Effective communication about a patient critical incident among providers is linked to better patient outcomes (The Joint Commission, 2015). However, competing priorities in learning essential hands-on nursing skills and patient safety concerns for students to practice in emergent clinical situations limit pre-licensure nursing students’ opportunities to practice critical communication within their program of study (Bartges, 2012; Guhde, 2014). As a result, new graduates continue to enter practice without developing the competency to verbally deliver a clear and focused patient report to another provider.
Challenges in research on interprofessional communication skill development include designing an effective and sustainable educational intervention that can be readily incorporated into nursing curricula with a reliable and valid outcome measurement. The purposes of this paper are to 1) describe an innovative method for using story guided online deliberate practice (DP) intervention to develop nurses’ critical communication skills, and 2) examine challenges and opportunities in implementing online DP intervention to provide pre-licensure nursing students opportunities to practice critical communication with another provider.
Deliberate practice is an educational strategy in skills development which emphasizes the importance of repetitive practice with immediate feedback and well-defined but adjustable goals (Ericsson, Krampe, & Tesch-Romer, 1993). Considering preserving faculty/student class time and cost effectiveness, a series of online low-fidelity DP sessions guided by audio clinical stories were developed based on the theoretical framework of DP. The online DP intervention engaged students in completing biweekly online DP sessions over a ten-week summer session that included receiving feedback from the researcher following each session. Aiming for mastery, additional optional practice sessions were also made available to students. The DP sessions were built on an online education platform provided by the University where students had familiar access.
Audio stories were selected to simulate a clinical scenario for the online DP sessions as stories have a unique power to help understand a situation and can facilitate learners to link actions with consequences (Sherwood, Durham, & Zomorodi, 2016). In each 45-minute DP session students 1) listened to a clinical story, 2) constructed and recorded a verbal SBAR report (Situation-Background-Assessment-Recommendation), an evidence-based standardized communication tool (Kaiser Permanente), to a provider, 3) completed a self-assessment checklist to assess their own performance, 4) answered four self-reflection questions, and 5) recorded a refined SBAR report. At the end of each session students listened to an example of a good SBAR report recorded by a practicing clinician. Within two days after completing a session, students received email feedback and links to their verbal reports from the researcher.
Upon IRB approval, the online DP sessions were pilot-tested by seven nursing students. A focus group was conducted to obtain student feedback and the DP sessions were modified according to the recommendations. Students were recruited from a class of pre-licensure nursing students enrolled in a 10-week summer course to participate in a pilot experimental study with random group assignment. All students (n=81) completed two online DP sessions, the only sessions completed by the control group (n=21). Students in the intervention group (n=22) completed an additional three biweekly DP sessions and had access to four optional sessions. For both groups, the two required DP sessions served as the pre and post-tests. The ISBAR Interprofessional Communication Rubric [IICR] (Foronda & Bauman, unpublished), a validated tool is the basis for assessing students’ SBAR reporting performances. In addition, students completed an online survey on their experience using the online DP sessions.
CHALLENGES AND OPPORTUNITIES:
The evaluation survey (n=46, 56.8% participation rate) revealed that while 93.5% of students were satisfied with their experience in completing the online DP sessions, 40.0% reported encountering technical difficulties (e.g. online recorder failures and Internet browser incompatibilities) which led to an interrupted learning experience for some students and data loss. Close collaboration with information technology experts would provide a more thorough test of the online sessions and post solutions for students to provide an improved and sustainable learning experience.
To score student SBAR recordings using the IICR depended on an acceptable inter-rater reliability among three independent raters and the development of a reliable and detailed scoring sheet for each story. A good SBAR report was more than just stating information; clinical relevancy, the order, and the length of the report are key considerations. The clinical judgment required by each story must match the student’s current clinical knowledge and experience. Further discussion with content experts is needed to determine how to best address this in future research when evaluating students’ performance.
The evaluation survey revealed students agreed that the DP sessions prepared them to report a patient critical incident using SBAR; 98% reported improvements yet many recommended more specific feedback to improve and suggested a face-to-face debriefing session. For DP to be effective, learners need feedback and mindful self-correction to assist achieving competency. More study is needed on the most effective and efficient method for providing meaningful feedback.
Story guided online DP is a highly satisfactory and cost effective methodology in providing pre-licensure nursing students opportunities to practice critical communications, a high-stakes skill, in a low risk environment. Building on a widely used online education platform presents opportunities for application to different institutions and settings. The technical, evaluation, and structural challenges can be addressed through careful planning. Further research and educational adaptation are needed to facilitate the development of a skill that has a direct impact on patient outcomes.