Patient safety may be compromised by failure to clearly communicate important details about patient status or misinterpretation of information shared (O’Daniel & Rosenstein, 2008). The failure to communicate effectively is frequently cited as the root of many evils in the workplace—especially in healthcare. Ineffective communication was identified as one of the root causes of 60% of the reported sentinel events (unexpected occurrence involving death or serious physical or psychological injury), in U.S. healthcare facilities in 2013 (Joint Commission, 2014).
Improving interprofessional teamwork and communication among healthcare workers has been identified as a key component by the Institute of Medicine (IOM) to address its six aims for improving safety and quality of healthcare (National Academies of Science, 2001). Congruent with this recommendation, the American Association of Colleges of Nursing (AACN) Essentials of Baccalaureate Education for Professional Nursing Practice state that effective communication is a vital skill for nursing students to learn in order to deliver high quality and safe patient care (AACN, 2008). Nurses must be as proficient in communication skills as they are in clinical skills. (AACN, 2016).
According to AACN (American Association of Critical-Care Nurses) Standards for Establishing and Sustaining Health Work Environments, “The health care organization provides team members with support for and access to interprofessional education and coaching that develop critical communication skills, including self-awareness, inquiry/dialogue, conflict management, negotiation, advocacy, and listening” (AACN, 2016). Using this critical element as a guide, the project team aimed to develop, implement, and evaluate innovative teaching strategies designed to enhance the communication skills and self-efficacy of senior nursing students by encouraging them to participate in and effectively manage difficult conversations in the workplace. This program featured strategies developed to assist nursing faculty in (1) teaching content related to communication, (2) encouraging students to practice communication skills in a safe environment, and (3) effectively evaluating student learning through direct feedback. In addition, the project encouraged student engagement in simulated situations (trigger video response and student-recorded cell phone videos) and illustrated problem-solving techniques supplementing lecture content. 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 (Nelms, Jones, & Gray, 1993). Project participants were senior nursing students (260) enrolled in an undergraduate (BSN) program at the main and satellite campus.
Four trigger video series were developed to model effective communication and facilitate (i.e., trigger) discussion in addressing difficult or crucial conversations in the workplace (e.g., incivility, delegation, performance issues, and hand-off reports). Students created cell phones videos recording the student’s use of scripted techniques provided in lecture to address a difficult conversation. Clinical faculty used structured debriefing during post conference to facilitate peer-review. The students used peer feedback to enhance future performance. Practice with student-recorded cell phone videos and scripted responses to trigger videos help to build students’ resilience and self-efficacy and may foster a healthy work environment.
The outcomes of this proposed teaching innovation were evaluated at several levels. First, the confidence level of participating students with communication skills was assessed before and after content delivery of each target topic in the course using a tool that incorporates skills featured in the Crucial Conversations methodology (Patterson, Grenny, & McMillian, 2011). Students indicated their experience and confidence with professional communication on a 5-point Likert scale (i.e., 1 = limited or no or little experience and/or confidence; 5 = considerable experience and/or complete confidence) in addressing typically difficult conversations encountered in the healthcare workplace (e.g., being bullied by a co-worker or supervisor, reporting an error involving a co-worker, and delegating tasks to reluctant or uncooperative subordinates). Secondly, nursing faculty evaluated student interactions in the prescribed scenarios through use of the project team’s developed rubric. Faculty members received an orientation for use of the rubrics to facilitate inter-rater reliability in assessing the self-recorded student communication videos. Lastly, students were evaluated on resiliency at the beginning and end of the semester using the Brief Resilience Coping Scale, comprised of 4-item, unidimensional outcome measure designed to capture to what extent an individual copes with stress in a resilient fashion (Smith et al., 2008).
The educational initiative had several significant effects. Students felt they could grow in positive ways by dealing with difficult situations (p=.048). Students reported feeling more comfortable in responding to a medication error situation (p<.011) and bullying (p< .011). Students were less likely to report the issue to their superior both for bullying and medication errors (p<.000). However, students were more likely to report a delegation situation to a superior p<.000. Bullying instruction facilitated a positive change in student perceptions about their skills in dealing bullying (p< .000).
The analysis of the results of the educational initiative indicated the students gained skills in communication that can support a healthy work environment. Students were more resilient in dealing with difficult conversations after the completion of these activities. A positive trend was noted with increased confidence and comfort in dealing with bullying and medication errors after the educational initiative. Students were less likely to avoid bullying incidences and felt they had gained skills to address bullying.