Nursing is commonly regarded as an art and a science, wherein nurses are required to practice with both scientific knowledge and empathy. However, an ongoing challenge is to maintain the concept of art—caring with empathy—in the ethical center of the nursing profession (Wei & Watson, 2018). Nursing is not merely a task-oriented profession but also a profession that requires building interpersonal relationships and advancing health (Watson, 2018). Thus, nursing education is not simply passing down knowledge and skills but also teaching the aspect of nursing caring. Keeping the concept of art in nursing requires intentional efforts to integrate it in nursing education, where nursing students have opportunities to learn the skills of communication, the ability of empathy, and the insights of self-efficacy.
Effective communication is essential in nursing because communication is more than a tool for nurses to exchange messages. It is also a means for nurses to express empathy and develop a rapport with others, which is a precondition of optimal patient care (Foronda, MacWilliams, & McArthur, 2016; Wei & Watson, 2018). However, effective communication skills to express empathy may not be intuitive to nurses and is not easy to master without proper training (Shafakhah, Zarshenas, Sharif, & Sabet Sarvestani, 2015). Pedagogical approaches that integrate effective clinical exposures and training into nursing education are needed to prepare students for clinical practice and help them to face the challenges of complex clinical environments.
The application of simulation and deliberate practice has become increasingly popular in nursing education (Johnston, Parker, & Fox, 2017; Welch & Carter, 2018). Although simulation-based education has achieved significant advances in nursing education (Gantt & Young, 2015), deliberate practice has not been widely applied in nursing education in China, especially the combination of scenario-based simulation and deliberate practice. Therefore, the purpose of this study was to evaluate the effectiveness of simulation-based deliberate practice on cultivating the capabilities of undergraduate nursing students' communication, empathy, and self-efficacy.
Nurses' competence in theoretical knowledge and clinical skills largely depends on their education in nursing schools. Nursing students' clinical preparation is an essential part of nursing education, which helps students transition to nurses and builds confidence (Logan & Clarke, 2016). The experience and success of students' clinical practice mostly rely on their preparation before entering the clinical settings. Inadequate exposure and preparation for clinical learning environments impede students' learning and professional development and increases nursing students' dropout rate (Bakker et al., 2018; Jamshidi, Molazem, Sharif, Torabizadeh, & Najafi Kalyani, 2016) and clinical nurses' turnover rate due to the challenge of being in work environments (Nantsupawat et al., 2017; Wei, Sewell, Woody, & Rose, 2018).
In the current health care setting, it is essential for nursing students to have proper training in nursing schools, especially in the areas of effective communication, self-efficacy, and empathy. Communication is the foundation for safe and high-quality patient care (Agency for Healthcare Research & Quality, 2017). Effective communication promotes not only nurse–patient relationships but also nurse–peer relationships. These relationships are vital to creating healthy and healing environments for both patients and health care professionals (Foronda et al., 2016; Wei, Sewell, et al., 2018). The capability of communicating efficiently is an underpinning skill for nursing students to grasp in their undergraduate education.
Empathy is an underlying foundation for nursing. For nurses to care for patients and families, having nursing knowledge alone is not sufficient. Patients and families valued not only nurses' and physicians' medical expertise but also their empathetic behaviors (Wei, Wei, Brown, Buck, & Mill, 2018). They felt cared for and respected when health care providers treated them with CARE—Competence, Altruism, Responsibility and respect, and Empathy (Wei, Wei, et al., 2018). Research showed that more than 80% of patients' complaints filed in hospitals were due to health care professionals' poor attitude or lack of communication skills (Ming, Wei, Cheng, Ming, & Beck, 2019; Wei, Ming, et al., 2018).
The beliefs of self-efficacy are perceptions that individuals have about their ability to act efficiently to achieve goals or handle challenging situations adequately. Even though these beliefs are perceived by individuals rather than individuals' actual capabilities, they affect individuals' performance and achievement (Bandura, 1977). A research study found that when nursing students did not feel they had adequate preparation before entering clinical sites, they did not feel efficient in communication, readiness, or emotional reactions to face challenges in their clinical settings (Jamshidi et al., 2016).
Current literature shows that nursing students currently still need improvement in their communication, empathy, and self-efficacy. Research shows that nursing students have limited training in communication skills (Chan & Lai, 2016) and that most nursing students require improvement in their communication skills in their communication behavior and ability (Shafakhah et al., 2015). One recent study found that almost 40% of the students reported they never received any communication training in their nursing schools, and more than 75% of the participants did not feel efficient to communicate and express empathy toward patients with cancer (Lin et al., 2017). Gaps exist between what students are taught and what they need to face complex clinical environments.
This study was guided by the combination of simulation-based nursing education and deliberate practice. Simulation is the technique of imitating actions and behaviors for the purpose of training, which has been adopted in health care education since the mid-1900s (Abrahamson et al., 1969). Simulation-based nursing education is a pedagogical approach, helping to expose students to various real-life scenarios and practice their clinical skills (National Council of State Boards of Nursing, 2019). Simulation-based educational interventions have shown positive effects, especially in students' psychomotor domain (Kim, Park, & Shin, 2016).
Although simulation focuses on providing students with opportunities to practice in real-life situations, the deliberate practice emphasizes ways for students to improve their individual performance. Deliberate practice stresses the importance of developing expertise through repetitive practice and constructive feedback (Ericsson, 2008), which has shown positive results in nursing education (Badowski & Oosterhouse, 2017; Bond et al., 2017). The combination of simulation-based education and deliberate practice has significantly increased the technical skills of medical residents (Corvetto, Pedemonte, Varas, Fuentes, & Altermatt, 2017).
Study Design, Setting, and Sample
The research ethics committee of the university approved this study. This was a randomized controlled trial conducted in a school of nursing in China in the fall semester of 2016, September 2016 to January 2017. The participants of the study were the first-year undergraduate students of the school.
A cluster-stratified sampling design was used with the stratification of the spring college entrance examination. A total of 373 students was admitted to the school in the fall semester of 2016. Based on students' examination scores, prior communication skills training, and demographics, we matched and included 132 of the first-year undergraduate students. These students were then randomly divided into experimental group and control group, with 66 students in each group.
The experimental group comprised 54 female students and 12 male students, and the control group had 52 female students and 14 male students. The demographics of the participating students were listed in Table 1. There were no significant differences in demographics between the students of the two groups and no dropouts during the study period.
Demographic Characteristics of Participants (N = 132)
Undergraduate Nursing Interpersonal Communication was the course chosen for the study. This course was taught in the first semester of the nursing program. The students in both groups had the same course content and teachers. Traditional teaching methods were used for the control group. The students in the experimental group were exposed to simulation-based deliberate practice in addition to traditional teaching. The intervention was conducted in four stages.
First, students were placed into small groups. Teaching occurred in group settings. The students in the experimental group were randomly divided into 11 groups, with approximately six students per group. Each group selected a student as the team leader. The duties of the team leader were to serve as a link between students and teachers and to organize course materials for in-class lectures and out-of-class group video recordings based on the topics given. The videos were simulated educational videos for the students in the experimental group to watch and discuss later.
Second, seminars were conducted about the history and the current state of simulation and deliberate practice. The seminars were initiated in the eighth week of the course. These seminars occurred twice per week for 2 weeks. The content of the specialized training was divided into three modules: the introduction of the deliberate practice, which introduced the definition of deliberate practice and simulation; the current state of the science of the deliberate practice, which explained the existing studies about deliberate practice and simulation; and the application and effects of simulation and deliberate practice in nursing, which addressed the application of the deliberate practice and situational simulation in clinical nursing work and the effects of deliberate practice and scenario-based simulation on establishing empathetic nurse–patient relationships.
Third, simulation-based deliberate practice was used to improve students' communication skills, empathy, and self-efficacy. The students in the experimental group then participated in simulation classes. In the classes, students were provided with opportunities to integrate the content they learned in the course and the seminars into their deliberate practice. The simulation classes were held twice per week for 8 weeks, and each class lasted 30 minutes. The simulation-based deliberate practice was structured and progressed as follows:
- Students watched the simulated educational videos and discussed the components of communication, empathy, and self-efficacy in the videos. In each simulation class, students first watched a video they made by themselves, with their teachers' guidance, based on the course content. Students were instructed to pay special attention to language skills and non-language caring actions in the video. After watching the video, students were asked to verbally explain the communication skills used in the video. After the completion of the students' discussion, teachers then commented on the hidden skills, the thinking process of problem solving, communication skills, and empathetic behaviors presented in the video. Students learned by the process of watching one another's play and learning from the teachers' summaries of the video.
- Students learned through scenario-based simulations. Each group then received a case scenario. Students worked as a group and conducted the simulation exercise based on the case scenario assigned to their group. Students were instructed to accurately replicate what was described in the case scenario in a simulation laboratory, including the arrangements of furniture and other materials. For each of the scenario-based simulations, students were required to practice and act according to the following steps: the purpose of their problem-solving decisions; the assessment of the goals, behaviors, and obstacles; the preparation of their activities; the steps required for problem solving; and the things about which they needed to be cautious. During the simulation exercise, each group leader was responsible for video recording so that students could watch their performance and receive constructive feedback for further improvement. One scenario-based simulation is provided as an example in Table 2.
- Students reflected on their communication skills and empathy ability. In this step, teachers guided students to review their performance based on the case scenarios and provided constructive feedback for further practice and improvement. Students were asked to evaluate and reflect on their own performance in the video recorded during their practice and identify the aspects that could be improved. At the end of each simulation class, students were asked to answer three questions related to their progress compared with the last training, any mistakes made during this time, and areas that could be improved next time. After every simulation class, teachers provided written constructive feedback about students' performance.
The fourth and final intervention stage was use of the We-Chat platform to learn. WeChat is a social medium platform that has been used as a mobile and interactive communication tool in education. All the students and teachers in the experimental group joined a WeChat group in which they shared different topics of communication videos, skills, and knowledge. Students and teachers shared relevant topics and videos to the WeChat group at least once every week during the study period. This platform provided students with opportunities to interact with team members and learn relevant communication knowledge at any time.
We used four tools to evaluate the effects of the intervention, including a demographic questionnaire, the Communication Skills Assessment Scale, the Jefferson Scale of Empathy-Health Professionals, and the General Self-Efficacy Scale.
Demographic Characteristics. The demographic characteristics of the subjects included gender, residence, siblings, and prior communication skill-training experiences.
Clinical Communication Ability Scale. The Clinical Communication Ability Scale was developed by Steyn, Borcherds, and van der Merwe in 1999. Yang, Shen, and Li (2010), on the basis of the original scale, created a Chinese version to fit the needs of Chinese nursing students. The scale had 28 items classified in six subscales—establishing rapport and respect, listening receptively, confirming with patients, sharing control, conveying information effectively, and checking perceptions (Yang et al., 2010). The items were rated from 1 to 4 on a 4-point scale. The total scores could range between 28 and 112, with higher scores suggesting stronger communication abilities. The internal consistency coefficient in this study was α = .88.
Jefferson Scale of Empathy-Health Professionals. The Jefferson Scale of Empathy was a 20-item scale developed by Jefferson Medical College to measure empathy in health education and patient care (Hojat et al., 2001). The items were appraised on a 7-point Likert-type scale from 1 (strongly disagree) to 7 (strongly agree). Based on this original version, Qiu, Jiang, and Li (2014) developed a Chinese version of the empathy scale for Chinese nursing students. The internal consistency coefficient in this study was α = .739.
General Self-Efficacy Scale. Students' self-efficacy was measured by the General Self Efficacy Scale (Zhang et al., 2018). This was a 10-item survey rated on a 5-point Likert scale. The total scores were between 10 and 50, with higher scores indicating higher students' self-efficacy. The internal consistency coefficient in this study was α = .87.
All participants completed the demographic questionnaire, Communication Skills Assessment Scale, Jefferson Scale of Empathy-Health Professionals, and General Self-Efficacy Scale at the beginning of the program. Although traditional teaching methods were used for the control group in the fall semester of 2016 (September 2016 to January 2017), the students in the experimental group were exposed to the simulation-based deliberate practice, in addition to the traditional teaching.
Data were analyzed using SPSS® version 23.0. The level of significance was set at .05. The normality of the distribution was assessed for all variables. We used chi-square tests for categorical variables and t tests for continuous variables. For example, the data collected from clinical communication ability, empathy competency, and general self-efficacy were continuous, and a t test was conducted to compare the scores of the students in the experimental and control groups.
A total of 132 nursing students participated in the study. The participating students were randomly assigned into two groups—the experimental group (12 men and 54 women) and the control group (14 men and 52 women). No significant differences were found between the characteristics of the two groups. In the experimental group, a total of 71.21% of participants came from rural areas and 69.7% had siblings at home. Of the participants, 93.94% of the students did not receive communication training courses. In the control group, a total of 65.15% of participants came from rural areas, and 72.73% of the students had siblings. Of the participants, 89.39% of the students did not receive communication training courses (Table 1).
The Clinical Communication Ability Scale Scores
The total score and each dimensional score of the clinical communication ability scale of the two groups were higher than those before the training, and the difference was statistically significant (Table 3). There were no performance differences between the experimental and control groups during the pretest. However, during the posttest, there were remarkable improvements in the experimental group, with a statistically significant difference (p < .01).
Comparison of Clinical Communication Ability Between the Two Group Before and After the Program (χ̄±s)
The Jefferson Scale of Empathy-Health Professionals Scores
Nursing students' perspective taking, compassionate care, transpositional consideration, and empathy ability total scores were higher than those of before training in both groups, with a statistically significant difference (Table 4). There were no performance differences between the experimental and control groups during the pretest. However, during the posttest, there were noteworthy improvements in the experimental group, with a statistically significant difference.
Comparison of Empathy Ability Scores Between the Two Groups Before and After the Program (χ̄±s)
The General Self-Efficacy Scale Scores
Students' self-efficacy scores significantly improved in the posttest of the experimental group (p = .003). There were no performance differences between the experimental and control groups during the pretest. However, during the posttest, there were noteworthy improvements in the experimental group (Table 5).
Comparison of Self-Efficacy Scores Between the Two Groups Before and After the Program (χ̄±s)
Nurse–patient communication is a skill that requires careful design and purposeful teaching. In this study, we examined the effects of a simulation-based deliberate practice program on nursing students' communication, empathy, and self-efficacy skill building. The use of simulation courses has gradually gained popularity in the nursing education in China; however, the combination of simulation with the deliberate practice theory to design and teach students' communication skills, empathy, and self-efficacy is still understudied. The findings of the study indicated that this program had a positive effect on nursing students' clinical communication ability, empathy ability, and self-efficacy. These findings can contribute to the current literature by providing evidence demonstrating the effectiveness of simulation-based deliberate practice.
Nurse–patient communication plays an important role in improving patient care quality (Agency for Healthcare Research & Quality, 2017). In our study, the scores of clinical communication ability of the students in the experimental group were improved significantly compared with those in the control group, indicating that simulation-based deliberate practice had the potential to promote the development of communication ability of nursing students. Although the reasons for students' improvement were multifactorial, we felt confident that, based on the principles of simulation and deliberate practice, the simulated training program provided students with opportunities to learn and express their feelings in a nonjudgmental environment and a relaxed state.
With the deliberate repetitive practice and constructive feedback based on the video recordings and group discussions in a simulated atmosphere, students' self-efficacy improved, and they were more capable of showing their empathetic feelings toward self and others. This program offered intensive exercises according to deliberate practice theory, which emphasizes the repetitive practice and immediate and constructive feedback to ensure continuous and efficient training. In this study, students did not just blindly practice for specific tasks but also were guided step by step to implement targeted training and achieve a clear goal. What is more, deliberate training and simulation created the link between practice and theory, which promoted the development of students' learning ability (Lendahls & Oscarsson, 2017).
The deliberate practice training based on situational simulation in this study was a process that enabled nursing students to effectively, repeatedly, and extensively train their theoretical knowledge and communication skills. In a previous study, researchers noted that the simulation teaching method filled the gap between traditional teaching methods and clinical practice (Parker, McNeill, & Howard, 2015). The deliberate, purposeful, and phased simulation-based communication training may fully arouse nursing students' enthusiasm and confidence in communication practice (Parker et al., 2015).
Empathy is considered to be one of the most critical capabilities of health professionals and is regarded as an essential focus of medical education courses (O'Sullivan et al., 2017). It reflects a natural ability to perceive and sense the emotional state of others and the motivation to care about other's well-being (Smith, Norman, & Decety, 2017). In this trial, we used methods such as scenario-based simulation, role-playing, and video recordings to help students develop skills in transpositional thinking and cognition in a high-contact working scenario so they could accurately identify and evaluate patients' emotional status. In the end, students also practiced using effective emotional and cognitive nursing interventions to meet patients' needs and alleviate patients' psychological distress. The results of this randomized control trial demonstrated the effectiveness of using simulation-based deliberate practice to improve students' empathy skills. The empathy training is vital to improve patients' care and satisfaction and reduce patients' complaints because more than 80% of the patients' complaints were due to the lack of communication skills and empathetic expressions in health care providers (Ming et al., 2019; Wei et al., 2018).
Self-efficacy is the degree of confidence that individuals perceive to exert control over events and activities (Bandura, 1977). In this study, the results showed that the overall self-efficacy scores of nursing students in the experimental group were significantly better than those of the control group after the intervention. The results indicated that deliberate practice based on scenario-based simulation could effectively improve nursing students' self-efficacy. In our experimental group, nursing students might have more confidence in their ability to adjust themselves when they received constructive feedback from the teachers who gave students immediate feedback according to their performance. Through constructive feedback, students could immediately realize the exact point that they needed to correct, and they could work on a specific area to improve. In this case, students could face themselves realistically, separating their areas needing improvement from their ability to improve.
This study conducted targeted training in the form of a group, the mutual promotion among the nursing students in the experimental group could have led to the improvement of group efficacy, which might have also promoted the enhancement of self-efficacy among individual nursing students. The literature (Quail, Brundage, Spitalnick, Allen, & Beilby, 2016) demonstrated that simulated learning experiences could improve students' overall self-efficacy, and communication training experience could bring positive changes to students' self-efficacy. The study by Banerjee et al. (2017) also found that after the intervention of a communication training program, participants' self-efficacy and communication skills improved significantly.
Implications for Practice
The findings of this study demonstrated that it was feasible to integrate the simulation-based deliberate practice into the teaching curriculum of undergraduate education. This study showed that the simulation-based deliberate practice not only promoted students' communication skills and empathy ability but also increased students' self-efficacy—the self-perception of capabilities. Based on the findings of the study, we can provide the following specific strategies to promote students' communication skills and their empathy ability and self-efficacy:
- Introduce the concept of deliberate practice to students and give them opportunities to understand the principles behind it, which helps students stay motivated.
- Assist students to set specific and realistic goals that students could reach in small steps to avoid causing frustrations in students.
- Provide constructive feedback immediately after students' performance. The feedback needs to be specific so that students can use it to improve.
- Reflect on students' performance with students. This study showed that video recording seemed to be an effective way to review and reflect on students' communication skills and empathetic training.
- Encourage students along the way of their practice to build their self-efficacy.
Limitations and Recommendation for Future Research
This study had several limitations. First, this study mainly focused on the teachers' training intervention for nursing students but did not conduct a questionnaire survey on the training program of nursing students and the satisfaction of teachers and nursing students. To our knowledge, this is the first time to implement the communication training program with the combination of deliberate practice and scenario-based simulation in China; thus, the implementation plan needs to be further improved in the future. Nonetheless, the short-term effects were observed in this study, and the long-term effects of deliberate practice based on scenario-based simulation should be further tracked and evaluated in the future. We also recommend conducting a longitudinal study to follow up with the undergraduate students to examine their confidence at work, job performance, and job satisfaction after graduation.
Compared with the traditional teaching methods, a simulation-based deliberate practice program was more suitable for the development of the modern nursing education model and could better meet students' clinical needs. The simulation-based deliberate practice model can effectively promote nursing students' communication ability and improve the effectiveness of students' communication, empathy, and self-efficacy abilities. In the meanwhile, it can stimulate students' interests to practice more and enhance the sense of participation, and thus improve training effect. The simulation-based deliberate practice program provides feasible teaching experience and teaching methods for improving the communication ability of nursing students.
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Demographic Characteristics of Participants (N = 132)
|Characteristic||Experimental Group (n = 66)||Control Group (n = 66)||χ2||p|
|Communication training course in the past|
Comparison of Clinical Communication Ability Between the Two Group Before and After the Program (χ̄±s)
|Dimension||Experimental Group||t||Control Group||ta||t1b||t2c|
|Establishing rapport and respect||18.33 ± 1.40||22.92 ± 1.00||−27.69**||19.12 ± 2.52||20.29 ± 1.92||−8.00**||−0.221||9.90**|
|Listening receptively||15.62 ± 2.07||18.98 ± 0.95||−15.38**||15.17 ± 2.32||16.36 ± 1.77||−9.34**||0.987||10.60**|
|Confirming with patients||15.18 ± 2.33||19.30 ± 0.84||−16.84**||14.94 ± 2.40||16.11 ± 1.95||−8.72*||0.588||12.25**|
|Sharing control||10.42 ± 2.05||14.52 ± 1.06||−11.73**||9.80 ± 2.08||11.00 ± 1.65||−8.85**||0.731||14.61**|
|Conveying information effectively||7.33 ± 1.58||11.39 ± 0.72||−18.11**||7.35 ± 1.68||9.29 ± 1.60||−6.59**||−0.053||9.77**|
|Checking perceptions||15.14 ± 2.39||18.82 ± 1.07||−16.03**||14.85 ± 2.57||16.03 ± 2.26||−9.26**||0.666||9.07**|
|Total||82.03 ± 5.82||105.94 ± 2.69||−32.82**||81.23 ± 6.55||89.08 ± 4.83||−15.77*||0.744||24.78**|
Comparison of Empathy Ability Scores Between the Two Groups Before and After the Program (χ̄±s)
|Dimension||Experimental Group||t||Control Group||ta||t1b||t2c|
|Taking||45.47 ± 4.04||49.48 ± 4.87||−10.52**||46.71 ± 4.05||47.80 ± 3.94||−12.74**||−1.765||2.18**|
|Compassionate care||30.85 ± 4.10||34.77 ± 4.68||−12.25**||31.35 ± 4.18||32.48 ± 3.15||−13.07*||−0.694||2.85*|
|Standing in the patient's shoes||11.73 ± 1.30||13.47 ± 0.73||−11.27**||11.97 ± 1.43||12.36 ± 1.42||−6.12**||−1.023||5.63**|
|Total||88.05 ± 7.00||97.73 ± 8.38||−12.98**||90.03 ± 6.50||92.74 ± 6.34||−16.46*||−1.688||3.86**|
Comparison of Self-Efficacy Scores Between the Two Groups Before and After the Program (χ̄±s)
|Content||Experimental Group||Control Group||t||p|
Key Elements of Simulation-Based Deliberate Practice for Communication
|Case||A breast cancer patient has just returned for chemotherapy. Because the patient is depressed and does not want to do any nursing care, she looks painful and tired, with tense facial expressions, and is frowning. The patient has a history of rejection and does not like to ask for help from nurses.|
|Objective||To learn communication knowledge, to use the corresponding communication skills and emotional attitudes and values.|
|Preparation||Prepare for the materials, environment, nurse, patient, and disease.|
Patients' goals: relieve emotional pain, anxiety, and worry.
Behavior: find a nurse for help.
Obstacle: does to like to seek help.
Nurse's goal: stay with the patient as long as she needs me.
Behavior: pause, take a deep breath, and remember the basic skills of empathy (e.g., sit down, make eye contact, use calm words, gently touch the patient if it seems okay with her).
Obstacle: has a history of rejecting help, self-doubt, and exhaustion.
Check your goal: Am I truly helping this patient, or am I unconsciously trying to establish my superior status?
Check your actions: Am I making good eye contact? Am I at the patient's eye level? Am I giving her my full attention? Do I appear calm? Did I remember to pause and breathe?
Check your obstacles: Am I having a bad day? Is the patient having an unusually bad day? What is the social history of the patient? Am I letting my dislike of this person show?
|Precautions||When communicating with the patient, remember to ask yourself the following questions:
What does the patient need at this time?
Am I providing it?
What is influencing the patient's emotions and mental status?
How can I help her?
What can I change in myself?