Communication in health care is defined as a process by which information is exchanged and shared during interventions (Hannawa, Garcia-Jimenez, Candrian, Rossmann, & Schulz, 2015; Manojlovich, Squires, Davies, & Graham, 2015). Communication skills include sensitivity regarding verbal and nonverbal messages as well as listening and responding skills (Bodie, Vickery, Cannava, & Jones, 2015; Oliveira et al., 2015).

Communication can negatively or positively affect nursing care. Failing to communicate relevant patient information to physicians is a primary cause of sentinel events (Henriksen et al., 2008). Both patients and providers experience improved satisfaction and quality of care when the communication skills of providers improve (Shankar, Dubey, Balasubramanium, & Dwivedi, 2013). The purpose of this study was to assess nursing students' attitudes toward learning communication skills and how they perceived the importance of nursing communication and caring efficacy over time. Students participated in the study three times: before and after a course on communication and after one semester. Nurse interns, who took the course during their nursing education, completed the questionnaire one time only.

BACKGROUND

Bandura's (1997) social cognitive theory proposed that, to learn a behavior, a person must observe, imitate, and target a positive reinforcement. Learners selectively focus on activities valuable and significant to them. Role-play as a teaching method allows students to practice specific behaviors and receive individual feedback (David, 2015; Escarti, Wright, Pascual, & Gutierrez, 2015) in a safe environment.

The role-play method was used in this study to facilitate learning and apply communication skills in a nursing laboratory environment. Students practiced their communication skills in different scenarios simulating children, families, and patients under stress. These role-playing activities involved health promotion, breaking bad news, intercultural communication, and public speaking.

Although some studies have investigated medical and dental students' attitudes toward learning communication skills, few studies have been undertaken among nursing students. Mullan and Kothe (2010) evaluated the communication skills of 209 nursing students and found improvement following a communication program. Ak et al. (2011) found that, in the emergency department, the number of undesirable events decreased among patients and nurses after 16 nurses attended a six-week communication program.

Bandura (1997) defined self-efficacy as "beliefs in one's capabilities to organize and execute the courses of action required to produce given attainments" (p. 3). Individuals with high self-efficacy tend to be more committed and set challenging goals, unlike individuals with low self-efficacy, who are easily discouraged by obstacles or failure; interested people could be predicted by their perceived self-efficacy rather than by their actual performance (Bandura, 1997; Shapka & Ferrari, 2003). Most studies have investigated the caring concept, but none have studied caring efficacy, except for Coates (1997) and Sadler (2003), in a pilot study. Caring efficacy has a significant positive relationship with clinical skills (Coates, 1997). Investigating communication among nursing students and interns is important in developing changes in nursing education that encourage interprofessional and team communication (Clancy & Tornberg, 2007).

METHOD

A descriptive, longitudinal design was used to collect data from a convenience sample of undergraduate nursing students (n = 29) and new graduate nurses participating in a one-year internship program (n = 29). Interns had completed all academic requirements for a baccalaureate degree.

Instrument

The questionnaire included sections on attitudes toward communication skills, perceived importance of communication, caring efficacy, and demographic information. Three instruments that had been tested for validity and reliability in previous studies were used as follows:

The Communication Skills Attitude Scale (CSAS; Rees, Sheard, & Davies, 2002) is a 26-item questionnaire that measures positive and negative attitudes toward learning communication skills. The CSAS uses a 5-point Likert scale with scores ranging from 1 (strongly disagree) to 5 (strongly agree).

Perceived Importance of Medical Communication (PIMC), modified for nursing (Langille, Kaufman, Laidlaw, Sargeant, & MacLeod, 2001), consists of 12 items that assess attitudes of nurses in communicating with patients and the importance of communication. It uses a 5-point Likert scale with scores ranging from 1 (strongly disagree) to 5 (strongly agree). The reported reliability coefficient was 0.79.

The Caring Efficacy Scale (CES) for nurses (Coates, 1997) is a 30-item questionnaire that uses a 6-point Likert scale to assess nurses' belief in their ability to demonstrate a caring attitude and develop a caring relationship with patients and caregivers. Coates tested reliability on a random sample of 47 new nurses and reported that the scale is valid and reliable.

Reliability Cronbach's alphas in the current study were .84, .76, and .75 for the CSAS, PIMC, and CES, respectively.

Procedure

The study was reviewed and approved by the Nursing College Research Committee. Participants were informed that their participation was voluntary and anonymous, and they had the right to withdraw at any time. Returning the questionnaire meant that they consented to be included in the study.

The students started their first clinical experience when the course began; data were collected from students before the course, after the course, and after one semester. The interns had taken the course one year earlier.

RESULTS

The students' average age was 20.93 years (SD = 0.52); their average grade point average was 3.63 (SD = 0.96). The interns' average age was 22.52 years (SD = 0.52); their average grade point average was 4.5 (SD = 0.65).

Mean scores for students at time 1, time 2, and time 3 and for the interns were determined as follows:

CSAS, ATTITUDE

Students: time 1, M = 3.76, SD = 0.34; time 2, M = 3.81, SD = 0.32; time 3, M = 3.75, SD = 0.38.

Interns: M = 3.65, SD = 0.41.

PIMC, PERCEIVED IMPORTANCE

Students: time 1, M = 3.35, SD = 0.24; time 2, M = 3.53, SD = 0.33; time 3, M = 3.41, SD = 0.21.

Interns: M = 3.39, SD = 0.28.

CES, CARING SELF-EFFICACY

Students: time 1, M = 3.30, SD = 0.37; time 2, M = 3.29, SD = 0.36; time 3, M = 3.19, SD = 0.42.

Interns, M = 3.56, SD = 0.50.

Repeated-measures analysis of variance indicated no significant differences over time regarding the students' attitudes toward learning communication skills, F(3,75) = .97, p = .39, or their perceived importance of nursing communication, F(3,75) = 1.94, p = .13; however, their caring efficacy improved, F(3,75) = 5.50, p = .002. The newly graduated interns reported higher scores for caring efficacy when compared to the students' scores. However, both groups showed high mean scores for the main variables.

DISCUSSION

No significant differences were found over time in the students' attitudes toward learning communication skills. This result was in agreement with Wright and colleagues (2009), who found no significant differences between first- and fourth-year medical students regarding their attitudes toward learning communication skills. However, two studies have found a significant difference between groups regarding their attitudes toward learning communication skills: female medical students had more positive attitudes than their male counterparts, thus making their communication more effective (Fazel & Aghamolaei, 2011; Shankar et al., 2013).

No significant differences were found over time regarding the students' perceived importance of nursing communication. This finding contradicts Wright and colleagues' (2009) findings, which indicated that fourth-year medical students had significantly higher scores compared to first-year students. A possible explanation could be that the students' attitudes and perceptions of the importance of learning about communication actually developed during their coursework and simultaneous role-play, along with their exposure to clinical training among different populations (e.g., pediatrics, pregnant women, psychiatric patients).

The nursing interns reported significantly higher scores in terms of caring efficacy compared to the students, which is supported by Bandura's theory and matches that of Sadler (2003), who investigated caring efficacy among 193 baccalaureate nursing students and found that seniors reported higher scores compared to novice students. Interns may have more experience, spend more time with patients, and, therefore, become more confident in their caring skills.

Limitations

These study results could only be generalized to students in the same nursing college who were taking the same course because the sample size was low and derived from only one educational organization.

Recommendations

Students need to be equipped with various skills for clinical practice in order to deal with patients' needs, anxieties, and concerns. Students' attitudes toward communication skills may lead to more accurate assessments and treatment processes, thereby increasing patient satisfaction and safety. Supplementing extracurricular activities with role-play to enhance students' efficacy and decrease their anxiety is recommended.

Replication of this study is also important to help understand factors other than time that could have affected the results, particularly with regard to more evidence-based studies and collaborative interprofessional approaches in nursing education (Keller, Eggenberger, Belkowitz, Sarsekeyeva, & Zito, 2013). Improving nurses' communication skills, which is one of the required nursing education core competencies, will consequently improve other incorporated core nursing education outcomes such as professionalism, problem solving, and leadership (Oh et al., 2011).

REFERENCES