experience. Only two studies reported high level of prior experience or training in group-based PE [36,48].
Nine studies focused on facilitating HCPs' skills in PE for adults, one for adolescents and children [50] and another for both adults and adolescents [45]. Target age group was not specified in the other studies. Most training aimed at improving competencies in PE for people with a specific condition. Six programs were designed for people with chronic pain and/or rheumatic illness [31,34,42,43,48,54], three targeted people with diabetes [28,35,50] and two were for people with cancer [32,36]. Four trainings involved generic PE [29,37,51,52].

Reactions to training
The results of the studies are presented in Table 3. Fifteen studies reported on reactions to the training with study-specific measures or interviews [30,31,33,[35][36][37]41,42,44,[46][47][48]50,52,54]. All reported some positive reactions by the HCPs. High satisfaction with the training in general was reported in eight studies [33,36,42,44,46,48,50,54]. In several studies, HCPs emphasized the importance of practicing skills and feedback [31,33,36,48]. Experiential learning was described as necessary and exciting yet simultaneously uncomfortable and even "daunting" [31]. The flexibility and long-term accessibility of e-learning training was appreciated [30,34] but the lack of interactivity and skill practice was perceived as a challenge [30,54]. The one study comparing elearning with workshop training found high satisfaction with both training formats but higher among workshop participants [54]. In another study the HCPs appreciated the opportunity to reflect, learn and share experiences with colleagues and patient  Training material was found easy to understand and useful.
Knowledge of hypertension improved from baseline (64%) to post-training (76%), and further at the 3-month follow-up (after delivery) (84%) However, only one of three settings showed significant improvement.
Self-management support was delivered effectively based on observation.

Adolfsson; 2004 [28]
The main results showed a conflict in roles. The HCPs knew their role in the traditional educational approach but not the empowerment approach, which they needed to grow into. At the same time as they started a new way of working, their role had changed from being an expert to being a facilitator. As experts they felt secure; as facilitators they needed support. Andersen; 2014 [29] Experience & behavior reported together: HCPs found it difficult to include disease-specific knowledge when working with a flexible patientcentered approach. They tended to stay in the role they found most comfortable during education sessions (most often that of embracer), rather than adopting new and more challenging PE roles. The HCPs theoretically understood the role of facilitator, but they did not know how to perform in this role in practice. The ability to juggle all educator roles depended on the ability to master each. In general facilitation of group dialogue was seen as a huge challenge. The model was a helpful tool in terms of improving educator awareness of more or less successful performance. Brooks; 2012 [39] Majority (82%) agreed on feeling more confident in leading groups after using the toolkit. Improvement in content adherence on "coping with craving" and "drug refusal skills". HCPs skillfulness, already in the adequate-to-average range at baseline, did not change. Self-reported use of educational/teaching aids increased from use in 71% of group to 91% following training.
Experience of delivery/using tool: High levels of satisfaction with the toolkit run groups and satisfaction with curriculum's ease of use. Majority (94%) agreed that the toolkit helped them conduct better groups. All felt the toolkit helped them lead successful groups and that it met their needs when leading groups. About a third (30%) agreed on needing to spend a lot of time learning the toolkit material before using it effectively in groups. Brooks; 2013 [40] Moderate or large baseline to post-training effect sizes for HCPs' adherence to toolkit content were identified for 13 of 21 targeted behaviors with the largest gains on items measuring active skill practice. Post-training adherence gains were largely maintained at the 6-month follow-up. There were no significant differences in posttraining or follow-up adherence on modules which received direct training versus modules which HCPs self-taught. No improvements in competence. Burlingame; 2002 [45] Improved group interaction in the adult sample, no difference between groups in the adolescent sample. Burlingame; 2007 [38] Limited support for the superiority of the workshop compared to manual only. No difference between workshop only and workshop with supervision. Improvements in knowledge of running groups was not maintained at a 5-month follow-up. Christou; 2019 [30] Reactions and experiences Four main themes: 1) Flexibility but lack of interactivity 2) Cognitive behavioral approach is a new way of working 3) Facilitating group work after i-BeST training 4) The need for managerial support The flexibility of the training was perceived as a major advantage. However, lack of interactivity was identified by most HCPs as the biggest challenge. HCPs found the online training to be acceptable for attaining knowledge but not adequate for developing skills. HCPs reported applying key principles of the cognitive behavioral approach within routine practice, but were reluctant to refer into the group-based PE. Coordination of implementation of the group PE throughout a large trust was perceived as necessary, including sufficient staff training for all HCPs. Cooper; 2019 [47] 71% intended to conduct more PE groups in the future, 13% were unsure and 3% reported not intending to (13% without a reply).
Increased self-efficacy in skills required for delivering problem-solving training.
Most responses to a question about important factors in sustaining problem-solving training cited the availability of referrals or ease of patient recruitment and support from leadership and other staff members. Dures; 2019 [31] Reactions and experiences reported together: 1) "Exciting but daunting" reflected the mixture of excitement and anxiety in training and delivery 2) "Skills practice and demonstrations were essential" captured the value of learning and practicing together, even though the process could be uncomfortable. Feedback was found invaluable 3) "An individual approach to a standardized intervention" showed how tutors negotiated adherence to the manual with delivery using their own words 4) "Becoming a better practitioner" described how training enhanced wider clinical practice 5) "Pragmatic and flexible" highlighted practical adaptations to facilitate training and intervention roll out. Hammond; 2005 [41] 87% stated that the training had influenced their delivery of group programs "in some way".
Behavior (self-reported): 53% had integrated some of the PE approaches into their multidisciplinary group arthritis education programs. Of the 48 respondents, 45 subsequently changed individual PE practice, 13 implemented the group program, 25 contemplated doing so and 10 did not. The barriers to change were limited staffing, access to facilities, time to make practice changes, funding for program costs and clinical time to deliver the program. Hurley; 2019 [48] HCPs were very satisfied with the training and completed it within 3-4 weeks (mean hours spent 9.1, SD 3.3). The most commonly cited positive Improvement in confidence and knowledge of all components of the group PE.

Behavior (self-reported and observations):
The fidelity scores were high, based on self-report, for content delivery. The program was delivered in  a "needs supportive manner", based on observation.
Keogh; 2018 [42] The HCPs were very satisfied with the training. The confidence in self-determination theory-based communication strategies and knowledge of some intervention content components significantly improved.
HCPs delivered the program in a "needs-supportive manner". However, goal setting was delivered below acceptable levels by all HCPs.
Keogh; 2018 [43] Behavior: The HCPs delivered a mean 20.5 behavioral change techniques per class (range 64.9-72.4% of 31 techniques). Of these, 17 techniques were fully delivered in each class representing moderate fidelity to the protocol (53.5-59.3%). A further 3.5 techniques were partially delivered. Techniques associated with "goals and planning" were often poorly delivered. Matsuda; 2015 [49] Increase in knowledge, self-efficacy and attitude, but not in skills Knowledge was gained through better understanding of basics (e.g. "understanding of basics of how to respond"), self-efficacy was expressed with some uncertainty (e.g. "I worry whether I can do it well") and motivation to improve skills was described (e.g. "I want to improve my nursing"). Parahoo; 2017 [32] Behavior and experience reported together: Themes: 1) Difficulties to keep to the structure of the intervention 2) Selective coverage of topics 3) Partner participation 4) Overall impression of the group and telephone session 5) Perceived benefits to participants Issues such as not keeping to the aim of the intervention, deviating from the content and/or reluctance in discussing sensitive issues such as sexual health were reported. The co-facilitator reported that the extent to which the HCPs followed the protocol varied greatly. Difficulties in implementing the behavioral components such as meeting behavioral targets and achieving them. Peters; 2019 [33] HCPs described that they had found the training especially inspiring because it incorporated nondidactic learning approach and discussion opportunity between HCPs with different backgrounds. HCPs suggested that future training should add advice and practice around how to better manage group dynamics.
Two themes: 1) "Reciprocity" showed how the HCPs were trained to deliver the program, then reciprocated in the program delivery as active participants, which then provided feeling of personal reward and expansion of their usual practice; 2) "Enhancements", encompassed suggested directions for future training and deliveries of the program. Richmond; 2016 [54] Interviews highlighted that while initially skeptical, HCPs found the online training acceptable. A number of strategies were identified to enhance future versions of the e-learning program such as including more skills practice. The workshop training received higher satisfaction Similar scores on knowledge and self-efficacy to deliver the majority of the program. The workshop group showed greater reduction in biomedical attitudes to low back pain management.
Clinical skills were similar between the intervention groups. 34% of the HCPs delivered the program in their practice (no difference between training modes). ratings than the e-learning training. The majority of the e-learning users were "satisfied" and the majority of workshop participants were "very satisfied". Richmond; 2018 [34] Three themes: 1) Anxieties about using a cognitive behavioral approach. It is different (using an exploratory questioning approach, using a facilitative therapeutic style, the contrast in content to their usual practice); it is not what patients expect; anxiety could be reduced 2) Experiences of implementing a cognitive behavioral approach. Difficulty identifying the right patients; surprisingly positive outcomes 3) Sustainability for future implementation of a cognitive behavioral approach. It is needed; Change is needed for it to happen. Sanchez; 2017 [53] Increased knowledge, confidence and skills in facilitating hearing education and peer-support groups. Sawtell; 2015 [50] Most HCPs thought the training was very good, motivating and comprehensive.

Experience and behavior reported together:
HCPs found organizing the groups burdensome in terms of arranging suitable dates/times and satisfactory group composition. Some HCPs also reported difficulties in mastering the psychological techniques.
Oservations and HCPs feedback indicated that the HCPs generally delivered activities as described in the manual. However, less time than was recommended was spent on some key exercises due to HCPs finding them difficult to deliver and/or not well received by groups. Also, while observations and HCPs feedback showed that fidelity of psychological techniques was good across sessions in half the sites, it was not optimal in the remainder. Difficulties in delivering the intervention particularly occurred when sessions had groups with members with a wide age range or few group members. Only 68% of possible groups were run. Stenov; 2019 [60] Reactions (based on observation) HCPs were very engaged in the training and considered themselves highly ready to change and agreed with the theoretical principle related to facilitating group-based, person-centered diabetes self-management education.

Experiences and behavior:
Three themes: 1) Increased awareness but implementation challenges remain (Some HCPs chose not to implement the methods because they conflicted with their practice relying on the biomedical model) 2) Readiness to change but unable to facilitate and create clearness (Other incorporated some approaches but was unable to structure the process, leaving patients uncertain about the aim) 3) Content and process tailored to the needs of group participants (One setting succeeded with implementation, tailoring content and process to patients' needs) Stephen; 2011 [36] Reactions and experiences reported together:  3) Overcoming challenges with adapted skills Counsellors described components of their experiential learning: co-facilitating online cancer support groups with an expert, debriefing online, and participating in an online peer supervision group, as critical to their becoming engaged. Despite initial challenges, the counsellors learned new skills, and adapted known clinical skills, to the text-only environment. Torenholt; 2015 [51] Experiences and behavior reported together: When HCPs rated the tools on a 1À10 scale (10 = optimal score) the mean score was 7.9 (SD = 1.1).
HCPs emphasized the applicability of the toolkit, and between 69% and 82% reported that the toolkit supported them in facilitating person-centered education and active involvement to a high or very high degree. Most (81%) reported that they would like to apply the toolkit again in future education to a high or very high degree. A quarter of the HCPs found it challenging to both focus on all participants and simultaneously support individuals. Five categories of educator experiences were identified: interaction and activity; personcenteredness; group dynamics and synergy; openness; and light and cheerful atmosphere. HCPs talked significantly less in situations where the toolkit was applied. Tveiten; 2016 [37] Reactions and experiences reported together: Three themes 1) Anticipation and interaction between theory and practice (adequate and motivating information about the training beforehand; organization and delivery allows for reflection and sharing of experience; variations and correlations between theoretical part of the training and own clinical practice; relevant themes) 2) Interdisciplinarity and patients' voice with meta-perspective (interdisciplinarity and patient involvement; qualified patient representatives and emphasis on the user) 3) Awareness and appreciation of the abilities that contribute to change in practice (increased understanding and awareness and improved skills; changes in own practice). Turner; 2014 [44] Satisfaction with the training was rated high (mean 9.3 of maximum score of 10). Improvement in self-efficacy.
Varming; 2018 [52] Most HCPs were satisfied with the training content and delivery. They highlighted the importance of practicing the new approach and tools before applying them in practice. Some felt that there was too little time to practice and discuss the approach during the training. Some would have preferred all nine tools to be introduced and practiced.

Experiences and behavior reported together:
HCPs had a positive response to the approach and found that the tools supported involving participants in education and support. The tools provided time for reflection in the PE that benefited patients and HCPs alike. HCPs found it challenging to allow patients to help set the agenda and to exchange experiences without educator control. representatives [37]. In one study HCPs appreciated that the training mirrored the teaching methods they were learning and would be applying in the PE programs [33]. Similarly, in another study HCPs showed engagement in self-assessing strengths and areas in need of professional development, mirroring the personcentered PE approach they were being trained in [35]. Suggestions for improvements included: more training in group facilitation; observations of PE being delivered by experienced HCPs; clinical supervision; mentoring; reduced time between training and offering PE; disease-specific training; training within clinic time; and involvement of the wider clinical team [31,33,50].
When comparing improvement in knowledge between training formats, limited support was found for workshop being superior to manual only. No differences were detected between workshop only and workshop with supervision [45]. Similar results were reported on knowledge and self-efficacy between e-learning and workshop groups [54]. Improvement in skills based on observation during training was reported in one study [53] and no improvement in skills was documented in another [49].
Two studies showed improvement in adherence to content [39] or behavior change techniques [40], with maintained improvement at six-month follow-up [40]. Neither study found improvement in skills but the HCPs were at an adequate-to-average level at baseline [39,40]. Two studies reported HCPs being able to deliver the PE in a person-centered way reflecting skills in communication [42,48]. Another study showed moderate fidelity to a protocol [43]. Goal setting support skills were categorized as suboptimal for one sample of HCPs in two studies [42,43]. A study comparing elearning with workshop training, found no between-group differences in skills [54]. One study showed that HCPs talked less in groups where an educational toolkit was applied [51]. Limited support was found for improved group facilitation skills in PE for adults (but not adolescents) when comparing trained versus untrained HCPs [45].
Seven studies applied qualitative methods during observations [29,32,35,46,48,[50][51][52]. One reported on observation separately and concluded that PE was delivered effectively [46]. The six other studies combined observational data with interview data when presenting the results. In one, implementation success varied between HCPs and/or settings, ranging from successfully adapting to the new approach, to finding it incompatible with current practice [35]. Another study found that although HCPs generally followed a manual, they delivered some types of PE, e.g. psychological support, suboptimally [50] and one found HCPs struggling to shift from providing an empathic environment to promoting active group participation and behavior change [29].
Two studies reported implementation statistics following training. In one study where 34% of the HCPs delivered a group program following the training, no difference was found between HCPs trained via e-learning or workshop [54]. In another study, part of a clinical trial, only 68% of possible PE groups were run [50].

Results on patient outcomes
Three studies reported on patient outcomes [38,45,47]. One study in an adolescent sample showed no difference between a training intervention group and a control condition without training. However, in the same study, adults whose HCPs had received training showed greater improvement in symptoms of anxiety and depression [45]. Another study showed no difference on patient outcomes between different training formats [38]. In a study with a single-group design, improvements were found on all patient outcomes (e.g. distress and coping) [47]. Six studies were part of larger trials and patient outcomes may be published elsewhere [31,32,42,43,46,50].

Benefits of training interventions.
In several studies HCPs described gains in confidence and skills after putting time and effort into preparation and practice. Some studies described how HCPs experienced the training and delivery of groups as making them better practitioners, not only when working with groups but also in their wider clinical practice [30,31,33]. They described becoming better at supporting self-management, communicating and looking at the patient holistically [30,31,33,37]. Participants recounted how, in their training for this program, they had learnt through modeling and practice, to build an inclusive atmosphere that would allow program attendees to feel acknowledged as individuals with their own rich and personal experiences, and therefore expertise [33, p. 2794].
Acquired skills in group facilitation were described in three studies [33,35,36]. In one, HCPs described having learned to step back and allow patients to help one another identify useful knowledge and self-management strategies [33]. Another study described using open-ended questions to facilitate reflection and allow group discussion where patients could share experiences, needs and concerns. This involved mastering group and individual level interventions simultaneously by making space for selfreflection and group discussions [35]. Experienced HCPs trained in delivering online PE described adapting group facilitation skills to the online written format [36]. Several studies described how the HCPs felt rewarded by seeing the positive changes in group participants [33,34,36].

Barriers to implementation.
Healthcare providers identified several barriers when implementing group-based PE. A major barrier was HCPs' lack of experience and skills in the new role. The group format was often experienced as highly different from the PE in their daily practice. HCPs described being more accustomed to providing advice and recommendations than using a communication style that promoted person-centeredness and empowerment [28,29,32,33,35,51] or a cognitive behavioral approach [31,34]. Some struggled to adapt their usual educational style to the new approach, finding it easy to fall back into the traditional approach, for example reverting to counselling mode or using PowerPoint presentations without much patient engagement [28,29].
In some studies HCPs reported that the patient-centered approach was also new to the patients and not necessarily what the patients expected and wanted [28,34,52]. Although many HCPs were highly motivated and theoretically well informed prior to implementation [28,29,31,35] some were also ambivalent about allowing patients to "take the center stage" [52]. As described in one study: The intervention required a way of working which was "completely unfamiliar territory" [31, p. 3].
Specifically, challenges with group facilitation were described in various studies [28][29][30]35]. Facilitating group dialogue was seen as a huge challenge, causing nervousness and even being "terrifying" due to lack of confidence and skills [30]. Difficulties with delivering sections on goal setting were also evident [28,29,32,35]. Other difficulties included maintaining the structure of the PE [32,35], conveying disease-specific knowledge using newly learned communication skills [28,29] and mastering psychological strategies [50].
3.4.5.3. Delivery support. The third theme concerns factors that support the delivery of group-based PE. The HCPs described how nervousness could be reduced and skills improved with practice and preparation. Access to online training material and manuals was perceived as helpful and so was working in pairs with another group facilitator [31,32,52].
In the two studies exploring experiences of using educational dialogue tools, the HCPs report mostly positive experiences even though the tools did not fit within all planned group sessions [51,52]. The tools were found to promote positive group dynamics, as described in the following excerpt: In response to open-ended questions, educators reported that the tools created room for participants to tell their stories, which enabled other participants to comment and elaborate, and that the tools ensured that the participants' perspective formed a clear starting point [51, p. 528].
A need for continuous support and supervision was described including more support from trainers during delivery, peer collaboration, feedback on performance and clinical supervision [28][29][30]33,34,47,52]. Time for administrative work and preparation was also reported as important for implemenation [34,47,50,52].

Discussion
This scoping review identified 27 studies on training for HCPs offering group-based PE published between 2002 and 2019. The results show a research field expanding in terms of both publication numbers and methodological approaches. HCPs' reactions to the training are generally positive. This is vital to ensuring HCPs' engagement, though the correlations between reactions to training interventions and skill-building may not be strong [55]. Several studies indicated positive short-term effects on learning outcomes, such as self-efficacy and knowledge. Findings on observed skills were mixed and the three studies that reported patient outcomes were inconclusive. Study-specific outcome measures were used in most studies; only a few used validated instruments and information on psychometric properties was generally lacking. Notably, only one validated self-report instrument on learning outcomes was used in more than one study. Use of validated instruments that specifically address selfefficacy in PE might be considered, such as the "Self-Efficacy and Performance in Self-Management Support" instrument [56].
The results on training efficacy should be interpreted with caution since a single group design was most common; only three studies included a control condition [38,45,54]; thereof one with randomization [54]. Only two studies included follow-up measures [38,46]. These results indicate a field still to mature. More research including longitudinal efficacy design and behavioral outcomes is clearly needed on training in both group-focused and individual PE [19].
Clear descriptions of interventions are essential to allow replication and comparison between studies [57,58]. Improved quality in descriptions of training for HCPs has been called for and criteria for describing development and evaluation of such training (CRe-DEPTH) have recently been suggested [57]. Available guidelines on reporting educational interventions to enhance HCPs' competencies are often content-and didactic method-specific [57]. CRe-DEPTH criteria are, however, broadly applicable, being generic in character while preserving flexibility to integrate different content and didactic methods. Although the majority of the studies included in this review reported on most of the items in CRe-DEPTH, the amount of detail provided varied considerably. Information on the theory underlying PE was usually given (frequently a person-based or cognitive behavioral approach) but the amount of detail varied substantially. Like all complex interventions, training in PE should be based on a clear theoretical framework [19,58]. The theoretical framework for the training itself was often not explicitly stated but the variety of training methods suggest use of different learning theories. The most frequently mentioned training methods were lectures, experiential learning with role-play, discussions, educational tools and manuals. Tailoring of the training was indicated by the use of methods such as discussions and experiential learning with feedback: most of the interventions included discussions and over half included some level of experiential training. This is promising, as tailoring is important for effectiveness [58], and practice with feedback has proven essential in teaching HCPs how to support their patients' self-management [19]. Training duration varied from three hours to five days. Only a minority [28,36,38,45,47,52] of the training interventions included follow-up. Thus, an essential training component was commonly lacking, as prolonged training has been identified as important in communication training for HCPs in general [59] and for competencies in PE [19]. Few trainings included clinical supervision [31,36,38], which provides an essential learning opportunity supporting implementation of skills into clinical practice [19,59]. This echos our qualitative findings concerning the HCP's perceived need for continuous post-training supervision and support [28][29][30]33,34,47,52].
A component on group facilitation training was commonly not specified. However, since experiential training and training in use of educational tools may have provided training in group facilitation this can be viewed as included in majority of the studies. In the remaining studies, lack of detailed training descriptions might explain this, but it could also indicate a lack of attention to group facilitation in some of the trainings. The latter could explain why HCPs described challenges and perceived a lack of skills related to facilitating groups. Such skills are essential to be able to promote person-centeredness, empower group members to see themselves as experts and share their experience with others, and prevent the passive role of student often seen in traditional didactic teaching [16,28,60]. It has even been indicated that the group process during PE might be more important for patient outcomes than the content of the PE program [61]. Despite decades-long agreement on person-centeredness and empowerment as vital in PE, HCPs still struggle with this approach [62], not least when working with groups [16,28,60]. This is also evident in our results from the qualitative studies on post-training experiences. Healthcare providers described having acquired important skills which improved their practice but also described challenges with taking on a different role as an educator, adapting to a personcentered communication style and group facilitation. This accords with a previous review concluding that change in clinical practice is not an automatic outcome of PE training and that proactively addressing contextual barriers may be necessary to support implementation [20].
Several studies that included training in use of educational tools such as dialogue prompts to promote active participation suggest that such tools may be useful. Our findings indicate potential for improved training in group facilitation and we encourage further exploration of tools for use during PE. The same goes for e-learning and tools supporting HCPs' awareness of their communication style, such as a validated self-assessment aiming to stimulate use of motivational interaction style [63].
Information on trainers and training development was unclear or lacking in several studies. Only one study mentioned involvement of patient representatives during training [37]. This is of interest as involving patient representatives during planning, delivery and evaluation of PE is increasingly considered essential for quality improvement in person-centered healthcare [64].
Several limitations and strengths of this review should be considered. We acknowledge that PE is a broad term and studies exploring training with a focus on overlapping topics such as clinical communication or recovery-based training were not included, as these have been reviewed elsewhere (e.g. [23,65]). For practical reasons, we decided to include training in delivery of PE grounded in cognitive behavioral theories but not those where the intervention was labelled therapy. This may have led to some relevant training being excluded. The snowballing method resulted in a considerable proportion of the included studies. This might indicate a potential for improvement in our original search strategy, but might also be considered a strength, as it complemented the original search. The inclusion of multiple HCP professions is an advantage, as PE is ideally provided by a multidisciplinary team and the results expand on reviews focusing on single professions, such as nurses [19]. Only the first author extracted the data but uncertainties were discussed with the second and last authors. We reported on 11 of the 13 recently proposed CRe-DEPTH criteria. Systematic inclusion of information on the two remaining criteria (educational resources and tailoring of training) would have further strengthened this review. However these criteria were addressed indirectly with information on educational material and tailoring embedded in our description of training methods. Reporting on the amount of detail in training descriptions, as suggested by the authors of CRe-DEPTH, would also have enhanced our results. In addition, we decided to place HCPs post-training experiences from the qualitative studies in a separate category, which allowed us to elaborate on barriers to and facilitators of implementing knowledge and skills but a detailed account of the results was beyond the scope of this review. Finally, we found the scoping review method suitable for our task, allowing inclusion of studies with different designs. We included a general evaluation of methodology but a scoping review does not aim to provide a rigorous quality assessment [22]. We acknowledge that although the quality of the qualitative studies was categorized as high with MMAT, a more specific instrument might have revealed added granularity on the quality, such as risk of primary study author bias.

Conclusion
This review includes 27 studies exploring training for HCPs aiming to promote competencies in group-based PE. The results show an expanding research field still in maturation. Firstly, the studies describe a wide variety of training. Duration ranged from three hours to five days and a minority included follow-up. Lectures and group discussions were the most commonly included training methods; more than half involved experiential learning, and use of educational tools was common. Secondly, many studies did not clearly describe the theoretical framework for the training or the training in group facilitation. More evaluations are therefore needed on theoretically grounded training with clear attention to training in group facilitation and continuous supervision and support. Thirdly, use of a comparison group, validated instruments and follow-up measures was rare. The results imply that HCPs generally react positively to participating in training. Several studies indicate positive short-term effects on self-efficacy and knowledge but findings on observed skills and patient outcomes were mixed. Qualitative findings of HCPs' experiences of PE following training involved benefits of the training but also barriers to making changes in practice due to perceived lack of skills in a new educator role, specifically regarding group facilitation. They suggested facilitating factors such as continuous support and clinical supervision. This review shows that further evaluations on training for HCPs providing group-based PE is needed before conclusions on training efficacy can be made. The use of the CRe-DEPTH is recommended in reporting to further advance the field.

Practice implications
Positive reactions and indications of positive short-term effects of training interventions could inspire HCPs in developing and evaluating training for HCPs offering PE in groups. However, this review shows that further evaluation of training for HCPs providing group-based PE is needed to draw conclusions about training efficacy. Future evaluations should focus on theoretically grounded training with emphasis on group facilitation, continuous supervision and support. Inclusion of comparison group, validated instruments and follow-up measures is encouraged.

Funding details
This study was funded by the Norwegian National Advisory Unit on Learning and Mastery in Health at Oslo University Hospital.

Declaration of Competing Interest
There are no conflicts of interest to declare.