Microcounseling in Japanese Nursing Education: A Narrative Review of Communication Skill Acquisition and Educational Implications

Abstract

Introduction

Communication competence is a core nursing competency, yet effective pedagogical approaches for systematic skill development remain underexplored in many cultural contexts. Microcounseling, developed by Allen Ivey in the 1960s, offers a structured framework for teaching discrete interviewing skills through modeling, practice, and feedback. It has been applied in Japanese nursing education since the 1980s, yet this nearly four-decade literature has not previously been synthesized.

Purpose

This narrative review synthesized research on microcounseling among Japanese nursing students, examining factor structures, skill acquisition patterns, and educational implications, to identify principles potentially useful for international nursing education.

Methods

A search of five databases and hand searching identified 33 records; after duplicate removal and screening, 10 studies met inclusion criteria, spanning 1988 to 2024. Findings were combined using narrative synthesis procedures structured by the Synthesis Without Meta-analysis (SWiM) guideline.

Results

Factor analyses consistently extracted four skill dimensions mapping onto Ivey’s three-tier hierarchy—attending, reflection, and influencing skills—demonstrating structural stability over more than 25 years. Acquisition was differential: questioning techniques improved with brief training, while reflection skills required extended practice; attending behaviors were learned readily but showed developmental fluctuation across the curriculum. A notable “confidence inversion” emerged, with higher self-efficacy reported for influencing than for reflection skills, despite the microskills hierarchy positioning reflection as foundational. Attending behaviors followed a U-shaped trajectory, with second-year students showing decreased confidence after initial clinical exposure, while reflection and influencing-behavior skills increased significantly between second and fourth years. Online learning environments may selectively constrain reflection skill development.

Conclusion

Within the limits of a small, single-country evidence base, these findings suggest principles that may inform nursing curricula: graduated skill introduction, explicit emphasis on listening foundations, and targeted support during early clinical experiences. Cross-cultural validation studies remain needed.

Keywords

microcounseling nursing students communication skills nursing education therapeutic communication skill acquisition Japan narrative review

Introduction

Communication competence is a universally recognized core competency in professional nursing. The World Health Organization (2020), the International Council of Nurses (2020), and the American Association of Colleges of Nursing (2021) have each emphasized communication as central to nursing practice. Wit et al. (2023) identified communication and collaboration as one of ten common competencies across nursing frameworks in five countries. These convergent findings underscore communication as a universal professional requirement that transcends national boundaries.

Despite this consensus, many nursing students struggle with patient communication during clinical experiences. Takano’s (2024) Japanese review cited an earlier survey in which 66.7% of nursing students reported communication difficulties after a foundational clinical practicum; commonly cited difficulties included conversation initiation, topic selection, reading patient emotions, and emotional self-regulation. Similar challenges have been documented internationally, highlighting the gap between recognizing the importance of communication and achieving competence.

Systematic reviews support structured communication training: Gutiérrez-Puertas et al. (2020) reported skill improvements in 68.4% of 19 interventions; Kerr et al. (2020) found significant post-training improvements in all seven randomized controlled trials reviewed; and Moore et al. (2018) reported a standardized mean difference of 0.18 (95% CI: 0.05–0.32) for empathy outcomes in their Cochrane review of communication training for healthcare professionals in cancer care.

Microcounseling represents one such systematic approach. Developed by Allen Ivey in the late 1960s, it deconstructs complex counseling processes into discrete, teachable microskills (Ivey et al., 1968), later organized as the microskills hierarchy (Daniels & Ivey, 2007; Ivey et al., 2018). This approach incorporates modeling, behavioral rehearsal, and video feedback—mechanisms aligned with Bandura’s (1977) social learning theory. Baker and Daniels’ (1989) meta-analysis demonstrated large effect sizes, and Kuntze et al. (2009) extended this empirically for basic and most advanced microskills. With approximately 450 empirical studies summarized at the time of writing and subsequent translations into more than 15 languages (Daniels & Ivey, 2007), microcounseling has achieved global implementation.

Briefly, attending behaviors encompass nonverbal and minimal verbal behaviors—eye contact, attentive body language, vocal qualities, and verbal tracking—that communicate presence (Ivey et al., 2018). The basic listening sequence comprises open and closed questions, encouragers, paraphrasing, reflection of feeling, and summarization. Influencing skills include interpretation, reflection of meaning, self-disclosure, feedback, information-giving, and directives. The hierarchy posits that effective influencing requires a relational foundation built through attending and listening.

Japan represents a particularly instructive case for examining microcounseling adaptation. Introduced by Fukuhara in the 1980s (Fukuhara et al., 2004), the approach has been applied to nursing education for nearly four decades, generating a body of research warranting synthesis. To date, however, no review has synthesized this literature, and international nursing educators have limited access to findings largely published in Japanese. This review aimed to examine research on microcounseling among Japanese nursing students, addressing four questions: (1) What research has accumulated and what methodological approaches characterize it? (2) What factor structures emerge for communication skills? (3) What patterns characterize skill acquisition? (4) What implications arise for nursing education? Findings were offered as hypotheses for further international investigation rather than as directly transferable conclusions.

Methods

Design and Guidelines

This review adopted a narrative synthesis approach rather than systematic review with meta-analysis. Three considerations guided the choice: (a) the heterogeneity of designs, outcome measures, and samples precluded meaningful statistical pooling; (b) with a small literature situated in a single national context, narrative synthesis was more appropriate for exploring conceptual and contextual relationships across studies (Sukhera, 2022); and (c) a primary aim was to examine how a Western-developed pedagogy has been culturally adapted—an interpretive question better served by narrative synthesis (Greenhalgh et al., 2018). Structured reporting procedures were nevertheless followed, consistent with Ferrari (2015) and the SWiM reporting guideline (Campbell et al., 2020). The PRISMA 2020 flow diagram (Page et al., 2021) was used to report study selection; PRISMA elements were adopted selectively for reporting purposes and should not be interpreted as claiming systematic review status.

Narrative Synthesis Procedure

Narrative synthesis followed the four iterative elements of Popay et al. (2006), with reporting guidance from Sukhera (2022): (a) developing a preliminary theoretical orientation in the microskills hierarchy; (b) tabulating study characteristics (Table 1) and grouping findings under four thematic categories (factor structure, skill acquisition, clinical application, self-efficacy); (c) exploring within- and between-study relationships through textual comparison; and (d) assessing robustness through theoretical coherence, consistency across independent research groups, and primary-source transparency.

Table 1.

Characteristics of Included Studies (N = 10)

Author (Year)	Purpose	Design	Sample	Skills measured	Key findings
Tamase (1988)	Effects of MC training on probe and reflection	Single-group pretest-posttest	16 obstetrical nursing students (mean age 24.1 yrs; completed 2-year nurse professional school course)	Open/closed questions; reflection of feeling	Open questions increased significantly (t = 3.7, p < .01); reflection of feeling unchanged. “What” 48%, “How” 34%, “Why” 9%.
Ichinohe et al. (1998)	Communication profile of graduating students	Cross-sectional	65 graduating students (n = 62 in factor analysis)	13 microskills, 28 items (basic and influencing)	Five factors extracted (61.5% variance); four interpretable: emotional understanding/reflection; active intervention (advice/direction); summarizing/paraphrasing; open questioning.
Kidachi et al. (2000)	Compare students vs clinical nurses	Cross-sectional comparative	176 practicing nurses (n = 147 in factor analysis after listwise deletion); compared with the same 65 graduating students as Ichinohe et al. (1998)	Microskills hierarchy (full)	Students (same dataset as Ichinohe et al., 1998): 4-factor interpretable; nurses: 7 factors extracted, 6 interpretable (cumulative variance 59.6%) — clinical experience promotes differentiation (Benner, 1984).
Nagano (2000)	Develop and validate Empathic Understanding Scale	Two-phase scale development	Pilot n = 18 RNs (8 psychiatric-ward nurses + 10 RNs in PHN program); main study n = 327 third-year nursing students	Empathic understanding (observer-based scoring)	Four-factor Empathic Understanding Scale grounded in microcounseling (observer-rated by 7 evaluators in pilot, 5 in main study): acceptance (42.1%); cognitive awareness (13.4%); reflective attitude regarding emotions and meaning (10.4%); verbalization prompting attitude (5.6%); cumulative variance 71.5%. Same 327-student dataset re-presented in Hasegawa et al. (2001).
Hasegawa et al. (2001)	Re-present empathic-understanding factor structure (Nagano, 2000 data) with liaison-nursing case application	Factor-analytic re-presentation with case application	327 students (Mie + Shizuoka prefectures); same dataset as Nagano (2000)	Empathic understanding components	Four-factor structure: acceptance (42.1%), cognitive awareness (13.4%), reflective (10.4%), verbalization prompting (5.6%); cumulative variance 71.5%. Framework applied to liaison-nursing case (mother of pediatric patient with brain tumor).
Kageyama et al. (2011)	Relationship building in psychiatric practicum	Single case study	1 student, 1 psychiatric patient	Microskills hierarchy; Travelbee’s model	Skills progressed: attending behaviors → basic listening (paraphrasing, reflection of feeling) → influencing skills. Influencing effective only after trust establishment.
Kondo (2015)	Characteristics of MC skill acquisition	Two-stage cross-sectional descriptive	Step I: 88 second-year students; Step II: 89 third-year students from the same cohort one year later (177 student-occasions across two time points)	Attending behaviors; listening skills	Attending high (4.10–4.35); verbal skills lower (3.11–3.60); paraphrase received the lowest self-rating (M = 3.11). Qualitative comments reveal confusion between listening and health education roles.
Kondo et al. (2020)	Develop & validate ICSS	Scale development/validation	208 second-year female students (133 valid responses)	ICSS: involvement, reflection, proactive (behaviours), proactive (instructions)	Four-factor ICSS confirmed; Cronbach’s α ≥ .86. Correlation with general self-efficacy (r = .373, p < .01).
Kondo (2023)	Verify ICSS validity	Validation	292 female year-3 students (354 distributed)	ICSS (validated against 4-factor structure of Kondo et al., 2020)	Three-factor structure emerged (proactive [instructions] and proactive [behaviours] subfactors of Kondo et al. (2020) merged into a single “influencing” factor). Confidence inversion: influencing (M = 3.41) > reflection (M = 3.33); attending highest (M = 4.18 on 6-point scales). “Reflection of meaning” and “confrontation” loaded on reflection factor.
Kondo et al. (2024)	CFA of ICSS; online environment effects	Cross-sectional CFA	429 students (all 4 years)	ICSS + online communication difficulty	Acceptable fit (GFI = .903, CFI = .949, RMSEA = .063). U-shaped trajectory in attending (Yr1 M=4.92 → Yr2 M=4.66 → Yr4 M=4.99). Among communication-environment variables, only reflection skills affected: online student-student communication difficulty negatively (β = −.094, p < .05); club/circle communication difficulty positively (β = .083, p < .05).

Note. Studies are ordered chronologically. Yellow highlighting marks revisions made in response to peer review and pre-submission verification. MC = microcounseling; ICSS = Interpersonal Communication Skill Scale; CFA = confirmatory factor analysis; GFI = goodness-of-fit index; CFI = comparative fit index; RMSEA = root mean square error of approximation.

Search Strategy

Literature searches were conducted in December 2025 across five databases: Ichushi-Web (Japanese medical literature), CiNii Research, PubMed, CINAHL with Full Text, and PsycINFO, with no date restrictions. Full search strings are provided in Supplemental Appendix A. English searches used: (microcounseling OR “micro counseling” OR microskills) AND (nursing students OR nursing education) AND (Japan OR Japanese). Japanese-database searches used equivalent translated terms. Hand-searching of the Japanese Journal of Microcounseling Research supplemented electronic searches.

Inclusion and Exclusion Criteria

Studies were included if they: (a) focused on nursing students in Japan, (b) used microcounseling or microskills as the primary conceptual framework, (c) measured communication skills, empathic understanding, or related outcomes, (d) were original research published in peer-reviewed journals or university bulletins, and (e) were written in Japanese or English. Studies were excluded if they: (a) were abstracts only, (b) were non-research publications, (c) mentioned microcounseling peripherally, or (d) focused exclusively on practicing nurses or other professionals without nursing student participants. University bulletins were included because they are an established venue for Japanese nursing research, especially scale-development work; the variable editorial rigor is revisited in the Strengths and Limitations section.

Selection and Data Extraction

Selection proceeded through duplicate removal, title/abstract screening, and full-text review. The primary author conducted initial screening and data extraction using a standardized form (bibliographic information, purpose, design, participant characteristics, microcounseling components, outcomes, key findings with effect sizes where reported, and limitations). Ambiguous decisions and extracted data were reviewed by co-authors and resolved through consensus. Fully independent duplicate screening was not conducted, given the small evidence base and narrative orientation; this is acknowledged as a limitation. PRISMA 2020 (Page et al., 2021) guided reporting of the selection process (Figure 1).

Figure 1.

Flow diagram of literature selection

Quality Appraisal

Although narrative reviews do not require risk-of-bias tools used to support pooling (Ferrari, 2015; Greenhalgh et al., 2018), a structured appraisal helps readers weigh individual studies. No single existing tool fitted the heterogeneous designs included here. Drawing on principles common to JBI critical appraisal tools (Joanna Briggs Institute, n.d.), MMAT 2018 (Hong et al., 2018), and COSMIN guidance (Mokkink et al., 2018), six dimensions were appraised for each study—design appropriateness, sampling, measurement quality, analytical rigor, reporting completeness, and internal consistency—rated as ✓ (clearly met), ◐ (partially met or unclear), or ✗ (not met or constrains inference). The full matrix and commentary appear in Supplemental Appendix B. Across the 10 studies, design appropriateness was uniformly adequate; sampling concerns were most prominent in Kageyama et al. (2011) and Tamase (1988); and measurement quality was strongest in the ICSS validation work (Kondo et al., 2020, 2024). Appraisal results informed cautious framing of conclusions rather than serving as a basis for exclusion.

Results

Study Selection and Characteristics

Database searches yielded 31 records, with two additional records identified through hand searching. After removing nine duplicates, 24 records were screened by title and abstract. Fourteen records were excluded: conference abstracts (n = 10), studies with nurses as sole participants (n = 3), and microcounseling not the primary focus (n = 1). Ten studies met inclusion criteria (Table 1). The studies spanned 1988 to 2024, encompassing experimental research (Tamase, 1988), cross-sectional surveys (Ichinohe et al., 1998; Kidachi et al., 2000; Kondo, 2015), a factor-analytic re-presentation with clinical case application (Hasegawa et al., 2001), scale development and validation studies (Kondo, 2023; Kondo et al., 2020, 2024; Nagano, 2000), and a single case study (Kageyama et al., 2011). The cumulative sample size totalled approximately 1,500 nursing students across diverse Japanese institutions, with each cohort counted only once across overlapping publications (see Strengths and Limitations). Notably, a substantial proportion of the most recent evidence (Kondo, 2015, 2023; Kondo et al., 2020, 2024) derives from a research programme led by a single principal investigator, a concentration revisited in the Discussion and Strengths and Limitations sections.

Factor Structure of Communication Skills

Factor analyses across multiple studies consistently extracted four skill dimensions mapping onto Ivey’s three-tier hierarchy (attending, reflection, and influencing), demonstrating structural stability over more than 25 years (Table 1). Ichinohe et al. (1998), surveying 65 graduating students at a single nursing programme (n = 62 in analysis), extracted five factors, four of which were interpretable: emotional understanding and reflection, active intervention, summarizing/paraphrasing, and open questioning. Nagano (2000) developed an Empathic Understanding Scale (main study n = 327 third-year students) and extracted a four-factor structure—acceptance attitude, cognitive awareness, reflective attitude regarding emotions and meaning, and verbalization prompting attitude (cumulative variance 71.5%). Hasegawa et al. (2001) re-presented these same factor-analytic findings in Japanese and extended the work by applying the framework to a liaison-nursing case; the factor-analytic results derive from a single 327-student sample (see Strengths and Limitations).

Kondo et al. (2020) developed the ICSS with second-year female students (n = 133), confirming four factors—involvement, reflection, proactive [behaviours], and proactive [instructions]—with Cronbach’s α ≥ .86 for each subscale. Kondo et al. (2024) validated this structure through confirmatory factor analysis (n = 429; GFI = .903, CFI = .949, RMSEA = .063). These dimensions align conceptually with Ivey’s microskills hierarchy.

A theoretically noteworthy finding emerged from Kondo (2023): when the Kondo et al. (2020) four-factor structure was applied to third-year students, the two proactive subfactors merged, yielding a three-factor solution (attending, reflection, influencing). Within this reduced structure, “reflection of meaning” and “confrontation”—classified in microcounseling theory as influencing skills—loaded onto the reflection factor. The “reflection of meaning” loading was already present in Kondo et al. (2020), strengthening the empirical basis for treating this as a stable feature of Japanese samples rather than a single-study artifact. This pattern is discussed below as a potentially culturally grounded phenomenon.

Kidachi et al. (2000) re-analyzed the same 65 graduating students with a refined 13-technique, 28-item questionnaire and added a comparison sample of 176 practicing nurses (n = 147). Students exhibited a four-factor structure while nurses showed six interpretable factors (cumulative variance 59.6%), suggesting clinical experience promotes skill differentiation, consistent with Benner’s (1984) novice-to-expert trajectory.

Skill Acquisition Patterns

Differential Acquisition by Skill Type

Tamase (1988) examined effects of a 10-hour, three-day microcounseling training program with 16 obstetrical nursing students. Open questions increased significantly (t = 3.7, p < .01), while reflection of feeling showed no change. Across pretest and posttest, “What” and “How” questions predominated (48% and 34%) over “Why” questions (9%). This pattern suggests questioning techniques with clear linguistic structures are more readily acquired than reflection skills requiring complex emotional processing.

Kondo (2015) examined the same cohort across two time points (Step I, n = 88 second-year students immediately after training; Step II, n = 89 third-year students one year later in applied role-play) and found similar patterns. In Step I, attending behaviors received high peer-observer ratings (eye contact 4.35, body movement 4.10, voice quality 4.29, verbal tracking 4.24 on 5-point scales; observer-rated subset n = 50, response rate 56.8%), while verbal techniques received lower self-ratings (open questions 3.60, closed questions 3.31, encouragers 3.43, paraphrase 3.11; n = 65 respondents, response rate 73.9%). Students reporting high difficulty made comments such as “I could only offer advice and educational information,” suggesting confusion between therapeutic listening and health education roles.

Confidence Inversion Phenomenon

Kondo (2023), with 292 female nursing students, documented a striking pattern: students reported higher self-efficacy for influencing skills (M = 3.41) than for reflection skills (M = 3.33), with attending behaviors highest (M = 4.18) on 6-point self-efficacy scales. The microskills hierarchy positions influencing skills as most advanced, building upon attending and reflection foundations; this inversion is interpreted theoretically in the Discussion. Because the pattern is based on self-report rather than observed performance, interpretation requires caution.

U-Shaped Developmental Trajectory

Kondo et al. (2024) analyzed skill patterns across all four undergraduate years with 429 students. Attending behaviors declined significantly from first year (M = 4.92) to second year (M = 4.66) before recovering by fourth year (M = 4.99). Reflection skills and influencing-behavior skills showed significant increases between second and fourth years, whereas influencing-direction skills did not differ significantly across years. This U-shaped pattern suggests second-year students, encountering initial clinical experiences, temporarily lose confidence before developing more realistic self-assessment and genuine competence. Because this is a cross-sectional finding from a single principal investigator’s research programme, longitudinal replication is needed.

Online Environment Effects

Kondo et al. (2024) examined COVID-19 pandemic impacts on skill development. Multiple regression revealed that, among the four ICSS factors, only reflection skills were significantly affected by communication-environment variables: difficulty in online student-to-student communication during classes and seminars showed a small negative association (β = −.094, p < .05), while difficulty in club/circle communication showed a small positive association (β = .083, p < .05). Attending behaviors and influencing skills were not significantly affected. Reflection skills require reading subtle nonverbal cues and responding with appropriate timing—processes disrupted by screen-mediated interaction. The positive association for club/circle communication is best treated as an empirical observation requiring replication.

Clinical Application

Kageyama et al. (2011) analyzed a psychiatric nursing practicum case using both Travelbee’s human-to-human relationship model and the microskills hierarchy. Across the eight-day encounter, attending behaviors were initially compromised by the patient’s articulation difficulties and symptom-related discontinuity, compounded by student anxiety (initial encounter phase, scenes 1–4). Self-disclosure and observation, supported by verbal tracking, encouragers, and paraphrasing, became pivotal in the emerging identity phase (scenes 5–7); reflection of feeling was introduced in the empathy phase (scenes 8–11); and influencing skills—logical consequences and information provision—were integrated effectively only after relational trust had developed in the sympathy phase, with rapport ultimately established on days 7–8 (scenes 12–14). As a single case, the study cannot establish generalizable patterns, but it provides a concrete illustration of microcounseling’s core premise: influencing skills require a foundation of established trust built through attending and reflection.

Self-Efficacy Relationships

Multiple studies documented relationships between communication skills and self-efficacy. Kondo (2023) found significant positive correlations between ICSS subscale and total scores and trait self-efficacy (r = .30–.36, p < .001). Kondo et al. (2020) reported similar associations with the same trait self-efficacy measure (r = .373, p < .01). Nagano (2000) provided early empirical support for the multidimensional structure of empathic understanding by developing and validating a four-factor scale, consistent with the framework’s premise that these dimensions are independently trainable. These findings support Bandura’s (1977, 1997) social cognitive and self-efficacy frameworks, in which mastery experiences, modeling, and feedback enhance both skills and self-efficacy beliefs. Because all observed associations are cross-sectional, the direction of influence cannot be established.

Discussion

This narrative review synthesized 10 studies examining microcounseling among Japanese nursing students over 36 years. Findings are interpreted with the evidence base in mind: a small, single-country literature in which much recent work derives from a research programme led by a single principal investigator. Implications for international nursing education are offered as hypotheses rather than firm prescriptions.

Structural Consistency and Theoretical Alignment

The consistent four-factor structure mapping onto three theoretical tiers—attending, reflection, and influencing—demonstrates stability across researchers, institutions, and time periods, supporting microcounseling-based conceptualization within Japanese samples. Alignment with Ivey’s microskills hierarchy (Ivey et al., 2018) suggests the framework may transfer to Japanese nursing contexts, though validation in other settings remains needed.

Cultural Adaptation of Advanced Skills

Kondo (2023) reported a factor-loading pattern, partially consistent with Kondo et al. (2020), in which “reflection of meaning” and “confrontation”—classified in Ivey’s hierarchy as influencing skills—loaded on the reflection factor in Japanese samples. Kondo (2023) attributed this primarily to wording-level similarity and called for further examination. We further hypothesize that this pattern may reflect a culturally grounded phenomenon. Japanese communication norms emphasize sasshi (empathic inference) and indirect acknowledgment of shared meaning, while direct confrontation is considered face-threatening. What Western theory frames as influencing intervention may therefore be experienced by Japanese participants as a deepening of mutual understanding—culturally adapted skill enactment rather than structural invalidity of the hierarchy (Fukuhara et al., 2004). The pattern has been observed in Japanese samples only; whether comparable loadings appear in other high-context cultures is a question for future research.

Differential Skill Acquisition

The finding that questioning improves more readily than reflection skills has practical implications. Fitts and Posner’s (1967) three-stage skill acquisition model may explain it: open questions have clear linguistic templates (“What…”, “How…”) that facilitate rapid cognitive understanding, whereas reflection requires simultaneous processing of verbal content, emotional tone, and nonverbal cues—an integration demanding extensive practice for automaticity.

Tamase’s (1988) finding that approximately 2 hours of dedicated reflection-of-feeling training proved insufficient, contrasted with Daniels et al.’s (1988) success with approximately 25 hours across six basic microskills, suggests a minimum practice threshold for advanced skill acquisition. Curricula may benefit from extended practice time for reflection skills, though the precise threshold requires further investigation.

Theoretical Grounding of the Confidence Inversion

The “confidence inversion” phenomenon—higher self-efficacy for influencing than for reflection skills—invites interpretation through three complementary theoretical lenses. First, it may reflect early professional identity formation (Cruess et al., 2015): curricular emphasis on patient education, discharge planning, and health promotion precedes sustained training in therapeutic listening, making influencing skills more readily available as markers of the role students are working to inhabit. The inversion may thus reflect appropriate identification with what students perceive as the nurse’s substantive work—a perception curricula themselves help shape.

Second, the pattern is consistent with miscalibration of self-assessment. Kruger and Dunning (1999) showed that limited skill leads to overestimation of competence; Eva and Regehr (2007, 2008) showed that unguided self-assessment correlates poorly with external performance measures in the health professions. Listening, with diffuse success criteria, is harder to self-assess than advice-giving, which offers clearer markers of “having said something.”

Third, Kageyama et al.’s (2011) case analysis illustrates microcounseling’s core premise (Ivey et al., 2018): influencing skills succeed only after a foundation of trust has been established through attending and reflection. The inversion may thus be predictive of practice difficulties rather than merely perceptual. Rogers’ (1957, 1959) client-centered framework converges: the three “core conditions”—empathy, unconditional positive regard, and congruence—need to be in place before directive interventions are likely to prove effective. Curricula might address this sequence explicitly.

U-Shaped Trajectory and Transition Shock

The U-shaped developmental trajectory, with second-year confidence decline (Kondo et al., 2024), aligns with Duchscher’s (2009) transition shock model and Kramer’s (1974) earlier reality shock concept—the underlying mechanism, a destabilizing gap between idealized and actual practice, also appears applicable to second-year students encountering sustained clinical responsibility. Benner’s (1984) novice-to-expert framework supplies a complementary vocabulary: skills initially fused into a global sense of competence become progressively differentiated with experience, contributing to temporary destabilization of self-assessment. The second-year decline can therefore be reframed as a predictable phase of professional identity development—recalibration of overly optimistic self-assessments against clinical reality—rather than a failure of training. Recovery by fourth year suggests students rebuild confidence on better-calibrated foundations. Explicit scaffolding during this transition (normalization, structured feedback, additional skill practice) may help. Because the trajectory has been described only in cross-sectional Japanese data, longitudinal and cross-cultural replication is essential.

Online Learning Implications

The selective constraint online environments may impose on reflection skill development holds continuing relevance as hybrid education persists post-pandemic. Reflection depends on perceiving subtle cues—facial microexpressions, postural shifts, voice tremors—that compress poorly through video interfaces. Educators might preserve face-to-face practice for reflection while using online platforms for content delivery and basic skill introduction.

Implications for Practice

Within the limits of a small, single-country evidence base, five tentative recommendations emerge: (a) sequence skill introduction by hierarchy—attending behaviors early, reflection skills with extended practice throughout, and influencing skills after foundational competence; (b) explicitly teach the relationship between listening and effective intervention to counter overvaluation of advice-giving; (c) support second-year clinical transitions by normalizing temporary confidence decreases; (d) prioritize face-to-face environments for reflection practice; and (e) use standardized instruments such as the ICSS (Kondo et al., 2020). These are hypotheses for curriculum development.

Strengths and Limitations

This review has several notable strengths. First, it provides the first synthesis of nearly four decades of Japanese microcounseling-based research in nursing education, opening international access to a literature largely published in Japanese. Second, structured reporting procedures were followed throughout, including a PRISMA 2020 flow diagram for study selection, application of the SWiM reporting guideline for narrative synthesis, and a structured six-dimension appraisal of all 10 included studies (Supplemental Appendix B). Third, dataset overlaps among included publications were explicitly identified and disclosed, with each cohort counted only once in cumulative sample tallies, preventing inflated impressions of replication. Fourth, the synthesis was theoretically anchored in the microskills hierarchy from preliminary orientation through final interpretation, providing conceptual coherence across heterogeneous designs. Fifth, methodologically diverse study types were included—experimental, cross-sectional, scale-development, and case-based—permitting examination of multiple facets of skill acquisition that no single design could address.

Several limitations nevertheless warrant acknowledgment and shape the confidence that can be placed in the conclusions above.

First, the evidence base is small (N = 10) and geographically concentrated in Japan; although cultural specificity is itself a focus of this review, claims about international applicability remain speculative and require empirical testing in other contexts. More fundamentally, the 10 included publications draw on only approximately eight independent data sets once documented dataset overlaps are taken into account (see Eighth point below)—and one of these (Kageyama et al., 2011) is a single-case analysis, leaving approximately seven quantitative data sets from which structural and trajectory patterns are synthesized. This small number of independent samples substantially constrains the inferential strength of the synthesis, particularly for patterns observed in only one or two data sets (e.g., the U-shaped developmental trajectory, the COVID-era online-environment effect, and the confidence inversion phenomenon), each of which requires independent replication before generalization is warranted.

Second, a substantial proportion of the most recent evidence—findings on the ICSS, the confidence inversion phenomenon, and the U-shaped trajectory—derives from a research programme led by a single principal investigator (Kondo, 2015, 2023; Kondo et al., 2020, 2024), albeit with different co-author teams across studies. Although this work is methodologically careful and theoretically coherent, the concentration of evidence within one programme is a meaningful potential source of bias; independent replication by other research groups is essential.

Third, no formal risk-of-bias assessment using a single standardized instrument was conducted; a structured appraisal across six methodological dimensions was instead applied to all 10 studies (Supplemental Appendix B). This appraisal was conducted by the primary author with co-author review rather than fully independently, and no single existing tool fits the heterogeneity of designs included.

Fourth, most studies relied on self-report measures, vulnerable to social desirability and calibration biases; observer-rated and, in particular, patient-rated outcomes are underrepresented. The confidence inversion finding, for example, cannot distinguish between actual competence differences and perceptual miscalibration.

Fifth, no study examined patient outcomes—arguably the ultimate criterion for evaluating communication training—so claims about educational effectiveness must be interpreted as claims about student skill acquisition and self-efficacy rather than about clinical impact.

Sixth, the review included both peer-reviewed articles and university bulletins (editorial review of the latter varies) and focused almost exclusively on Japanese-language literature; relevant work in other non-English venues may have been missed. Absence of evidence from other countries should not be interpreted as absence of microcounseling work in nursing education globally.

Seventh, as with all narrative syntheses, reviewer judgment shaped selection, grouping, and interpretation of evidence; preregistered inclusion criteria and transparent reporting mitigate but do not eliminate this.

Eighth, two pairs of included publications share underlying datasets: Hasegawa et al. (2001) and Nagano (2000) report findings from a single 327-student empirical sample, and Ichinohe et al. (1998) and Kidachi et al. (2000) appear to describe overlapping cohorts of graduating students from the same institution. Kondo (2015) additionally reports the same cohort across two time points (Step I, n = 88 second-year students; Step II, n = 89 third-year students one year later). All overlapping cohorts were counted only once in cumulative sample tallies. Both pairs of publications were retained because each member contributed distinct analyses (clinical-application focus in Hasegawa; comparison with practicing nurses in Kidachi), but the structural-replication evidence for the four-factor solution among graduating students rests on these two original datasets rather than on independent confirmation.

These limitations together point to priorities for future research: experimental designs, observer- and patient-rated outcomes, replication by independent research groups, and—most urgently—cross-cultural studies that examine whether the patterns observed in Japanese samples generalize to other educational and cultural contexts.

Conclusion

This narrative review synthesized 36 years of research on microcounseling among Japanese nursing students. Five findings structured the synthesis: consistent four-factor skill structures mapping onto microcounseling theory’s three-tier hierarchy; differential acquisition with questioning techniques improving more readily than reflection skills; a confidence inversion in which students undervalue listening relative to intervention skills; a U-shaped developmental trajectory with second-year confidence decreases; and online environments that may selectively constrain reflection skill development. Direct international transfer requires caution given the single-country evidence base, but each finding generates hypotheses for curriculum design beyond Japan.

Microcounseling offers a theoretically grounded framework for the systematic development of communication skills. Japan’s nearly four-decade experience provides evidence-based insights for nursing educators internationally. Future research should prioritize experimental designs, behavioral and patient-rated outcomes, replication by independent groups, and cross-cultural testing.

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Footnotes

Acknowledgments

The authors gratefully acknowledge the researchers whose work contributed to this review and the Japanese Association of Microcounseling for advancing microcounseling research in Japan. The authors thank the reviewers and the editorial team of SAGE Open Nursing for their constructive feedback during the review process. We also thank the Japanese researchers whose decades of work made this synthesis possible.

ORCID iDs

Takayuki Fujii

Taiga Seo

Yuji Nogami

Ethical Considerations

This study is a narrative review of published literature and did not involve human subjects or primary data collection. Therefore, institutional review board approval was not required. All reviewed studies were previously published in peer-reviewed journals and obtained appropriate ethical approvals as reported in their original publications.

Consent to Participate

Not applicable. This study is a narrative review of previously published literature and did not involve recruitment of participants.

Consent for Publication

Not applicable. This manuscript does not contain any individual person’s data.

Author Contributions

TF conceptualized and designed the study, conducted the literature search, performed data extraction and analysis, and drafted the manuscript. TS contributed to interpretation of findings and manuscript revision. YN contributed to study design, verified data extraction, and critically revised the manuscript. All authors read and approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

All data analyzed in this narrative review are available from the cited published articles. No new data were generated during this study. All data generated or analyzed during this review are included in the published article and its supplementary appendices. The full search strings (Supplementary Appendix A) and structured quality appraisal (Supplementary Appendix B) are available with the manuscript.

Use of Generative AI in Scientific Writing

During the preparation of this manuscript, the authors used Paperpal in order to improve language and readability. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.

Supplemental Material

Supplemental material for this article is available online.

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