Improving interprofessional teamwork and communication among health care workers has been identified as a key component by the Institute of Medicine (2001) to address its six aims for improving safety and quality of health care. Effective communication is a vital skill for nursing students to learn in order to deliver high-quality and safe patient care and is one of the key elements included in the American Association of Colleges of Nursing (2008) Essentials of Baccalaureate Education for Professional Nursing Practice. In 2005, the American Association of Critical-Care Nurses established standards for healthy work environments to support and foster excellence in patient care through six essential standards, including skilled communication, noting “nurses must be as proficient in critical communication skills as they are in clinical skills” (American Association of Critical-Care Nurses, 2016, p. 2).
Effective communication is frequently emphasized as essential for undergraduate nursing student preparation to enter the workforce and transition into practice. Students need to apply content learned in the classroom to their clinical practice (Fleming & Mills, 1992). However, classroom instruction alone does not provide opportunities for students to apply communication strategies.
The Nursing Executive Center, a research platform of The Advisory Board ( https://www.advisory.com/about-us), conducted the New Graduate Nurse Performance Survey in 2007 to identify specific nursing competencies that students may fail to bring to the practice environment (Berkow, Virkstis, Stewart, & Conway, 2008). Many of these competencies are focused on effective communication (e.g., communication with interprofessional team, ability to accept constructive criticism, recognition of unsafe practices by self and others, communication with physicians, conducting appropriate follow up, ability to take initiative, and delegation of tasks). There is a gap in the literature about which teaching methodologies are effective for teaching communication skills that address these types of difficult conversations.
Teaching effective communication skills to undergraduate nursing students has been debated in the literature for several years. Grant and Jenkins (2014) conducted a literature review noting that although there has been an increase in the use of active learning methods—including role-play and simulation with standardized patients—it has been difficult to discern the best approaches to teaching communication skills due to inconsistent use of theoretical frameworks and accompanying outcome measures.
Video can be used to present real-life situations and trigger problem solving following the presentation of a short, emotionally charged, and unresolved interaction. Trigger videos allow students to analyze and determine a course of action in a safe environment and model behavior in ways that are real to students. Video production may further student understanding and serve as a valuable learning tool (Chan et al., 2010; Rasi & Poikela, 2016). The use of student-developed videos using a smart-phone was noted as a helpful communication teaching method in a quasi-experimental study with nursing students in South Korea (Choi, Song, & Oh, 2015).
This article describes the development, implementation, and evaluation of innovative teaching strategies to enhance senior nursing students' communication skills related to difficult conversations in the workplace. Kolb's experiential learning model (doing, reviewing, concluding, and planning) served as the theoretical framework for development of nursing students' knowledge, comfort, and skills in managing difficult workplace conversations (Kolb, 1984). The specific aims were to (a) develop innovative strategies used by faculty to introduce students to the concept of effective communication in the workplace; (b) provide opportunities for students to use these approaches to practice difficult conversations; and (c) assess students' learning or behavior change after reviewing trigger videos demonstrating simulated situations in the workplace.
As a pilot study, this project used a quasi-experimental one-group pretest–posttest design to evaluate students' comfort level with managing effective communication with difficult conversations (Privitera & Ahlgrim-Delzell, 2018). Study data were collected over a 4-month period (January to April 2018) and were managed using REDCap (Research Electronic Data Capture) a secure, Web-based application designed to support data capture for research studies. Students' survey responses were exported to SPSS Windows® (version 25). Analysis included results of statistical measures for central tendency and students' paired t test to compare means and categorical variables (expressed as counts with percentages) for survey response rates and final student assessment. The significance threshold was set at 0.05. The project was approved by the university office of human research protection. A hospital clinical research nursing unit (closed on weekends) provided a realistic setting for filming the videos. Written release and permission from every participant appearing in the footage provided the university with legal rights to use the videos for educational purposes.
Project participants were senior nursing students (n = 88) enrolled in the undergraduate baccalaureate nursing program at the University of Pittsburgh School of Nursing at the main campus and in the Transition to Professional Practice course at a regional campus. Students were informed of the purpose of the project, and completion of the surveys served as an indication of students' consent and willingness to participate.
Video production services were supported by an Innovation in Teaching grant from the university. A senior faculty member involved in graduate simulation education provided consultation for this teaching initiative. Primary authors with experience in leadership and management instruction prepared scripts related to content focused on effective communication. The authors developed a series of videos that were used by faculty on two campuses to prompt (trigger) class discussion about effective communication related to common workplace issues including how to address a medication error with a colleague, appropriately delegate, respond to bullying, and provide performance feedback.
A teaching guide and associated rubric for peer review and final assessment of the students' use of effective communication were developed to maintain consistency of feedback and grading (Table 1). Kolb's experiential learning theory served as a theoretical framework for the teaching guide highlighting the impact of direct experience or practice on learning (Ng, Van Dyne, & Ang, 2009). The rubric identified a structured approach to communication and measured student behavior in response to the trigger scenario. The tool included student observation of personal aspects of communication (e.g., private setting, personal space, language, verbal/nonverbal congruence) and use of assertive and scripted communication techniques. Faculty members responsible for supervising the clinical activities of senior nursing students during their transition to practice clinical rotation received instruction from the project leader about how to use the rubric to facilitate interrater reliability in assessing the self-recorded student communication videos (Table 1).
NUR 1134: Transition into Professional Nursing Effective Communication Skills in Addressing a Difficult Conversation in the Workplace Faculty Rubric
A faculty-developed survey was administered to students after viewing each trigger video demonstrating a difficult conversation in the workplace. The five-question survey included questions about the students' prior experience with a similar situation as demonstrated in the video (yes/no) and the students' comfort in observing/responding to the trigger scenario. Additional items measured the students' likelihood to avoid or report the scenario to a supervisor and student perception about whether they had the skills to handle the scenario (5-point Likert scale: 1 = limited or no or little experience and/or confidence to 5 = considerable experience and/or complete confidence). Students completed the same survey posteducational instruction again after viewing videos showing good and bad examples of handling these difficult conversations or situations.
Upon completion of instructional content and surveys for each video series, students wrote a script based on a difficult conversation they witnessed during their clinical rotation. Students created a smartphone video depicting their use of scripted techniques to manage the scenario described in their scripts. Students met in small groups to view each other's smartphone videos. Faculty led a group debriefing after each video, and students provided peer feedback to enhance future performance during their final faculty assessment (Figure 1). Finally, clinical nursing faculty individually assessed students' response to a trigger video using the project team rubric incorporating skills featured in the Agency for Healthcare Research and Quality's (2019) TeamSTEPPS curriculum to improve patient safety. Student scores resulted from faculty observation of the behaviors associated with effective communication as listed on the rubric.
Teaching Workplace Interprofessional Communication Effectively (TWICE)—an educational initiative time line.
Eighty-eight senior-level BSN nursing students were eligible to participate in this project including 69 students from the main campus and 19 students from the regional campus. The response rate for completion of both the pre- and postsurveys were as follows: effective communication of a medication error (79.5%), delegation (67%), bullying (61.3%), and performance management (39.7%).
Witnessing a Difficult Conversation
Many students witnessed difficult situations related to delegation (79%) in their clinical rotations. Just over half of the students (51%) had witnessed bullying between staff or health care providers. However, few students (35%) had witnessed situations such as those portrayed in the effective communication related to a medication error and performance management videos.
Preinstruction, students were unsure whether they would report the delegation issue. However, postinstruction students were likely to report the issue to their preceptor or supervisor (p < .001). Students tended to trend toward feeling uncomfortable in responding to a delegation problem (p = .074). Students' beliefs were unchanged related to using avoidance to address the situation. Students' perception remained unchanged about whether they had the skills to appropriately delegate care.
Effective Communication: Medication Error
Preinstruction students reported that they were uncomfortable in responding to a medication error but thought they were unlikely to avoid coping with the medication error and would likely report the error. Postinstruction students responded that they would be able to respond to a medication error (p = .011). However, students were unsure if they would avoid (p = .004) or report (p < .001) the medication error. No difference was found pre- and postinstruction in the students' belief that they have the skills (somewhat agree) to use effective communication in handling a medication error.
Students were uncomfortable in responding to the bullying preinstruction. Postinstruction, the students responded that they were somewhat comfortable in addressing bullying (p < .001). Preinstruction, students were unsure if they would avoid addressing bullying, but postinstruction reported that they were unlikely to use avoidance (p = .015). They were likely to report the bullying to their supervisor preinstruction, but postinstruction were undecided whether they would report the bullying (p < .001). Students were unsure whether they could address bullying preinstruction but somewhat agreed that they had the skills to address bullying postinstruction (p < .001).
No significant differences were found in students' comfort level, use of avoidance, tendency to report the issue, or belief in having the skills to address the performance management issue pre- and postinstruction.
Faculty evaluation of students' ability to use an effective communication technique after viewing one of the four trigger videos presented during the classroom instruction ranged from 12 to 15 points of a possible 15. Eighty-five percent of the students received a perfect score, and the remaining 15% scored between 12 and 14.5 points.
Using lecture alone to teach effective communication skills may not be the best way for all students to learn these complex concepts. Incorporating teaching strategies that address a variety of learning styles increases the likelihood that a learner will succeed in the course (Fleming & Mills, 1992). In this project, faculty addressed different learning style preferences by offering a variety of teaching strategies including lecture, trigger videos, and production of a student-created smartphone video with peer review in small-group discussions. The trigger videos provided faculty with consistent examples to promote class discussion and to support lecture content with teaching strategies to encourage student engagement and interaction.
The use of a student-created smartphone video supported Kolb's classic experiential learning model that recommends providing opportunities to practice a skill after education to increase the likelihood of engaging in the use of the skill by doing, reviewing, concluding, and planning (Ng et al., 2009). Trigger videos assisted the student to visualize a real-time workplace situation addressing a difficult conversation, increased active class participation with instruction of effective communication techniques, and evaluated the students' comfort and use of effective communication techniques to address a difficult conversation. Students frequently provided examples of difficult conversations they had witnessed or participated in during their clinical practice, especially related to bullying in the workplace. The smartphone video assignment allowed students to practice responding to a difficult conversation. Students participated in small-group sessions (up to 20 students) with faculty to view each other's videos and provide feedback using an assessment tool developed by faculty. Students were hesitant to provide feedback for need for improvement, which may have been due to the number of videos reviewed in the session or to student reluctance to provide less than positive feedback to a peer. Additionally, these smartphone video review sessions provided faculty with the opportunity to provide coaching in a small-group setting that may have been more effective than in a large classroom setting when modeling effective communication skills.
The evaluation of the educational initiative was conducted over a single term at one university with 88 participants, thus limiting the generalizability of the study. A total of nine surveys were administered throughout the term in response to trigger videos. There were fewer surveys returned toward the end of the semester, which may be a result of survey fatigue (Ben-Nun, 2008; Hochheimer et al., 2016). With continued study, the frequency of survey administration will be considered. Use of a quasi-experimental one-group pretest posttest study design did not contribute to the internal validity of the study as compared to having a control group, thus limiting the ability to determine the effect of the teaching strategies. Future considerations would be to use one campus as a control group and the other as the experimental group to determine the effect of the initiative and to survey the instructors for their input of their experience with use of the educational initiative in the classroom.
Faculty evaluators were trained to assess students' communication techniques using the rubric at the beginning of the semester. Student scores from the final faculty evaluation of students' response to a trigger video were high. However, high scores in response to trigger videos do not directly equate to the students' effectiveness in communication in the clinical setting.
The project addressed multiple adult learning styles and provided faculty with resources for student instruction. Application of Kolb's theoretical framework provided students with the opportunity to practice effective communication skills. Trigger and smartphone videos allowed students to observe, practice, and receive feedback in managing difficult conversations, whereas previously the content was taught in lecture form with no practice. The rubric allowed for objective measurement of these behaviors. Survey responses and faculty assessment provided a proof of concept that use of these teaching strategies provides practice for nursing students with effective communication and may improve skills in managing difficult conversations in the workplace.
- Agency for Healthcare Research and Quality. (2019). TeamSTEPPS® 2.0 self-paced course. Retrieved from https://www.ahrq.gov/teamstepps/instructor/onlinecourse.html
- American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from https://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf
- American Association of Critical-Care Nurses. (2016). AACN standards for establishing and sustaining healthy work environments: A journey to excellence (2nd ed.). Aliso Viejo, CA: Author.
- Ben-Nun, P. (2008). Respondent fatigue. Encyclopedia of Survey Research Methods, 2, 742–743.
- Berkow, S., Virkstis, K., Stewart, J. & Conway, L. (2008). Assessing new graduate nurse performance. Journal of Nursing Administration, 38, 468–474. doi:10.1097/01.NNA.0000339477.50219.06 [CrossRef]18997551
- Chan, L.K., Patil, N.G., Chen, J.Y., Lam, J.C., Lau, C.S. & Ip, M.S. (2010). Advantages of video trigger in problem-based learning. Medical Teacher, 32, 760–765. doi:10.3109/01421591003686260 [CrossRef]20795807
- Choi, Y., Song, E. & Oh, E. (2015). Effects of teaching communication skills using a video-clip on smart phone on communication competence and emotional intelligence in nursing students. Archives of Psychiatric Nursing, 29, 90–95. doi:10.1016/j.apnu.2014.11.003 [CrossRef]
- Fleming, N.D. & Mills, C. (1992). Helping students understand how they learn. Teaching Professor, 7(4), 44–63.
- Grant, M.S. & Jenkins, L.S. (2014). Communication education for prelicensure nursing students: Literature review 2002–2013. Nurse Education Today, 34, 1375–1381. doi:10.1016/j.nedt.2014.07.009 [CrossRef]
- Hochheimer, C.J., Sabo, R.T., Krist, A.H., Day, T., Cyrus, J. & Woolf, S.H. (2016). Methods for evaluating respondent attrition in web-based surveys. Journal of Medical Internet Research, 18, e301. doi:10.2196/jmir.6342 [CrossRef]27876687
- Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.
- Kolb, D.A. (1984). Experiential learning: Experience as the source of learning and development. Upper Saddle River, NJ: Prentice Hall.
- Ng, K.Y., Van Dyne, L. & Ang, S. (2009). From experience to experiential learning: Cultural intelligence as a learning capability for global leader development. Academy of Management Learning & Education, 8, 511–526. doi:10.5465/amle.8.4.zqr511 [CrossRef]
- Privitera, G.J. & Ahlgrim-Delzell, L. (2018). Quasi-experimental and single-case experimental design. In Research methods for education (pp. 333–370). Thousand Oaks, CA: Sage.
- Rasi, P.M. & Poikela, S. (2016). A review of video triggers and video production in higher education and continuing education PBL settings. Interdisciplinary Journal of Problem-Based Learning, 10, 7. doi:10.7771/1541-5015.1609 [CrossRef]
NUR 1134: Transition into Professional Nursing Effective Communication Skills in Addressing a Difficult Conversation in the Workplace Faculty Rubric
|Behavior||Possible Points||Constructive Feedback|
|Did the student observe personal aspects of the communication one would have to observe (e.g., private setting, personal space, language)?||4|
|Did the student use assertive communication techniques?||4|
|Are verbal and nonverbal communication congruent?||1|
|Student will use SBAR scripting tool to address the situation and will be evaluated using the associated scoring scale.|
| SBAR technique||5|
| 1. Situation (1)|
| 2. Background (1)|
| 3. Assessment (2)|
| 4. Recommendation (1)|
| Time limit observed (3 minutes maximum)||1|
| Total score (student must score at least 11.5 to be considered satisfactory).||15|