communication assignment for nursing students

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Week 3: Communication Part A

Unit Learning Outcomes:

At the end of this chapter, the learner will:

• Discuss effective therapeutic communication and professional communication.
• Demonstrate therapeutic communication skills to communicate with patients and their families.

Overview of this chapter

This chapter includes information  related to therapeutic communication and communication skills to care for your patients and families. This is the first section focuses on techniques to apply effective therapeutic communication and professional communication. The second part includes different therapeutic communication tools, documentation guidelines and different types of communication.

1. Introduction of Communication

When you think of communication, talking to another person or texting them might come to mind first. However, while talking and texting are methods of communication delivery, they are not representative of a comprehensive definition of communication.

A more comprehensive understanding of communication refers to the  sharing  of information, ideas, and feelings, typically aimed at  mutual understanding . In this way, you must consider the sender, the recipient, and the transaction. Simply put, the sender is the person sharing the message, the recipient is the person receiving and interpreting the message, and the transaction is the way that the message is delivered and the factors that influence the context and environment of the communication. As you can see, communication is a complex process. It involves more than just what you say and takes many forms as reflected in  Figure 3.1 .

Figure 3.1 : Forms of communication.

There are  three types of communication :

• Verbal communication is  oral communication  that happens through spoken words, sounds, vocal intonation, and pace. It can occur face-to-face, one-on-one, or in groups, over the telephone, or video conferencing. As a nurse, you will engage in verbal communication with clients, families, colleagues, and interprofessional teams.
• Non-verbal communication is a type of communication that occurs through  facial expressions, eye contact, gestures,  and  body positions  and  movements . As a nurse, you will learn that your non-verbal communication is important because it can both reinforce or contradict what you say verbally. Additionally, non-verbal communication is used more often than verbal communication. Thus, you must become aware of your non-verbal communication.
• Written communication is a type of communication that occurs through  written words, symbols, pictures,  and  diagrams . You are probably familiar with some informal, written types of communication, such as texting or emailing someone, posting a picture on Instagram, or using an emoji in Twitter. You may also have engaged in more scholarly forms of written communication such as letters and papers. As a nurse, written communication also involves documentation notes and scholarly writing like essays, peer-reviewed publications, protocols, practice standards, and best practice guidelines. You may not be familiar with some of these types of written communication yet, but you will become more acquainted with them over the course of your nursing program.

Professional Communication

Exercises: Check Your Understanding

II. Communication in Professional Practice

A. Therapeutic communication  is at the foundation of the nurse-client relationship as reflected in  Figure 3.2 . It is different than the conversations you have with friends, peers, family, and colleagues. Therapeutic communication has a  specific purpose within the healthcare context. It is intended to develop an effective interpersonal nurse-client relationship that supports the client’s wellbeing and ensures holistic, client-centered, quality care.

The word “ therapeutic ” is related to the word therapy: it means having a restorative and healing effect on the mind and body as well as doing no harm. It is important to consider how you communicate and how this affects the client.

Point of Consideration

Learning Therapeutic Communication

Therapeutic communication is a learned activity that requires knowledge and continued practice and self-reflection.

Exercises: Therapeutic Communication/nontherapeutic Communication

Watch the first part of the video “Nontherapeutic vs therapeutic communication”    https://www.youtube.com/watch?v=Ik_hwMHVHM4  

• Students to work independently or in groups to answer the following questions(#3).
• Get back together and discuss the students’ responses.
• Discuss appropriate therapeutic techniques to correct the observed nurse patient interaction. Explore students’ thoughts and reflections.
• Watch the second  part of the video demonstrating appropriate therapeutic communication.
• Remember that communication in the nurse-patient relationship should focus on the patient and patient needs, not on the nurse or an activity in which the nurse is engaged.

III. Communication Strategies

There are many  communication strategies  that should be used to  facilitate therapeutic communication . See  Table 3.1  for a list of these strategies and considerations and examples on how they build the therapeutic relationship.

Table 3.1 : Communication strategies.

Film Clip 3.4 : Demonstration of how to avoid false reassurance. http://pressbooks.library.ryerson.ca/communicationnursing/wp-content/uploads/sites/99/2020/06/How-to-Avoid-False-Reassurance.mp4?_=2

3. Share your take-aways  from this exercise to the class

IV. Barriers to Effective communication:

Effective communication is an important part of nursing skill. There are several barriers for effective communication. Some of those example are language, culture, noise, perception, special needs such as hearing/vision difficulty and  medication. For more information:  https://med.libretexts.org/Bookshelves/Nursing/Nursing_(Ulutasdemir)/03%3A_Effective_Communication_in_Nursing/3.07%3A_Barriers_to_Effective_Communication

Nurses optimize communication through active listening to patients and families. Sometimes there are invisible needs of those around us.

1. View the following video and reflect on the often invisible needs of those around us and the difference we can make by creating caring human connections. Encourage students to verbalize their thoughts, impressions, feelings, etc.  

View the video: Empathy: The Human Connection to Patient Care:  https://youtu.be/cDDWvj_q-o8?si=duFev4pzDJAk7u5E

2. Communicating with Patients:   https://batch.libretexts.org/print/url=https://med.libretexts.org/Bookshelves/Nursing/Nursing_Fundamentals_(OpenRN)/02%3A_Communication/2.03%3A_Communicating_with_Patients.pdf

• What strategies would you implement when communicating with patients with impaired hearing and vision?
• List therapeutic techniques and non-therapeutic responses of communication

Review: Documentation/charting guidelines:

Please review Documentation: Using Technology to Access Information : https://batch.libretexts.org/print/url=https://med.libretexts.org/Bookshelves/Nursing/Nursing_Fundamentals_(OpenRN)/02%3A_Communication/2.05%3A_Documentation.pdf

Review Documentation/charting guidelines for Montgomery college nursing students. You can find this document in the Blackboard under this week content.

Review sample  and discuss importance of different types of notes.

Exercise: SAMPLE DOCUMENTATION 

Sample Documentation of Expected Findings 

Patient denies cough, chest pain, or shortness of breath. Denies past or current respiratory illnesses or diseases. Symmetrical anterior and posterior thorax. Anteroposterior-transverse ratio is 1:2. Respiratory rate is 16 breaths/minute, unlabored, regular, and inaudible through the nose. No retractions, accessory muscle use, or nasal flaring. Chest rise and fall are equal bilaterally. Skin is pink, warm, and dry. No crepitus, masses, or tenderness upon palpation of anterior and posterior chest. Lung sounds clear bilaterally in all lobes anteriorly and posteriorly. No adventitious sounds. SpO2 saturation 99% on room air.

Sample Documentation of Unexpected Findings

Patient reports shortness of breath for five to six hours. Patient has labored breathing at rest. Nail beds are cyanotic. Respiratory rate is tachypneic at 32/minute with neck and abdominal accessory muscle use. Lung expansion is symmetrical. Pursed-lip breathing noted with intermittent productive cough. Reports coughing up blood-tinged green sputum for two days. Anterior and posterior chest walls have no tenderness, masses, or crepitus upon palpation. On auscultation bilateral coarse crackles over lung bases. Expiratory wheezes are audible and heard with stethoscope scattered throughout lung fields. Pulse oximetry 93% on room air.

Exercises :  Practice Writing Nursing Documentation

Patient Scenario

Mr. Hernandez is a 47-year-old patient admitted to the neurological trauma floor as the result of a motor vehicle accident two days ago. The patient sustained significant facial trauma in the accident and his jaw is wired shut. His left eye is currently swollen, and he had significant bruising to the left side of his face. The nurse completes a visual assessment and notes that the patient has normal extraocular movement, peripheral vision, and pupillary constriction bilaterally.

Additional assessment reveals that Mr. Hernandez also sustained a fracture of the left arm and wrist during the accident. His left arm is currently in a cast and sling. He has normal movement and sensation with his right hand.

Mrs. Hernandez is present at the patient’s bedside and has provided additional information about the patient. She reports that Mr. Hernandez’s primary language is Spanish but that he understands English well. He has a bachelor’s degree in accounting and owns his own accounting firm. He has a history of elevated blood pressure, but is otherwise healthy.

The nurse notes that the patient’s jaw is wired and he is unable to offer a verbal response. He does understand English well, has appropriate visual acuity, and is able to move his right hand and arm.

Based on the assessment information that has been gathered, the nurse plans several actions to enhance communication. Adaptive communication devices such as communication boards, symbol cards, or electronic messaging systems will be provided. The nurse will eliminate distractions such as television and hallway noise to decrease sources of additional stimuli in the communication experience.

Practice writing  admission nurse’s note. Share your notes with the class for further discussion.

Activity: Check Your Understanding

What are your key-take away from today? Share your thoughts with the class

 Assignment 

Review assignment instructions in the Blackboard

• Nurses and their Specialties
• Reflection on “professionalism in nursing”

V.  Recommended Resources

Read the American Nurses Association’s  Principles for Nursing Documentation .

COMMUNICATION INTRODUCTION: https://www.ncbi.nlm.nih.gov/books/NBK591817/

References and Attributions

1.Professional Communication: Retrieved from:  http://Introduction: Therapeutic Communication.    Creative Commons Attribution-NonCommercial 4.0 International License

2. Communicating with Patients: Retrieved from: https://batch.libretexts.org/print/url=https://med.libretexts.org/Bookshelves/Nursing/Nursing_Fundamentals_(OpenRN)/02%3A_Communication/2.03%3A_Communicating_with_Patients.pdf

The Novice Nurse's Guide to Professional Nursing Practice Copyright © by Kunjamma George and rbertiz is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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Communication

Communicating with Patients

Open Resources for Nursing (Open RN)

Therapeutic communication is at the foundation of the nurse-client relationship. It is different than the conversations you have with friends, peers, family, and colleagues. Therapeutic communication has a specific purpose within the healthcare context. It is intended to develop an effective interpersonal nurse-client relationship that supports the client’s wellbeing and ensures holistic, client-centered, quality care.

Therapeutic communication is further defined as, “The purposeful, interpersonal information-transmitting process through words and behaviors based on both parties’ knowledge, attitudes, and skills, which leads to patient understanding and participation.” [1] Therapeutic communication techniques used by nurses have roots going back to Florence Nightingale, who insisted on the importance of building trusting relationships with patients and believed in the therapeutic healing that resulted from nurses’ presence with patients. [2] Since then, several professional nursing associations have highlighted therapeutic communication as one of the most vital elements in nursing.

Read an example of a nursing student effectively using therapeutic communication with patients in the following box.

An Example of Nursing Student Using Therapeutic Communication

Ms. Z. is a nursing student who enjoys interacting with patients. When she goes to patients’ rooms, she greets them and introduces herself and her role in a calm tone. She kindly asks patients about their problems and notices their reactions. She does her best to solve their problems and answer their questions. Patients perceive that she wants to help them. She treats patients professionally by respecting boundaries and listening to them in a nonjudgmental manner. She addresses communication barriers and respects patients’ cultural beliefs. She notices patients’ health literacy and ensures they understand her messages and patient education. As a result, patients trust her and feel as if she cares about them, so they feel comfortable sharing their health care needs with her. [3] , [4]

Active Listening and Attending Behaviors

Listening is obviously an important part of communication. There are three main types of listening: competitive, passive, and active. Competitive listening happens when we are focused on sharing our own point of view instead of listening to someone else. Passive listening occurs when we are not interested in listening to the other person and we assume we understand what the person is communicating correctly without verifying. During active listening , we are communicating verbally and nonverbally that we are interested in what the other person is saying while also actively verifying our understanding with the speaker. For example, an active listening technique is to restate what the person said and then verify our understanding is correct. This feedback process is the main difference between passive listening and active listening. [5]

Touch is a powerful way to professionally communicate caring and empathy if done respectfully while being aware of the patient’s cultural beliefs. Nurses commonly use professional touch when assessing, expressing concern, or comforting patients. For example, simply holding a patient’s hand during a painful procedure can be very effective in providing comfort. See Figure 2.7 [6] for an image of a nurse using touch as a therapeutic technique when caring for a patient.

Therapeutic Techniques

Therapeutic communication techniques are specific methods used to provide patients with support and information while focusing on their concerns. Nurses assist patients to set goals and select strategies for their plan of care based on their needs, values, skills, and abilities. It is important to recognize the autonomy of the patient to make their own decisions, maintain a nonjudgmental attitude, and avoid interrupting. Depending on the developmental stage and educational needs of the patient, appropriate terminology should be used to promote patient understanding and rapport. When using therapeutic communication , nurses often ask open-ended statements and questions, repeat information, or use silence to prompt patients to work through problems on their own. [7] Table 2.3a describes a variety of therapeutic communication techniques. [8]

Table 2.3a Therapeutic Communication Techniques

In addition to the therapeutic techniques listed in Table 2.3a, nurses and nursing students should genuinely communicate with empathy. Communicating honestly, genuinely, and authentically is powerful. It opens the door to creating true connections with others. [9] Communicating with empathy has also been described as providing “unconditional positive regard.” Research has demonstrated that when health care teams communicate with empathy, there is improved patient healing, reduced symptoms of depression, and decreased medical errors. [10]

Nurses and nursing students must be aware of potential barriers to communication. In addition to considering common communication barriers discussed in the previous section, there are several nontherapeutic responses to avoid. These responses often block the patient’s communication of their feelings or ideas. See Table 2.3b for a description of nontherapeutic responses. [11]

Table 2.3b Nontherapeutic Responses

Strategies for Effective Communication

In addition to using therapeutic communication techniques, avoiding nontherapeutic responses, and overcoming common barriers to communication, there are additional strategies for promoting effective communication when providing patient-centered care. Specific questions to ask patients are as follows:

• What concerns do you have about your plan of care?
• What questions do you have about your medications?
• Did I answer your question(s) clearly or is there additional information you would like? [12]

Listen closely for feedback from patients. Feedback provides an opportunity to improve patient understanding, improve the patient-care experience, and provide high-quality care. Other suggestions for effective communication with hospitalized patients include the following:

• Round with the providers and read progress notes from other health care team members to ensure you have the most up-to-date information about the patient’s treatment plan and progress. This information helps you to provide safe patient care as changes occur and also to accurately answer the patient’s questions.
• Review information periodically with the patient to improve understanding.
• Use patient communication boards in their room to set goals and communicate important reminders with the patient, family members, and other health care team members. This strategy can reduce call light usage for questions related to diet and activity orders and also gives patients and families the feeling that they always know the current plan of care. However, keep patient confidentiality in mind regarding information to publicly share on the board that visitors may see.
• Provide printed information on medical procedures, conditions, and medications. It helps patients and family members to have multiple ways to provide information. [13]

Adapting Your Communication

When communicating with patients and family members, take note of your audience and adapt your message based on their characteristics such as age, developmental level, cognitive abilities, and any communication disorders. For patients with language differences, it is vital to provide trained medical interpreters when important information is communicated.

Adapting communication according to the patient’s age and developmental level includes the following strategies:

• When communicating with children, speak calmly and gently. It is often helpful to demonstrate what will be done during a procedure on a doll or stuffed animal. To establish trust, try using play or drawing pictures.
• When communicating with adolescents, give freedom to make choices within established limits.
• When communicating with older adults, be aware of potential vision and hearing impairments that commonly occur and address these barriers accordingly. For example, if a patient has glasses and/or hearing aids, be sure these devices are in place before communicating. See the following box for evidence-based strategies for communication with patients who have impaired hearing and vision. [14]

Media Attributions

• beautiful african nurse taking care of senior patient in wheelch
• Abdolrahimi, M., Ghiyasvandian, S., Zakerimoghadam, M., & Ebadi, A. (2017). Therapeutic communication in nursing students: A Walker & Avant concept analysis. Electronic Physician, 9 (8), 4968–4977. https://doi.org/10.19082/4968 ↵
• Karimi, H., & Masoudi Alavi, N. (2015). Florence Nightingale: The mother of nursing. Nursing and Midwifery Studies, 4 (2), e29475. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4557413/ . ↵
• “ beautiful african nurse taking care of senior patient in wheelchair ” by agilemktg1 is in the Public Domain ↵
• This work is a derivative of Human Relations by LibreTexts and is licensed under CC BY-NC-SA 4.0 ↵
• Flickr - Official U.S. Navy Imagery - A nurse examines a newborn baby..jpg ” by MC2 John O'Neill Herrera/ U.S. Navy is in the Public Domain ↵
• American Nurse. (n.d.). Therapeutic communication techniques . https://www.myamericannurse.com/therapeutic-communication-techniques/ ↵
• Balchan, M. (2016). The Magic of Genuine Communication. http://michaelbalchan.com/communication/ ↵
• Morrison, E. (2019). Empathetic Communication in Healthcare. https://www.cibhs.org/sites/main/files/file-attachments/empathic_communication_in_healthcare_workbook.pdf?1594162691 ↵
• Burke, A. (2021). Therapeutic Communication: NCLEX-RN. https://www.registerednursing.org/nclex/therapeutic-communication/   ↵
• Smith, L. L. (2018, June 12). Strategies for effective patient communication. American Nurse . https://www.myamericannurse.com/strategies-for-effective-patient-communication/ ↵
• Smith, L. L. (2018, June 12). Strategies for effective patient communication. American Nurse. https://www.myamericannurse.com/strategies-for-effective-patient-communication/ ↵
• Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing interventions classification (NIC) . Elsevier, pp. 115-116 ↵

About the Author

name: Open Resources for Nursing (Open RN)

Communicating with Patients Copyright © 2021 by Open Resources for Nursing (Open RN) is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Open Access

Peer-reviewed

Research Article

An online communication skills training program for nursing students: A quasi-experimental study

Roles Data curation, Formal analysis, Investigation, Project administration, Resources, Software, Visualization, Writing – original draft

Affiliation Department of Nursing Science, Kyungbok University, Namyangju, Korea

Roles Conceptualization, Methodology, Supervision, Validation, Writing – review & editing

* E-mail: [email protected]

Affiliation College of Nursing and the Research Institute of Nursing Science, Seoul National University, Seoul, South Korea

• Jeongwoon Yang, 
• Sungjae Kim

• Published: May 4, 2022
• https://doi.org/10.1371/journal.pone.0268016
• Peer Review
• Reader Comments

In South Korea, in 2019, approximately 45.5% of newly-graduated nurses quit their jobs within one year of employment. To better understand the adjustment to nursing practice upon graduation, we developed an online communication skills training program based on nonviolent communication and evaluated its effectiveness. A quasi-experimental design was adopted. The sample included 28 participants in the experimental group and 27 in the control group after one participant in the control group dropped out. The participants were fourth-year nursing students at the K and S University in Gyeonggi Province, South Korea, with some clinical training in a hospital setting. Data were analyzed using the χ 2 test, Fisher’s exact test, and independent t-test. Participants’ empathy, communication skills, anger, and self-efficacy were assessed before and after the training, as well as across the two groups. The experimental group showed significantly higher levels of empathy, communication skills, and self-efficacy compared to the control group after the program completion. However, there were no significant differences in anger. This study suggests the effectiveness of the online version of the nonviolent communication training. Therefore, providing this program to nursing students scheduled for graduation may help retain newly-graduated nurses.

Citation: Yang J, Kim S (2022) An online communication skills training program for nursing students: A quasi-experimental study. PLoS ONE 17(5): e0268016. https://doi.org/10.1371/journal.pone.0268016

Editor: Sergio A. Useche, Universitat de Valencia, SPAIN

Received: October 20, 2021; Accepted: April 20, 2022; Published: May 4, 2022

Copyright: © 2022 Yang, Kim. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All data generated or analysed during this study are included in the Supporting information files.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

As of 2019, approximately 20,000 nursing students graduated from the 203 nursing schools in South Korea [ 1 ]. After completing a minimum of 130 theoretical courses and 1,000 clinical hours to be equipped with the competency required of nurses in clinical practice, those who pass the licensure exam become registered nurses [ 1 ].

Approximately 45.5% of the newly-graduated nurses in Korea quit their jobs within one year of employment [ 2 ], many of whom leave the profession entirely. Thus, Korea has a relatively low proportion of active nurses among the Organization for Economic Co-operation and Development (OECD) countries, despite having the highest proportion of newly-graduated nurses [ 3 ]. In Korea, it is time-consuming for a newly-graduated nurse to exhibit at least 90% proficiency as compared to that of a skilled nurse; further, on an average, over 25% of the annual cost-to-company is spent on training newly-graduated nurses [ 4 ]. Hence, the resignation of nurses within one year of employment is inefficient not only for nurses themselves, but also for the organization.

Premature resignation of newly-graduated nurses has been attributed to rotating shifts, including night shifts [ 5 ], stress from inexperience in nursing-related tasks [ 6 ], workload and burnout due to understaffing [ 7 ], and inefficient communication with fellow nurses [ 6 , 8 ]. Communication problems significantly contribute to interpersonal workplace conflict [ 9 ] and cause low work efficiency and job satisfaction [ 10 , 11 ]. Newly-graduated nurses, when subjected to harsh criticism, become pessimistic about their competency and feel alienated from their organization [ 12 ]. This, in turn, markedly undermines their efficiency and confidence in nursing work [ 9 ], ultimately forcing them to quit their jobs [ 10 ]. Further, approximately 60–70% of nurses in Korea and abroad have reported to have experienced verbal violence in the hospital [ 9 , 13 ], which highlights the gravity of such communication problems.

Newly-graduated nurses with low levels of empathy fail to engage in effective interaction and communication with their clinical supervisor, which increases their job stress and turnover intention [ 10 ]. Further, newly-graduated nurses who are not able to engage in respectful conversations with colleagues do not develop a sense of belonging, and experience elevated job stress [ 14 ]. These findings suggest that the communication difficulties experienced by newly-graduated nurses in their workplace are associated with their communication skills. Hence, fostering effective communication skills in newly-graduated nurses would help prevent premature resignation.

Studies have reported that nurses with effective communication skills show high levels of empathy and self-efficacy [ 9 , 15 ]. That is, nurses adept at effective communication can engage in conversations with fellow nurses and patients using empathy. In addition, effective communication skills enhance work efficiency [ 16 ] and improve self-efficacy, thereby increasing job satisfaction [ 14 ]. In hospital settings, wherein nurses work on rotating shifts, effective communication among nurses is essential for continuity in patient care [ 17 ]. Moreover, because nursing work often involves highly stressful situations due to the urgency and gravity of dealing with human lives [ 18 ], lack of communication or minor communication errors may lead to medical malpractice [ 19 ]. Preceptors who train newly-graduated nurses often use a strict tone with them due to the risks and possibility of errors in patient care [ 20 ]; newly-graduated nurses may take such a tone personally [ 20 ] and react with feelings of anger. Considering such work situations and conditions, training in communication skills as part of undergraduate nursing education would help newly-graduated nurses improve their empathy, self-efficacy, and anger management ability [ 21 ]. Further, better communication skills could also help prevent premature turnover [ 22 ].

Communication skills can be improved through practice and training [ 23 ]. Effective communication skills involve clearly delivering one’s opinion and accepting the other person’s opinion [ 24 ], and nonviolent communication (NVC) encompasses these factors. Nonviolent communication, also referred to as compassionate communication, is a conversation model developed by Marshall Rosenberg based on Mahatma Gandhi’s values and Carl Rogers’ therapeutic principles [ 25 ]. It comprises two key factors: expressing honestly and listening empathetically [ 25 ]. It is a conversation technique based on compassion toward others, which also helps one engage in introspection and build relationships with others [ 25 ]. Therefore, by learning and practicing NVC, we reason that the nurses would be able to empathize with their fellow nurses, understand the meaning of their words and their intentions, and appropriately and honestly express their own emotions and needs in a clinical setting.

Currently available modules for communication training and education for nursing students focus on therapeutic communication when interacting with patients [ 26 ]. Such programs rarely train nursing students on self-expression during conversations with colleagues. To the best of our knowledge, there are no online NVC training courses that are specific to undergraduate nursing students or nurses; however, online NVC courses for health professionals in general and an offline course for nurses do exist [ 27 ]. Communication courses are generally lower division courses targeting first- or second-year students who have not begun their clinical training [ 28 ]. Therefore, it is helpful for fourth-grade students who are about to graduate to receive communication training once again since their skills are limited in that they may not necessarily translate their service to the context of understanding the reality of clinical nursing settings. However, due to the global pandemic (COVID-19), online education began in the first semester for the cohort starting in 2020 [ 29 ]. Thus, this study aimed to develop and evaluate the feasibility of an NVC-based online communication skills training program (NVC-CST program) to address the needs of nursing students. The NVC-CST program that we have developed focuses on fostering students’ empathy, self-efficacy, appropriate anger expression, and communication skills.

Materials and methods

The present study used a quasi-experimental pretest-posttest design. Volunteer participants were randomly assigned into the experimental group or control group using the Research Randomizer computer program ( https://www.randomizer.org ). The effectiveness of the online NVC-CST program was also tested.

Participants

Fifty-six nursing students at the K and S University in Gyeonggi Province, South Korea, were enrolled in the study. The inclusion criteria were (a) fourth-year nursing students, and (b) having experienced clinical training at a hospital. The exclusion criteria were (a) minors under the age of 18 (as per Article 2 of the Child Welfare Act of the Republic of Korea) and (b) currently being on a leave of absence.

The sample size to achieve the study objectives was determined using the G*Power Program (version 3.1); the minimum sample size was calculated to be 42, with 21 participants in the experimental group and 21 in the control group (effect size = 0.80, significance = .05, power = .80, two-tailed test). Considering a potential 30% withdrawal rate, 56 students were enrolled. The number of groups (2) and the total number of people (56) for the groups were entered into the Research Randomizer program. Subsequently, the participants were assigned to the experimental and control groups based on the numbers assigned to them by the program. One participant from the control group dropped out (due to personal reasons, even after having attended the program twice), resulting in 28 participants in the experimental group and 27 in the control group. The effect size was established with reference to 0.87, as reported in a Korean study that analyzed NVC-based interventions [ 24 ].

Procedure and data collection

The public institutional review board (IRB No. P01-202010-12-001) approved this study, and data were collected from October 5, 2020 to November 15, 2020. Additionally, the study protocol was in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki). Students were informed about the nature of the study, following which they provided signed consent to participate, prior to enrollment. Both the experimental and control groups completed the same questionnaire both before and after the intervention. The experimental group was instructed to access an online platform to participate in the NVC-CST program twice a week. Due to the pandemic, both sets of participants had been taking online classes without physically attending school; therefore, there was no contamination between the experimental and control groups. To prevent the diffusion effect, the duration of access to each 30-minute session was restricted to 3 hours. We also monitored the number of participants on the online platform to confirm that participants in the experimental group participated regularly. No communication program was provided to the control group. However, upon completion of the NVC-CST program, the control group students were allowed access to the program upon request.

The Nonviolent Communication-based online Communication Skills Training (NVC-CST) program

The NVC-CST program aims to help students acquire the skills of expressing their emotions and situations, empathizing with others, and accepting others during conversations, by enabling the students to practice communication skills learned online.

Specifically, this program entails educating participants about the fundamental principles of NVC and helping them practice these skills by applying the principles while communicating with fellow nurses. Various communication case studies were developed with reference to qualitative studies that examined the clinical experiences of newly-graduated nurses in the Korean cultural context [ 12 , 30 ]. The facilitator of the program was a nursing professor with 15 years of clinical nursing practice and experience in training various groups on NVC. The program utilized cognitive and behavioral approaches, including lectures, conversation demonstrations, assignments, and testimonies. A lecture was provided on each session’s topic. Moreover, demonstrations of both ineffective communication and NVC-based communication were provided. Students were given an assignment to apply the topic of each session to daily life, and they were instructed to write a testimony after each session, except the introductory one.

The NVC-CST program involved four stages, comprising eight sessions overall ( Table 1 ). Session 1 comprised an introduction to the NVC-CST program and an explanation of the objectives, with a focus on building a trusting relationship between the facilitator and the participants. Session 2 covered the four principles of NVC; the focus was on distinguishing between observations and feelings and understanding needs and requests. Students were assisted in understanding these four principles of NVC using a case study of a nurse from the period of his/her graduation to the achievement of a senior position. Session 3 focused on understanding that “feelings” and “needs” are connected, as well as understanding the positive energy of “needs”. Further, an example of a conversation with a fellow nurse was provided to help students realize that others’ needs are as important as one’s own. Session 4 comprised various clinical practice cases to provide intensive training on empathetic listening and honest self-expression.

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https://doi.org/10.1371/journal.pone.0268016.t001

Session 5 comprised practices in correcting ineffective communication habits with the goal of fostering the competency to distinguish “observation” from “evaluation”. In particular, examples of criticizing or disparaging conversations that commonly occur among nurses in clinical practice were used to show the difference between criticism and objective observation. Here, the focus was to distinguish between the two. Session 6 comprised practices intended to improve recognition of one’s own and others’ feelings and needs. In this session, instances of conversations in a clinical setting was presented to provide students an opportunity to indirectly experience them. Session 7 involved learning about the appropriate ways to express anger and the steps involved in anger expression. Based on the NVC principle that views anger as an alarm for bodily and mental responses, this session trained students in appropriately expressing anger, instead of ignoring or suppressing it. For example, helping them objectively describe a situation in which they experienced anger. Session 8 comprised expressing gratitude and learning about the possible barriers to empathy. Various speech patterns that hinder empathy, such as analyzing and diagnosing, correcting, stopping the flow of emotion, sympathizing, and investigating, were described using examples of conversations among clinical nurses. In the latter part of Session 8, students were given time to briefly meditate and reflect on themselves.

The Empathy Quotient-Short Form (EQ-Short-K) [ 31 ], a Korean-adapted version of the Empathy Quotient-Short Form [ 32 ], was used to assess empathy. The EQ-Short-K has 11 items that are responded to using a 3-point Likert scale ranging from 0 (disagree) to 2 (strongly agree). Total scores can range from 0 to 22, with a higher score indicating higher levels of empathy. The reliability of this instrument, as measured by Cronbach’s α, was .88 at the time of development [ 31 ] and .82 in the present study.

Self-efficacy.

The New General Self-Efficacy Scale (NGSE) [ 33 ] was employed in the present study to assess self-efficacy; it has been used in a previous Korean study [ 34 ]. This instrument has eight items that are responded to using a 7-point Likert scale. The average score is the mean item response, ranging from 1–7, where a higher score indicates higher self-efficacy. Cronbach’s α was .84 in the Korean study [ 34 ] and .91 in the current study.

The Korean State-Trait Anger Expression Inventory (STAXI-K) [ 35 ] is a Korean standardized version of Spielberger’s [ 36 ] STAXI. There are 24 items that assess anger expression across three subscales: Anger-in, Anger-out, and Anger Control. Items are responded to using a 4-point Likert scale. The anger score was calculated as follows: [(Anger-in score + Anger-out score)–Anger Control score + 16]. Total scores range from 0 to 72, with higher scores indicating higher levels of anger expression. Cronbach’s α was .74 for Anger-in, .73 for Anger-out, and .81 for Anger Control in the Chon et al. [ 35 ] STAXI-K study; in the current study, these values were .68, .76, and .78, respectively.

Communication skills.

Communication competencies were measured using the Global Interpersonal Communication Competency Scale (GICC-15) [ 37 ]. The GICC has 15 items that are responded to using a 5-point Likert scale and consists of three subscales: Relationship, Language, and Interpersonal Competency. The total score is the mean item response, with a range of 1–5, where a higher score indicates higher communication skills. Hur [ 37 ] reported a Cronbach’s α = .72 at the time of development. Cronbach’s α was .86 in the current study.

Data analysis

Participant characteristics were analyzed using frequencies, percentages, means, and standard deviations. The normality of the baseline scores for both groups was tested using the Kolmogorov–Smirnov test, and baseline homogeneity was tested using the Chi-squared test, Fisher’s exact test, and t -test. The differences between the two groups with respect to empathy, self-efficacy, anger, and communication skills based on the NVC-CST program were analyzed using independent sample t -tests. SPSS version 26.0 (IBM Corp., Armonk, NY, USA) was used for the analyses, and the significance level was set at p < .05.

Participants who participated in the NVC-CST were the experimental group, and those who did not participate were set as the control group. Both the experimental (M age = 24.4 years) and control groups (M age = 24.3 years) were fourth-year nursing students, of whom 11 (19.6%) were men and 44 (80.4%) were women. Forty-one students (75%) lived at home, six (10.7%) in a dorm, and eight (14.3%) lived alone. There were no statistically significant differences in the demographic characteristics between the two groups at baseline. Further, there were no statistically significant differences in empathy, anger, communication skills, or self-efficacy between the two groups at baseline ( Table 2 ).

https://doi.org/10.1371/journal.pone.0268016.t002

At posttest, the experimental group showed significant changes in empathy, self-efficacy, and communication skills, after the eight-session NVC-CST program, compared to the control group. However, there were no significant differences in the anger scores between the two groups ( Table 3 ).

https://doi.org/10.1371/journal.pone.0268016.t003

This study examined the effectiveness of an NVC-based online communication skills training program for fourth-year nursing students who were scheduled to graduate. Given that in-person classes or direct contact was not an option due to the COVID-19 pandemic, the program was designed to be administered online. An online program was anticipated to have limitations considering that NVC-based communication training largely utilizes demonstrations resembling the actual situation, role play, and group activities [ 38 ]. However, the results of this study indicate that an online program can be effective as well. Previous studies have suggested that the effectiveness of online education is influenced by the duration of the program, the lecturer’s competence, and learners’ motives [ 39 ]. Therefore, we speculated that the duration of the NVC-CST program in this study, competence of the facilitator, and study participants were appropriate for this purpose. Specifically, eight 30-minute sessions can be considered effective for online communication training [ 40 ]. Further, various approaches were utilized, such as providing lectures and demonstrations by a skilled expert and writing testimonies of students’ experiences. These appear to have engaged the students and strengthened their learning motivation. Moreover, most participants were fourth-year students who were scheduled to become newly-graduated nurses within a year. We reason that they would have been motivated to acquire communication skills that would help them in clinical practice. Furthermore, this study’s results confirmed that besides knowledge, skills can also be acquired via an online program, consistent with previous results that showed that clinical training can be performed online [ 41 ]. Moreover, watching videos online also fosters learning [ 42 ]. This implies that providing repetitive training by periodically offering the NVC-CST program online would help students make effective communication a habit.

The significantly higher posttest scores for empathy in the experimental group compared to the control group could be attributed to the fact that NVC, which is the fundamental principle of the NVC-CST program, is based on respect and the understanding of others [ 38 , 43 ].

In light of past findings indicating that empathy has a positive effect on one’s interpersonal competency [ 38 , 44 ], and that empathy of newly-graduated nurses affects their interactions with their preceptors [ 10 ], nursing students who completed training through the NVC-CST program would be more likely to have improved interpersonal competency, and, therefore, have fewer difficulties when interacting with their preceptors as newly-graduated nurses. This is because the program provides for practicing conversations using the NVC principle of observation, where the other person’s words and behaviors are accepted objectively without judgment or criticism; consequently, the person can carry on a conversation based on respect and consideration [ 25 ]. Furthermore, engaging in a mutually respectful, empathetic conversation by recognizing one’s own needs in addition to others’, and by not trying to assert one’s own needs, would deepen the bond during a conversation [ 25 ].

Consistent with previous studies indicating that NVC training resulted in significantly improved communication skills [ 25 , 27 , 38 ], this study found that NVC training significantly improved the posttest scores on communication skills. Thus, communication skills can be improved with practice and training [ 24 , 43 ], and an online NVC-CST program can be as effective as in-person training. Thus, this study’s results support expanding the platform for delivering communication training programs. Furthermore, the take-home assignments and brief testimonies utilized in the NVC-CST program also probably contributed to increasing the effectiveness of the program. Though practicing communication skills through methods such as role play is effective, having students apply the learned skills when talking with their family and friends in their daily lives contributed to developing their communication skills. Additionally, instructing participants to write a short testimony of their experiences while completing the given assignments helped them recognize the positive changes in their conversations, which further strengthened their motivation for learning. In a previous study, engaging in NVC increased one’s self-expression and understanding of others [ 23 ], which is consistent with the results of the present study.

Self-efficacy refers to confidence in resolving a difficult situation or a challenging task [ 23 ]. Our results are consistent with previous findings that hospital staff who underwent a program that integrated mindfulness and NVC showed marked improvements in self-efficacy [ 45 ]. Thus, acquiring effective communication skills through the NVC-CST program can increase a nursing student’s sense of self-efficacy in dealing with various situations.

Next, the NVC-CST program did not affect the participants’ anger expression, which is inconsistent with previous results showing that NVC positively changed the anger expression of inpatients receiving treatment for alcohol use disorder [ 23 ]. This may be attributable to differences in the study samples. Specifically, the present study utilized a student sample with no known anger expression issues, whereas the previous study employed individuals with an alcoholism problem who had issues with emotion regulation. Furthermore, the period during which this study was conducted may have affected the results. Aside from the possibility that the participants were not specifically placed in situations that could cause anger, it is also possible that the online nature of the NVC-CST program did not provide ecologically valid communication training by introducing anger-provoking situations. Anger management is not a skill like empathy or communication that can be improved with repeated training; instead, it requires an exploration of individual needs in the contexts of anger-provoking situations or people. Therefore, it would have been difficult to provide training specific to anger expression through an online program. Further, though the stages of anger expression were described in words, the details were perhaps not sufficient to vividly portray the reality, which would have undermined the effectiveness of the training. However, while levels of anger did not diminish, improvements in other skills such as empathy, communication skills, and self-efficacy may have also improved anger management. Designing a role play to practice NVC when nurses experience frustration and anger because their needs are not met in clinical settings could further enhance the effectiveness of the program.

In this study, an online NVC-CST program was provided to fourth-year nursing students who were scheduled for graduation, to examine its effectiveness. The program improved students’ empathy, communication skills, and self-efficacy. Administering the program to newly-graduated nurses could improve their nursing performance. Communication skills can be improved through practice, confirming the program’s effectiveness for nursing students scheduled for graduation. Repeated exposure to the NVC-CST program before graduation could help these students maintain good relations with their fellow nurses. This would be based on empathy and an understanding of needs in various communication situations, such as handovers, after being trained by their preceptors in a clinical practice. This could ultimately help newly-graduated nurses adjust to the clinical setting and prevent premature resignations. Notably, this study substantiates the effectiveness of an online education/training program; the NVC-CST program can be utilized in communication training for nursing students without time and place restrictions. However, the unidirectional format should be revised to implement measures to enhance students’ concentration and participation. We also suggest advancing this program by utilizing virtual reality or online simulations, along with communication education and training scenarios for use with nursing students.

This study demonstrates what is likely to help new nurses adapt to their clinical practice. Successful clinical adaptation also allows nurses to keep their jobs. Although there are various factors related to the turnover of hospital nurses, the strength of this study is that it focuses on areas that can be improved.

It often takes long to improve organizational, environmental and cultural factors, and structural problems that contribute to higher turnover. This implies that turnover is influenced by various factors that are involved in a complex relationship. Nevertheless, from the perspective of a new nurse, NVC can be a passive strategy for helping them continue in their jobs and preventing interpersonal problems. This is because, through NVC, the ability to express one’s needs and understand others’ points of view can be improved, which are vital for appropriate workplace engagement.

However, this study has several limitations. The participants were sampled from nursing schools in a specific region; therefore, the findings may not be generalizable to nursing students in other schools. Additionally, it was not possible to directly verify whether this program had a positive effect on the turnover rate and whether the participants experienced improved interpersonal relationships in their actual clinical practice. Future research evaluating the effectiveness of the program should include follow-up assessments after graduation and in the first year of work. For this reason, we propose a follow-up study comparing NVC training among first-year nurses and nurses not trained in NVC.

Supporting information

https://doi.org/10.1371/journal.pone.0268016.s001

https://doi.org/10.1371/journal.pone.0268016.s002

Acknowledgments

We would like to thank our research assistant, Dr. Soonah Jung, who assisted us with data collection.

• 1. Ministry of Health and Welfare. Health and welfare statistical year book 2019. Seoul, Korea: Ministry of Health and Welfare; 2020.
• 2. Ministry of Health and Welfare. National survey on health and medical personnel. Seoul, Korea: Ministry of Health and Welfare; 2020; 2019.
• 3. Organization for Economic Co-Operation and Development, OECD. Health statistics. Paris, France: OECD; 2018. https://doi.org/10.1080/02331888.2018.1469023 pmid:30906095
• View Article
• Google Scholar
• PubMed/NCBI
• 25. Rosenberg M, Chopra D. Nonviolent communication: A language of life: Life-changing tools for healthy relationships. 3 rd ed. Encinitas, California: Puddle Dancer Press; 2015.
• 36. Spielberger CD. Professional manual for the State-Trait Anger Expression Inventory. Psychological Assessment Resources; 1988.
• 42. Bandura A. Social-learning theory of identificatory processes. In: Goslin DA, editor. Handbook of socialization theory and research. Chicago, Illinois: Rand McNally; 1969. pp. 213–262.

• Section One: Introduction
• Section Two: Learning and Teaching Resources to Support Integration of Mental Health and Addiction in Curricula
• Section Three: Faculty Teaching Modalities and Reflective Practice
• Section Four: Student Reflective Practice and Self-Care in Mental Health and Addiction Nursing Education
• Section Five: Foundational Concepts and Mental Health Skills in Mental Health and Addiction Nursing
• Section Six: Legislation, Ethics and Advocacy in Mental Health and Addiction Nursing Practice
• Section Seven: Clinical Placements and Simulations in Mental Health and Addiction Nursing Education
• Section Eight: Reference and Bibliography
• Section Nine: Appendices and Case Studies

Section Five

• Therapeutic Relationships Teaching activities and resources

Also in this section

• Recovery Oriented Approach Teaching activities and resources
• Trauma-Informed Care Teaching activities and resources
• Harm Reduction Teaching activities and resources
• Mental Health, Illness and Addiction Teaching activities and resources
• Mental Status Examination (MSE) Teaching activities and resources
• Suicide Risk and Self-Harm Assessment Teaching activities and resources
• Crisis Intervention Teaching activities and resources

This section supports educators with the knowledge and skills required to incorporate the foundational concept of therapeutic relationships into mental health and addiction entry-level nursing curricula.

At the end of this section, the educator will:

• At the end of this section, the educator will ensure students achieve the following:
• Identify the definition, purpose and theories which inform the nurse-client therapeutic relationship.
• Recognize and understand different phases of the therapeutic and non-therapeutic relationship.
• Recognize professional boundaries, counter transference, transference, and power dynamics of the nurse-client therapeutic relationship.
• Understand concepts of therapeutic use of self in providing care (i.e., health promotion, prevention, supportive care).
• Understand and implement effective therapeutic communication skills (i.e., listening, respect, empathy) in assessment and care planning.
• Promote cultural competency and safety (i.e., creating inclusive, safe space) in therapeutic relationships.

CASN/CFMHN Competencies

Therapeutic relationships.

A “therapeutic relationship” is a relationship that occurs between a client and the nurse that is goal-directed and works towards advancing the best interest and outcomes for the client (RNAO, 2006b). Establishing therapeutic relationships recognizes that effective nursing care is dependent on the nurse coming to know his or her client and engaging in a relationship that supports recovery. Key qualities of a therapeutic relationship include active listening, trust, respect, genuineness, empathy, and responding to client concerns (RNAO, 2006b).

The phases of a therapeutic relationship (Forchuk, 2000) include orientation, working and resolution. Nurses must also be prepared to experience a series of non-therapeutic phases, which include orientation, grappling and struggling and mutual withdrawal. Respecting boundaries that define the limits of the professional role is also important in a therapeutic relationships (RNAO, 2006b). Establishing and maintaining a sense of self-awareness allows a nurse to assess when counter transference and transference—inappropriate meanings and feelings are assigned to the client or vice versa—has taken place, and to assess his or her own ability to address client dynamics (RNAO, 2006b).

Therapeutic relationships are of critical importance to nursing practice and help promote awareness and growth to work through difficulties (RNAO, 2010b). Therapeutic relationships were originally highlighted in psychiatric nursing literature (RNAO, 2010b) before being recognized as fundamental to all nursing (Orlando, 1961; Peplau, 1952; Sundeen, Stuart, Rankin, & Cohen, 1989) and focus on the value associated of developing therapeutic relationships (Brown, 2012).

Establishing therapeutic relationships works in tandem with person-centred-care principles that reflect the belief of getting to know the whole person. Caring for the ‘whole person’ entails coming to know the person with respect to all components—biological, psychological, emotional, physical, personal, social, environmental, and spiritual—and treating the person holistically rather than treating only their illness or disease (Lovering, 2012; Morgan & Yoder, 2012). According to RNAO’s Best Practice Guideline Person- and Family- Centred Care (2015):

“When optimized, health-care partnerships can improve the autonomy of individuals to make decisions related to their health care and can increase their satisfaction with care.” (RNAO, 2015, p. 21).

Recent health-care restructuring resulted in removal of organizational policies and supports that encourage the manifestation of therapeutic relationships (RNAO, 2010b). It is therefore even more important for nursing to place an emphasis on the importance of this best practice in mental health and addiction curricula. The RNAO Nursing Best Practice Guideline Establishing Therapeutic Relationships (2006) developed a Framework for Therapeutic Relationships that organizes learnings around requisite knowledge and capacities for establishing therapeutic relationships, as well as the phases of therapeutic relationships.

For more information about therapeutic practice, see Resources in this section.

Teaching and Learning Activities

The following are teaching and learning activities that can be employed in the classroom to further support nurses in the integration of theory, principles and best practices related to therapeutic relationships.

• Process recordings (Appendix B, C, and D)
• Case studies (Section 9.3)
• Communication labs
• Simulation (standardized patients; lived client experience/family experience, peer support)
• Appendix E).Reflective assignments (pre- and post-clinical practice; portfolios; logs; diaries; journals–
• to death across all health-care settings and situations.interventions. Applicable for mental health promotion of and well-being in clients from birth Group role play: Learning exercise for the application to practice of relational care
• Clinical supervision/peer supervision
• Peer learning
• Handouts (reflective questions)
• Lived client experience/family experience— Appendix H
• Photography
• Narratives/stories

Learner Engagement Questions

The following are thought-provoking and engaging learner questions that can be used to further discussions with nursing students regarding establishing therapeutic relationships. These questions can be used either to stimulate discussion, engage students in critical thinking or be tied to class assignments and/or reflection exercises.

• How would you know that you have established a therapeutic relationship?
• Can we have therapeutic relationships with anybody?
• What do therapeutic boundaries look like in different settings/situations? Which boundaries never   change?
• When is it okay to touch? When is it okay to use humour?
• How do you terminate the therapeutic relationship? How do you say “Goodbye”?
• How would you determine if it’s your needs and/or the client’s needs that are being met?
• How do you address observed boundary violations between other clinicians and clients?
• How long can you sit without saying anything? Describe the importance of silence.
• What would it be like to be a patient in this setting?

Evaluation and Self-reflection

The following tools can be used to evaluate students in their understanding and application of therapeutic relationships:

• Assignments, such as analysis of a video to determine understanding of concepts related to therapeutic/non-therapeutic relationships
• Questions on exams regarding theoretical concepts

SELF-REFLECTION

• Journaling (Appendix E)
• Pre- and post-clinical placement reflections
• Process recordings (Peplau, 1952; 1988; 1989) ( Appendix B, C, and D )
• Positive Spaces
• RNAO Rainbow Nursing Interest Group
• Nova Scotia Rainbow action project
• Link to Pride health (Capital health)
• Transgender Archives and Studies (University of Victoria)

VIDEOS AND FILMS

• Movie clips of therapeutic and non-therapeutic relationships:  Reel Psychiatry
• One Flew over the Cuckoo’s Nest
• RNAO videos on therapeutic relationship
• Hey Doc, some boys are born girls: Decker Moss at TEDxColumbus
• Ivan Coyote Why we need gender-neutral bathrooms
• Unconditional love -- journey with our transgender child : Christy Hegarty at TEDxBloomington Love Life, A Recovery Story

RNAO RESOURCES

• Registered Nurses Association of Ontario. (RNAO). (2006). Establishing Therapeutic Relationships . Toronto: ON, Registered Nurses’ Association of Ontario.
• Registered Nurses Association of Ontario. (RNAO). (2015). Person- and Family-Centred Care . Toronto: ON, Registered Nurses’ Association of Ontario.
• Registered Nurses Association of Ontario. (ND) Establishing Therapeutic Relationships Video.
• Registered Nurses Association of Ontario. (RNAO). (2007). Embracing Cultural Diversity in Health Care: Developing Cultural Competence . Toronto: ON, Registered Nurses’ Association of Ontario.

REFERENCE MATERIALS

• Alex, M. R., Whitty-Rogers, J., & Panagopoulos, W. (2013). The Language of Violence in Mental Health: Shifting the Paradigm to the Language of Peace. Advances in Nursing Science, (3), 229-242.
• Lasiuk, G., (2015) Mental Status Exam (Chapter 11). In W. M.A.,Psychiatric & mental health nursing for Canadian practice (3rd Canadian ed., pp175-197). Philadelphia, PA: Wolters Kluwer.
• Bouchard, L., Montreuil, M., & Gros, C.P. (2010). Peer support among inpatients in an adult mental health setting. Issues in Mental Health Nursing, 31(9), 589-598.
• College of Nursing Standards
• Eliason, M. J., Dibble, S., DeJoseph, J. (2010). Nursing’s silence on Lesbian, gay, bisexual, and transgender issues: The need for emancipatory efforts. Advances in Nursing Science, 33(3), 206-218.
• Goldberg, L., Ryan, A., & Sawchyn, J. (2009). Feminist and queer phenomenology: a framework for perinatal nursing practice, research, and education for advancing lesbian health. Health Care For Women International, 30(6), 536-549.
• Gros, C.P., Jarvis, S., Mulvogue, T., Wright, D., (2012), Les interventions infirmières estimées bénéfiques par les adolescents à risque de suicide Santé mentale au Québec, (37) 2, 193-207
• Lasiuk, G. (2015). The assessment process. In W. Austin & M. A. Boyd (Eds.), Psychiatric & mental health nursing for Canadian practice (3rd ed., Chapter 10, pp. 148–164). Philadelphia, PA: Wolters Kluwer.
• McGibbon, E.A. (Ed.). (2012). Oppression: A Social Determinant of Health. Black Point, NS: Fernwood.
• McGibbon, E.A., & Etowa, J.B. (2009). Anti-Racist Health Care Practice. Toronto, On: Canadian Scholars’ Press.
• Montreuil, M., Butler, K., Stachura, M., & Gros, C. P. (2015). Exploring helpful nursing care in pediatric mental health settings: The perceptions of children with suicide risk factors and their parents. Issues in Mental Health Nursing, 36(11), 849-859.
• Orlando, I. (1961). Orlando’s Dynamic Nurse-Patient Relationship: Function, process and principles. New York: Putman.
• Orlando, I. (1972). The discipline and teaching of nursing process, an evaluation study. New York: Putnam.
• Peplau, H.E. (1952). Interpersonal Relations in Nursing. New York: G.P. Putnam’s Sons.
• Wright, D & Gros, C.P. (2010) Let’s Talk About Sex: Promoting Staff Dialogue on a Mental Health Nursing Unit. Journal for Nurses in Staff
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• Open access
• Published: 08 April 2024

Development of interprofessional education programmes in nursing care and oral healthcare for dental and nursing students

• Satoru Haresaku 1 ,
• Toru Naito 2 ,
• Hisae Aoki 1 ,
• Maki Miyoshi 1 ,
• Mayumi Monji 1 ,
• Yojiro Umezaki 2 ,
• Mami Miyazono 1 ,
• Rui Egashira 2 &
• Akiko Chishaki 1  

BMC Medical Education volume  24 , Article number:  381 ( 2024 ) Cite this article

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Interprofessional education (IPE) is essential for healthcare students to collaborate effectively in multidisciplinary teams. This study aimed to identify the effect of IPE programmes in nursing care and oral healthcare on dental and nursing students’ perceptions of interprofessional collaboration.

The study included 101 third-year dental and 98 fourth-year nursing students. The participants were divided into mixed-professional groups of four (2 dental and 2 nursing students). They participated in nursing care and oral healthcare training programmes that included student-on-student training and discussion groups. Questionnaires regarding perceptions of interprofessional collaboration were distributed to the participants before and after the programmes to compare the programmes before and after and between the dental and nursing students. The Wilcoxon signed-rank test and chi-square test were used to compare the data.

Data from 79 dental students (42 males and 37 females) and 89 nursing students (4 males and 85 females) who completed both questionnaires were used for the comparisons. Perceptions of the differences between the approaches of different health professionals to nursing care, the roles of other professionals, and the need for multiprofessional collaboration improved significantly among both dental and nursing students after the programmes. Although the perception of their ability to communicate with unfamiliar or new people improved significantly only among the nursing students, other perceptions of their ability to communicate did not improve for either group. More dental students than nursing students chose nursing trainings as good programmes to participate in with other professional students, while more nursing students than dental students chose oral care trainings as good programmes. Many students commented that they learned about nursing and oral healthcare skills as well as the importance of teamwork and communication with other professionals. Seven students commented that they were more motivated to become dentists and nurses.

Conclusions

This study showed that IPE programmes for nursing care and oral healthcare might be effective at helping students understand other professionals and promoting multiprofessional collaboration. However, further studies are needed to develop IPE programmes to improve attitudes and abilities related to interprofessional communication skills.

Peer Review reports

Currently, approximately 15% of the population worldwide, or approximately 1 billion individuals, live with one or more disabling conditions. More than 46% of older people (over the age of 60) have disabilities, and more than 250 million older people experience moderate to severe disability [ 1 ]. Furthermore, these percentages and numbers are expected to increase as the percentage of older people in the global population increases from 12% in 2015 to 22% in 2050 [ 1 , 2 ].

Nurses play an important role in providing nursing care for older people [ 3 , 4 ]. In addition, they can perform oral assessments and make dental referrals through physicians [ 5 , 6 ] and can perform collaborative oral healthcare with oral health professionals [ 7 ]. Oral health professionals can provide professional oral healthcare to prevent aspiration pneumonia and postoperative complications [ 8 , 9 , 10 ]. Therefore, both dental and nursing students need to learn about oral healthcare, nursing care, and interprofessional communication skills and to understand interprofessional healthcare practices [ 11 ].

Interprofessional education (IPE) is essential for healthcare students to collaborate effectively in multidisciplinary teams [ 12 ]. The World Health Organization (WHO) has consistently underscored the importance of IPE [ 13 ], and the World Dental Federation reported on IPE and collaborative practices in 2020 [ 14 ]. A study commissioned by the WHO reported that IPE is taking place in many countries, including Japan [ 15 ]. Among the many benefits of IPE, respondents note practice- and policy-related positive outcomes, such as improved access to care, health outcomes and quality of care, as well as workforce morale, practices and productivity. A survey of U.S. and Canadian dental schools indicated that the majority of schools that responded to the survey had established IPE programmes, most frequently with medical and nursing schools and dental hygiene programmes [ 16 ]. Several studies have shown that IPE between oral health professionals and nurses has a beneficial impact on students’ understanding of team medicine [ 17 , 18 , 19 , 20 , 21 , 22 ]. However, there are few studies and reports on IPE in Japan [ 11 , 23 ]. Moreover, to our knowledge, no studies of IPE programmes have included a combination of nursing care training and oral healthcare training.

The purpose of this study was to identify the effect of IPE programmes in nursing care and oral healthcare on dental and nursing students’ perceptions of interprofessional collaboration.

Design and sample

This was a follow-up, cross-sectional study (Fig.  1 ). The participants were 101 third-year dental students in a 6-year dental school and 98 final-year nursing students in a fourth-year nursing school. All students were recruited for this study because the course was included in each school curriculum. The dental and nursing schools belong to the same school cooperative area in Fukuoka Prefecture, Japan. The nursing school enlists the cooperation of dental school in oral healthcare education.

Flow chart illustrating the selection of study participants

Before the baseline study, the dental students had learned basic medical and dental sciences, but they had not learned subjects related to clinical dental work and had not participated in dental clinical training programmes. The nursing students had learned most nursing subjects, including the completion of 45-h oral healthcare programmes and clinical training programmes in hospitals and care facilities. The 45-h oral healthcare programmes were taught and instructed by multiple health professionals, such as dentists, dental hygienists, speech-language-hearing therapists, and nurses [ 24 ].

Content of the IPE programmes

The nursing care and oral healthcare programmes were developed for dental students by dental faculty members [ 25 ] and were established as IPE programmes for dental and nursing students by the dental and nursing faculty members in this study. The programmes had four sections: orientation programmes that included two learning videos, nursing care training programmes, oral healthcare programmes, and four lectures (Table  1 ). In the video learning programmes, the students watched a video on nursing care skills and a video depicting a doctor struggling with various cases in home healthcare. In the nursing training programmes, the students performed student-on-student training in basic nursing skills. In addition, they wore old-age simulation suits (Sakamoto Model Ltd., Kyoto, Japan) to experience the joint limitations, muscle weakness, and visual field narrowing that elderly people experience. In the oral healthcare programmes, they participated in training on denture removal and fitting using an oral simulator with full dentures in the mandible and partial dentures in the maxilla (Sakamoto Model Ltd., Kyoto, Japan). In addition, they underwent training in student-on-student oral healthcare. In the lectures, three physicians and a dentist used slides to provide information on practices and healthcare for elderly people. After the training programmes, self-introduction between dental and nursing students in the orientation programme (P1) and a group discussion programme (P11) was added to promote interprofessional communication.

The dental and nursing students were divided into four groups and were further subdivided into mixed-professional subgroups of four (2 dental and 2 nursing students). The nursing care and oral healthcare training programmes were conducted on separate days for each group, and student-on-student training was performed within the subgroup.

The orientation and lecture programmes were conducted in a hall with a 600-seat capacity on the same grounds. The nursing care training programmes were conducted in a training room in the nursing school, and the oral healthcare training programmes were conducted in the affiliated hospital.

Structured questionnaires

The first paper-based questionnaire was based on a previously developed questionnaire used to assess the effectiveness of IPE programmes on improving students’ perceptions of interprofessional collaboration [ 26 ].

The questionnaire consisted of 2 parts (Table  2 ): self-perceptions of one’s skills in communicating with other health professionals (Q1-6) and understanding of the role of other health professionals and the need for interprofessional collaboration (Q7-12). A four-point Likert response scale was used for each item, with choices including “agree”, “somewhat agree”, “somewhat disagree”, and “disagree”. These response choices for the question items were scored as “4”, “3”, “2”, and “1” for all items except Q1, Q3, and Q7. The latter questions were negative and reverse scored, and the response options for those items were “1”, “2”, “3”, and “4”; therefore, a score of 4 indicated the highest level of positive perception.

The second web-based questionnaire survey was conducted via Google Forms (Google LLC, California, USA). Three items related to the students’ opinions about the programmes were added to the items in the first questionnaire: a) “Which programmes were good to participate in?”, b) “Which programmes were good to participate in together with other professional students?”, and c) “What were the positive and negative aspects of participating in the IPE programme with other professional students?”.

The students chose only 3 out of 15 programmes for questions a) and b), and they provided their comments for question c). Two researchers, who were nurses (M.M1 and M.M2), had worked more than 10 years as nursing faculty members and were experts in qualitative data analysis, read all the descriptive comments in question c) and coded the sentences based on their similarities. The researchers subcategorized the sentences into 30 and 28 groups according to the dental and nursing students’ comments, respectively. The sentences were further categorized into 14 and 15 groups, respectively. Finally, a researcher and dentist who had worked for 15 years as a dental faculty member and 6 years as a nursing faculty member checked the analysis to ensure validation.

McDonald’s omega was used to assess the reliability of the questionnaire items with regard to perceptions of interprofessional collaboration practices in the first and second questionnaires. McDonald’s omega coefficients for students’ perceptions of interprofessional collaboration before and after the programmes were 0.740 and 0.773, respectively.

Data procedure

The first questionnaire survey was conducted immediately before the orientation programme on 30 September 2022, and the second was conducted immediately after the summary lecture programmes on 17 November 2022 (Fig.  1 ). Data from students who did not participate in the explanation of the study or did not complete the consent form were excluded from the study.

All procedures involving human participants were approved by the Ethics Committee of Fukuoka Gakuen, Fukuoka, Japan (approval no. 612) and were in accordance with the Ethical Guidelines for Clinical Research (the Ministry of Health, Labour and Welfare, Tokyo, Japan, no. 415 of 2008) and the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Statistical analyses

The Kolmogorov‒Smirnov test was used to confirm the normality of the data. Since the data were confirmed to not be normally distributed, a Wilcoxon signed-rank test was used to compare students’ perceptions before and after the programmes, and a Mann‒Whitney U test was used to compare dental students’ and nursing students’ perceptions. A chi-squared test or Fisher’s exact test was used to compare the differences between dental and nursing students in terms of the percentage of responses regarding whether the students felt that the programmes were good.

Data were analysed at the 5% significance level. Statistical analyses were performed using the IBM SPSS Statistics software program (version 28.0; IBM Corporation, Armonk, NY, USA).

A total of 79 (78.2%) dental students and 89 (90.8%) nursing students participated in the surveys and completed the consent form (Fig.  1 ). Most of the dental students were male (68.1%), and most of the nursing students were female (95.5%). The mean age at baseline was 23.1 ± 3.8 years for dental students and 21.8 ± 0.9 years for nursing students.

Table 3 shows a comparison of the dental students’ and nursing students’ perceptions of interprofessional collaboration before and after the programmes. The range of the mean perception level at baseline was 2.27–3.73 for the dental students and 2.24–3.91 for the nursing students. The total perception levels were significantly greater for the nursing students than for the dental students both before and after the programmes ( P  < 0.05). The perception levels of the dental students for Q7, Q8, Q11, and Q12 and those of the nursing students for Q1, Q6-8, Q11, and Q12 were significantly greater after the programmes than before ( P  < 0.05).

Table 4 shows the distribution of programmes that the students indicated were good programmes to participate in or were good to participate in with other professional students (choosing the top 3). Among the types of programmes, the largest percentage of students indicated that it was good to participate in student-on-student oral healthcare training (P10, 52.4%), with percentages of 40–50% for P3, P8, and P15. The percentages of students who selected P1, P5, P6, and P7 were significantly greater among dental students than nursing students ( P  < 0.05), although the percentage of students indicating P9 was significantly lower among dental students than nursing students ( P  < 0.001). The type of programme with the largest percentage of student support for participation with other professional students was training in transferring patients from wheelchairs to beds (P7, 59.4%), which showed percentages for P5 and P7 of 40–50%. The percentages for P5, P6, and P7 were significantly higher for dental students than nursing students ( P  < 0.001), although the percentages for P9, P10, and P11 were significantly higher for nursing students than for dental students ( P  < 0.05).

Table 5 shows the comments from dental and nursing students on the IPE programmes. The dental students commented that they “have learned many things from new experiences” ( n  = 17), “have learned many things from nursing students” ( n  = 14), “have learned nursing skills from nursing students” ( n  = 11), “have learned the needs and importance of teamwork” ( n  = 10), and “could understand other professionals” ( n  = 10). In addition, all their comments were positive. The nursing students commented that they “gained confidence in performing oral healthcare” ( n  = 25) and “were able to review nursing care skills” ( n  = 23). In addition, they commented that they “have learned many things through mutual teaching interprofessionally” ( n  = 22) and learned “from new perspectives” ( n  = 20) and “from new experiences” ( n  = 19). However, some nursing students had negative comments, such as “the programmes were not appropriate for fourth-year nursing students but might be good for the lower-year nursing students” ( n  = 5), “some students were not taking the trainings seriously” ( n  = 3), and “there was nothing to be taught by dental students” ( n  = 3).

This follow-up and cross-sectional study was the first to report on IPE programmes that included student-on-student nursing care and oral healthcare trainings and their effectiveness in improving students’ perceptions of multiprofessional collaboration. The results showed that at baseline, the nursing students’ perception levels were higher than those of dental students. The fourth-year nursing students had already earned credits in most nursing subjects and had experienced clinical nursing care in hospitals and care facilities. In addition, the nursing students in the nursing school had completed 45-h oral health and healthcare courses that could improve their level of perception of the importance of collaboration with healthcare workers in oral healthcare practice [ 24 ]. Conversely, the dental students had earned credits only basic medical and dental subjects and had not experienced clinical dental practice. Therefore, the differences in learning and experiences between dental and nursing students might affect the differences in their perception levels at baseline.

After the IPE programmes, both dental and nursing students’ levels of perception of their understanding of other health professionals, collaborative healthcare, and the role of professionals that they aspired to achieve improved. Previous studies on IPE programmes have shown significant improvements in knowledge and perceptions of oral health and oral healthcare among nursing students [ 17 , 18 , 19 , 20 , 21 , 22 ]. A previous study reported that nursing students had low perceptions of oral health before the implementation of the IPE programme [ 22 ]. The present study might be the first to show that the IPE programme was effective at improving the perceptions of nursing students who already had a high level of education in nursing and oral healthcare [ 27 ] and improving dental students’ understanding of other professionals through nursing care training programmes.

The level of perceived interprofessional communication skills did not improve significantly among the dental students, although the levels improved slightly for some of the nursing students. The discussion time in the programmes was only 30 min, which might have been insufficient to improve the students’ perceptions. A previous comparison of IPE programmes between nursing and dental hygiene students reported that both student groups enjoyed working with each other, sharing skill sets and experiencing each other’s professional language [ 17 ]. In this study, approximately 70% of the dental students were male and almost all the nursing students were female. Therefore, the difference in the sex ratio in this study might be a barrier to interprofessional communication, although further studies are needed to prove this finding. Moreover, because the nursing programmes were developed by academic dental staff, dental students might not have a good understanding of this aspect of nursing, which might contribute to their lack of improved confidence in their interprofessional communication skills. A previous study reported that an interprofessional problem-based learning programme for medical and nursing students was effective at improving students’ ability and attitudes with regard to interprofessional communication and collaboration [ 28 ]. Therefore, IPE programmes with problem-based learning programmes should be developed in collaboration with dental and nursing staff to improve their perceptions.

Programmes that involved student-on-student oral health care training, the use of age simulation suits, the use of a film depicting the struggles of home healthcare doctors, and home healthcare doctors’ lectures were popular among both dental and nursing students. A programme using age simulation suits was effective at reducing negative attitudes towards elderly people in caregiving settings and enhancing empathy and role-taking in relation to this population [ 29 ]. Therefore, such programmes might increase students’ interest in home healthcare practice and geriatric medicine. For dental students, the programmes that were selected as good programmes to participate in with other professional students were nursing skill training programmes, but for nursing students, they were oral healthcare programmes. The results showed that students’ satisfaction with other professional skills programmes might improve if they teach these programmes to each other in IPE. These programmes might also improve students’ understanding of other health professionals.

The comments from the dental and nursing students on the IPE programmes revealed that the students had learned many things, such as the difficulties and importance of communicating with students in other professions, oral healthcare skills, and nursing care skills cultivated through mutual teaching, as new experiences from new perspectives. This new understanding might contribute to improving students’ perceptions of interprofessional collaboration practices. However, there were some negative comments among the nursing students in the programmes. As mentioned above, there were significant differences between the dental and nursing students with regard to their learning status as professional subjects. Many fourth-year dental students were not able to participate in this study because they needed to complete rounds in each dental clinical department or dental hospital in small groups and lacked the time to participate in the programmes throughout the school year. Differences in their learning and experience of their professional subjects might have affected the nursing students’ negative comments and improvements to their perception of interprofessional collaboration practices. Therefore, the coordinators of IPE programmes should consider students’ learning status when they choose the participants in programmes.

There are several limitations associated with this study. First, one Japanese dental school and one Japanese nursing school were investigated, and the sample of students was selected without a power calculation. There were 29 dental schools and 267 nursing schools in Japan at the time of the study [ 30 ]. The results of this study are therefore not generalizable. Second, perceptions of collaboration with other healthcare professionals might have been greater for these nursing students than for other nursing students because these students had completed 45-h oral healthcare programmes before the present study [ 24 ]. Third, 78.2% of the dental students and 90.8% of the nursing students participated in the study. This difference might have affected the results of this study because people interested in the topic were more likely to respond than people who were not interested [ 31 ]. Fourth, there were differences in the knowledge and experiences of the dental and nursing students. IPE for dental and nursing students with the same levels of knowledge and experience might be more effective at improving their perceptions of interprofessional collaboration practices. Fifth, the accuracy and relevance of the videos were not validated. However, 44.6% of the students chose video learning II as a good programme for participation. This programme might have affected their understanding of elderly care nursing. Finally, the same Likert scale was used in the previously developed questionnaire to assess the effectiveness of IPE programmes on the improvement of students’ perceptions of interprofessional collaboration [ 24 ]. However, the small range of the scale (Levels 1–4) might lead to a small estimate of the impact of the programmes on improving perceptions of interprofessional collaboration practices.

Despite several limitations of this study, the advantage of this study compared to previous IPE studies involving dental and nursing students is that teaching their professional skills to each other may provide students with a better understanding of interprofessional collaboration practices than learning them separately.

This study showed that IPE programmes in nursing care and oral healthcare might be effective at improving the understanding of other professionals and multiprofessional collaboration among dental and nursing students but not at improving interprofessional communication skills among dental students. However, further studies are needed to develop IPE programmes to improve attitudes and abilities related to interprofessional communication skills.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available as ethics approval was granted on the basis that only the researchers involved in the study could access the identified data. However, the data are available from the corresponding author upon reasonable request.

Abbreviations

• Interprofessional education

United Nations, Department of Economic and Social Affairs. Ageing and disability. 2022. https://www.un.org/development/desa/disabilities/disability-and-ageing.html . Accessed 31 Aug 2023.

World Health Organization. Ageing and health. 202. https://www.who.int/news-room/fact-sheets/detail/ageing-and-health . Accessed 31 Aug 2023.

Compton RM, Murdoch NH, Press MM, Lowe ME, Ottley KM, Barlow M, et al. Capacity of nurses working in long-term care: a systematic review qualitative synthesis. J Clin Nurs. 2023;32:1642–61.

Article   Google Scholar  

Appelgren M, Bahtsevani C, Persson K, Borglin G. Nurses’ experiences of caring for patients with intellectual developmental disorders: a systematic review using a meta-ethnographic approach. BMC Nurs. 2018;17:51.

Kohli R, Arora G, Blanc AF, Pham E, Gubrud-Howe P. Oral health clinical training and dental referral program for nurses: an interprofessional collaborative project. Geriatr Nurs. 2021;42:880–6.

Haresaku S, Uchida S, Aoki H, Akinaga K, Yoshida R, Kubota K, et al. Factors associated with nurses’ performance of oral assessments and dental referrals for hospital inpatients. BMC Oral Health. 2020;20:68.

Obana M, Furuya J, Matsubara C, Tohara H, Inaji M, Miki K, et al. Effect of a collaborative transdisciplinary team approach on oral health status in acute stroke patients. J Oral Rehabil. 2019;46:1170–6.

van der Maarel-Wierink CD, Vanobbergen JNO, Bronkhorst EM, Schols JMGA, de Baat C. Oral health care and aspiration pneumonia in frail older people: a systematic literature review. Gerodontology. 2013;30:3–9.

Yi Mohammadi JJ, Franks K, Hines S. Effectiveness of professional oral health care intervention on the oral health of residents with dementia in residential aged care facilities: a systematic review protocol. JBI Database System Rev Implement Rep. 2015;13:110–22.

Camus-Jansson F, Longueira-Diaz N, Salinas-Diaz B, Granic-Chinchón A, Cueto-Urbina W, Parra-Parra M, et al. Preoperative oral practices and incidence of postoperative complications in hospital medical-surgical procedures: a meta-analysis. Med Oral Patol Oral Cir Bucal. 2023;28:e217–28.

Numasawa M, Nawa N, Funakoshi Y, Noritake K, Tsuruta J, Kawakami C, et al. A mixed methods study on the readiness of dental, medical, and nursing students for interprofessional learning. PLoS One. 2021;16:e0255086.

Cox M, Cuff P, Brandt B, Reeves S, Zierler B. Measuring the impact of interprofessional education on collaborative practice and patient outcomes. J Interprof Care. 2016;30:1–3.

World Health Organization. Framework for action on interprofessional education and collaborative practice. 2010. https://www.who.int/publications/i/item/framework-for-action-on-interprofessional-education-collaborative-practice . Accessed 31 Aug 2023.

FDI World Dental Federation. Optimal oral health through inter-professional education and collaborative practice. 2021. https://www.fdiworlddental.org/sites/default/files/media/news/collaborative-practice_digital.pdf . Accessed 31 Aug 2023.

Rodger S, Hoffman SJ. Where in the world is interprofessional education? A global environmental scan. J Interprof Care. 2010;24:479–91.

Formicola AJ, Andrieu SC, Buchanan JA, Childs GS, Gibbs M, Inglehart MR, et al. Interprofessional education in U.S. and Canadian dental schools: an ADEA team study group report. J Dent Educ. 2012;76:1250–68.

Grant L, McKay L, Rogers L, Wiesenthal S, Cherney S, Betts L. An interprofessional education initiative between students of dental hygiene and bachelor of science in nursing. Can J Dent Hyg. 2011;45:36–44.

Google Scholar  

Czarnecki GA, Kloostra SJ, Boynton JR, Inglehart MR. Nursing and dental students’ and pediatric dentistry residents’ responses to experiences with interprofessional education. J Dent Educ. 2014;78:1301–12.

Farokhi MR, Muck A, Lozano-Pineda J, Boone SL, Worabo H. Using interprofessional education to promote oral health literacy in a faculty-student collaborative practice. J Dent Educ. 2018;82:1091–7.

Nierenberg S, Hughes LP, Warunek M, Gambacorta JE, Dickerson SS, Campbell-Heider N. Nursing and dental students’ reflections on interprofessional practice after a service-learning experience in appalachia. J Dent Educ. 2018;82:454–61.

Coan LL, Wijesuriya UA, Seibert SA. Collaboration of dental hygiene and nursing students on hospital units: an interprofessional education experience. J Dent Educ. 2019;83:654–62.

Dsouza R, Quinonez R, Hubbell S, Brame J. Promoting oral health in nursing education through interprofessional collaborative practice: a quasi-experimental survey study design. Nurse Educ Today. 2019;82:93–8.

Yoshikawa Y, Hikiji H, Ariyoshi W, Okinaga T, Nishihara T. A trial of elderly support education for healthcare professionals and the effect on interpersonal education for undergraduate students of Kyushu Dental University, Seinan Jogakuin University, and Nishi Nihon Institute of Technology. JJDEA. 2020;36:3–12.

Haresaku S, Kubota K, Yoshida R, Aoki H, Nakashima F, Iino H, et al. Effect of multi-professional education on the perceptions and awareness of oral health care among undergraduate nursing students in a nursing school. J Dent Educ. 2021;85:786–93.

Takiuchi H, Makino M, Naito T. The developing educational program of oral medicine to adapt the medical and welfare for elderly who require long-term care. Health Sci Health Care. 2014;14:54–61.

Tsunemi S, Kihira T. Changes in students’ self-awareness for interprofessional work through interprofessional education. J Hyogo Univ Health Sci. 2020;8:7–18.

Haresaku S, Umezaki Y, Egashira R, Naito T, Kubota K, Iino H, et al. Comparison of attitudes, awareness, and perceptions regarding oral healthcare between dental and nursing students before and after oral healthcare education. BMC Oral Health. 2021;21:188.

Lin YC, Chan TF, Lai CS, Chin CC, Chou FH, Lin HJ. The impact of an interprofessional problem-based learning curriculum of clinical ethics on medical and nursing students’ attitudes and ability of interprofessional collaboration: a pilot study. Kaohsiung J Med Sci. 2013;29:505–11.

Gerhardy TH, Schlomann A, Wahl HW, Schmidt LI. Effects of age simulation suits on psychological and physical outcomes: a systematic review. Eur J Ageing. 2022;19:953–76.

Ministry of Education, Culture, Sports, Science and Technology. School basic study. 2017. http://www.mext.go.jp/b_menu/toukei/chousa01/kihon/1267995.htm . Accessed 31 Aug 2023.

Groves RM, Couper MP, Presser S, Singer E, Tourangeau R, Acosta GP, et al. Experiments in producing nonresponse bias. Public Opin Q. 2006;70:720–36.

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The study was supported by Grants-in Aid for Scientific Research (21K10292 and JP 22K10304) from the Japan Society for the Promotion of Science (KAKENHI).

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SH, MM1, and MM2 searched and reviewed the literature, analysed the data, and wrote the manuscript. TN and HA mainly created the nursing care and oral healthcare programmes, issued the questionnaires, and contributed to analysing the data. YU, MM3, and RE managed the students, instructed the training programmes, and assisted in finding documents, issuing the questionnaires, and examining the manuscript. TN and AC critically reviewed the manuscript and supervised the whole study process. All the authors have read and approved the manuscript.

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Correspondence to Satoru Haresaku .

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Haresaku, S., Naito, T., Aoki, H. et al. Development of interprofessional education programmes in nursing care and oral healthcare for dental and nursing students. BMC Med Educ 24 , 381 (2024). https://doi.org/10.1186/s12909-024-05227-2

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Strategies for sustaining and enhancing nursing students’ engagement in academic and clinical settings: a narrative review

Mohammad reza ghasemi.

1 Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Iran

Hossein Karimi Moonaghi

2 Department of Medical Education, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

Abbas Heydari

Students’ engagement in academic-related learning activities is one of the important determinants of students’ success. Identifying the best teaching strategies to sustain and promote nursing students’ engagement in academic and clinical settings has always been a challenge for nurse educators. Hence, it is essential to provide a set of strategies for maintaining and enhancing the academic engagement of nursing students. The purpose of this review was to explore and summarize the strategies that nurse educators use to sustain and promote nursing students’ engagement in academic and clinical settings. A narrative literature review was conducted. CINAHL (nursing content), ProQuest, Medline, the Cochrane, Google Scholar, and Scopus were searched. Of 1,185 retrieved articles, 32 teaching strategies were identified and extracted from the nursing literature. We used thematic analysis approach to organize these strategies into five main categories as follows: technology-based strategies (15 articles), collaborative strategies (10 articles), simulation-based strategies (two articles), research-based strategies (two articles), and miscellanea learning strategies (three articles). As a general comment, these strategies have the potential to promote nursing students’ engagement. Among the strategies discussed in this review, the use of technology, particularly the response system and online learning, was more common among nursing educators, which is in line with today’s advances in smart technologies. The collection presented in this review can be used as a starting point for future research to evaluate the effectiveness of an educational intervention on the academic engagement of nursing students. Nevertheless, due to the lack of experimental studies, the optimal strategies remain to be elucidated through future high-quality experimental study.

Introduction

One of the essential requirements of healthcare systems to meet the broad needs of patients is the employment of well-qualified nurses [ 1 ]. In this respect, one of the important responsibilities of nursing education systems is providing high-quality education to nursing students and preparing competent nurses so that they can provide patients with safe and high-quality care in the future [ 2 - 4 ]. As a step toward that end, nursing educators need to use new educational strategies to actively engage nursing students in learning activities in academic and clinical settings [ 5 , 6 ]. Previous studies have shown that increasing academic engagement of students could increase their desirable academic performance and success [ 7 ]. Recent evidence indicates that engagement in academic-related learning activities is one of the important determinants of students’ success in university [ 8 - 10 ]. As a result, identifying the best teaching strategies to sustain and promote nursing students’ engagement in academic and clinical settings has always been a challenge for nursing educators. Hence, it is essential to provide a set of strategies for maintaining and enhancing the academic engagement of nursing students.

In educational literature, the concepts of academic engagement, student engagement (SE), educational engagement, student involvement, and school engagement have often been used interchangeably [ 11 ]. In this study, the term ‘SE’ was used. The concept of SE has been extensively studied in educational literature as an important determinant of quality in academic education. Several definitions of this concept have been proposed; however, one of the most widespread definitions of SE is provided by the prolific author, Kuh [ 12 ]. Kuh [ 12 ] defined SE as “the time and effort students devote to activities that are empirically linked to desired outcomes of college and what institutions do to induce students to participate in these activities.” However, several authors argue that this concept is more than student involvement in school-related activities. It is rather a multidimensional concept, whose dimensions include behavioral, emotional, cognitive, and motivational [ 11 , 13 , 14 ]. SE, also, refers to the quality of the effort that learners spend on the targeted educational activities such as attending classrooms, studying, doing practical work, and engaging with professors or other students to reach the desired outcomes [ 15 ]. In the most recent definition of SE proposed by Kahu [ 13 ], the amount of time students spend on learning-related activities is considered as one of the main components of SE. In clinical disciplines such as nursing, many educational activities are accomplished in clinical settings. Hence, it is expected that the concept of SE in nursing education includes at least two concepts of “academic engagement” and “clinical engagement [ 16 ].” However, a search of the literature revealed small number of studies regarding clinical engagement, and this concept has recently become an important issue in nursing students’ education. In addition, most nursing researchers have not provided a unique definition for the concept of SE [ 11 , 16 ]. Recently, Bernard [ 14 ] using concept analysis, theoretically defined SE as “a dynamic process marked by a positive behavioral, cognitive, and affective state exhibited in the pursuit of deep learning.” This definition included the previously discussed dimensions and focused on deep learning; however, this definition lacks practical and measurable characteristics of SE, particularly time spent to engage with educational activities. Given the lack of an operational definition of SE in nursing education, based on the literature, we used the following working definition for conducting the current review. SE is “the investment of time, effort, and other relevant resources by both students and their institutions intended to optimize the student experience and enhance the learning outcomes and development of students, and the performance and reputation of the institution [ 11 ].”

In the last decade, many nurse researchers have investigated various educational strategies to explore and develop the best ways to increase nursing students’ academic engagement. The result of these efforts has led to the creation of new teaching strategies or modification of the techniques used by other disciplines. However, the lack of a study that reviews these strategies and techniques as a collection is felt. Previously, Crookes et al. [ 17 ] explored the strategies and techniques that nurse educators have employed to help nursing students to contextualize theory learned in the classroom to their practice. However, most of those techniques borrowed from other disciplines. Therefore, the ultimate purpose of this review was to explore and summarize the strategies that nursing educators use to sustain and promote nursing students’ engagement so that we can provide a set of these educational strategies to nursing educators and researchers. This review has been carried out as part of a nursing doctorate dissertation attempting to assess the lived experiences of nursing students on academic engagement activities.

The following question was used to guide this non-systematic narrative literature review: What strategies or techniques have nursing educators used to sustain and promote nursing students’ academic or clinical engagement? To answer this question, we reviewed the literature to identify the most significant studies and theoretical foundations regarding the academic and clinical engagement strategies used by nursing educators.

1. Sources of information and search strategy

The following databases were searched for peer-reviewed scholarly articles: CINAHL (nursing content), ProQuest, Medline, the Cochrane, Google Scholar, and Scopus. Two authors (G.M.R. and K.M.H.) with the assistance of one librarian searched the databases using predefined search strategies. They individually screened the titles and abstracts of retrieved studies against the inclusion criteria for choosing relevant articles. We used several combinations of the following search terms ‘engagement, nurse, student’ and their related concepts by using the Boolean operator, “AND”, to obtain any link between them. The scope of the search was limited to English-language written international articles and publication dates were limited from January 2000 to June 2019. To find additional articles, we manually examined the reference sections of the retrieved studies and relevant review.

2. Selection criteria

To keep the focus directly on nursing students, the inclusion criteria for selecting articles were as follows: The sample should be nursing students and the used strategies must be done by nursing educators. As well, we included original articles, reviews, innovative papers, discussion papers, learning projects, and theoretical frameworks. We excluded the dissertations and articles related to the other professions. Duplicate articles were also excluded. Given that we intended to provide a comprehensive set of educational strategies for sustaining and promoting nursing students’ engagement, we did not appraise the quality of included studies and did not remove any studies due to the low quality.

Of 1,185 retrieved articles, 32 articles have met the selection criteria. Fig. 1 shows the process of study selection for inclusion in review.

PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Nursing researchers have explored and applied several strategies/techniques for sustaining and promoting nursing students’ engagement. Given the heterogeneity of the educational methods, we used a thematic analysis approach to collate, summarize, and map the literature to identify themes across the retrieved studies based on the similarities of concepts and teaching techniques that educators had used. The second author reviewed each paper and data was coded to describe the main teaching methods. Similar codes were grouped together into categories to organize the main teaching strategies/techniques. New categories were developed or modified as analysis continued. At the end of analysis, we organized these strategies into five main categories as follows: technology-based strategies (15 articles), collaborative strategies (10 articles), active learning strategies (three articles), simulation-based strategies (two articles), and research-based strategies (two articles). It should be noted that there are some similarities between and within categories. Table 1 summarizes the students’ engagement strategies. Regarding the methodology of retrieved studies, five were innovative, 10 were discussion paper, six were quasi- experimental, five were descriptive, and six were qualitative studies.

Summary of Students’ Engagement Strategies

1. Technology-based strategies

There is growing evidence that shows the value of technology for engaging students in academic learning activities [ 18 ]. We found 15 articles discussing the importance of using online and offline technologies in promoting nursing students’ engagement.

1) Online technologies

a. Kahoot in the classroom: Kahoot is a free web-based technology that incorporates a quizzing program to increase the participation of learners during the lecture. As well, it can be used as a mean for formative assessment of students. It is believed that the learners’ attention is reduced in the first minutes after the beginning of the lecture and educators need to alter the situation and engage the learners to regain their attention [ 19 ]. The underlying assumption of Kahoot method is that an interesting program could increase students’ participation during the lecture. Barnes [ 20 ] introduced this technique as an innovative tool for nurse educators for engaging students during the lecture. However, the effectiveness of Kahoot to increase the engagement of nurse students is under research and currently, there is no experimental research that examined the effectiveness of this method.

b. Online teaching techniques: Along with advances in technology and the Internet, many traditional teaching methods have been transformed into interactive web-based educational methods [ 21 ]. In recent years, web-based courses provide many opportunities for actively engaging nursing students in learning activities [ 22 - 24 ]. Nursing education experts believe that online forum courses can bridge the gap between theory and practice in nursing discipline as well as it can facilitate the process of nursing students’ engagement [ 17 ].

c. Asynchronous discussion boards: These boards enable multiple learners to engage in discussion with each other. All discussions of the learners are collected on a board and the members contribute their comments by responding to the initial discussion question or by responding to each other. It is believed that asynchronous discussion boards, by use of the Web and other Internet technologies, encourage deeper learning and help students to be more engaged in learning activities related to analysis, synthesis, decision-making, and the use of knowledge [ 25 ]. In nursing education, Dickson [ 26 ], proposed the basic structure of asynchronous discussion boards for enhancing the engagement of nurse students. The foundation of the technology is that educators can enhance students’ engagement by posting a series of questions on the discussion board and then encourage those students to reflect and respond actively to those questions. At present, no experimental research has evaluated the effectiveness of this technology in terms of SE.

d. Posting videos on YouTube: Johnston et al. [ 27 ] incorporated a collection of YouTube videos into the bioscience course to support nursing students’ engagement. The total number of views, comments, and subscriptions from students were collected directly from the Biological Sciences YouTube channel over four semesters. The videos are highly successful; with more than 300,000 views, 1.5 million minutes of viewing and more than 5,000 international subscribers during the study. More than 90% agreed that watching videos increased their engagement time in learning. Authors concluded that posting educational videos on YouTube can significantly engage students in learning activities and enrich the student experience and performance [ 27 ].

e. Virtual Community: Giddens et al. [ 28 ] designed and implemented an intervention called “the neighborhood virtual community (VC)” to assist first-semester baccalaureate nursing students (n=350 participants) in learning complex, health-related content. They described VC as an online teaching application presenting an imaginary community with multiple interconnecting character stories. VC included households’ and health care nurses’ characters. Students should follow the character stories each week during the semester by logging on to the Website. Using a two-group quasi-experimental study, they found that engagement in learning activities were significantly higher in the experimental group than those of the control group (analysis of variance, F=2.40, p<0.05). In addition, a significantly positive relationship (r=0.416, p<0.001) between the frequency of VC use and perceived benefits among students was found [ 29 ]. In another study, using VC in nursing education leading to the improvement of students learning through emotional connectedness to families and engagement of characters into learning activities [ 30 ].

2) Offline technologies

a. Response systems (clickers): Response systems are a set of software and hardware that educators have used to attract learners’ attention and increase their engagement during the class lecture. By asking questions in the classroom, the educator encourages the students to respond to these questions through a technology-based response pad called “clickers”. Using this system, students can get instant feedback from the educator regarding the asked questions. In this way, clickers actively engage students during the lecture. Recently, several nursing schools across the world used this technology [ 31 - 34 ]. Filer [ 35 ] in a pilot quasi-experimental study with 90 nursing students assessed the impact of an audience response system (clickers) on students’ engagement and participation in the classroom. The control group responded verbally, while the intervention group responded anonymously using the clickers to questions posed during the lecture. The author found that students in the intervention group reported a greater level of motivation (p<0.001); were more comfortable in the classroom (p=0.00); and expressed a higher level of participation (p<0.001) than students in the control group. In addition, almost all students indicated the clickers were easy to use and they would like to use it in future classes [ 35 ]. In another quasi-experimental study, Revell and McCurry [ 36 ] compared the effectiveness of a personal response system with didactic presentations. These interventions were incorporated within two undergraduate courses, nursing research (n=33) and junior medical-surgical nursing (n=116). The efficacy of each intervention was evaluated by multiple-choice, true-false, and quiz questions. Authors found that using a personal response system could significantly increase faculty-student participation and enhance active learning (p<0.001) compared with the lecture [ 36 ]. In a study with 47 first-year nursing students, Fifer [ 33 ] evaluated the perceptions of first-year nursing students regarding the use of student response system technology. A 14-item Likert scale survey was used to collect students’ perceptions. More than 80% of the student had a positive perception regarding the strengths of this technology for increasing SE. Many students expressed that this method maintained their focus during the lecture [ 33 ]. Berry [ 32 ] incorporated clickers to enhance student interaction and learning in a didactic pediatric nursing course. Exam grades and level of participation were monitored and exam scores and final scores were compared between two groups of ‘with clickers’ (n=65) and ‘without clickers’ (n=61). Student t-tests demonstrated that one of the three-course exams and final course grades were significantly higher for the students who used clickers (mean±standard deviation, 93.33±1.99 versus 95.03±1.64; p<0.001). Satisfaction feedback also supported the use of clickers as a tool to engage students and enhance learning outcomes [ 32 ].

b. Barcode scanning: Quick response (QR) code is a specific two-dimensional code that are used to encode and decode information such as text, Uniform Resource Locator links, Short Message Service messages with a mobile device that is equipped with a camera and QR reader software. QR codes can be integrated with learning activities such as linking a specific topic to information on the Internet, reviewing information, or evaluating classroom assignments. As an interactive technology-based approach, many health care systems incorporate barcode scanning or QR codes into nursing students’ clinical rotations to ensure patient safety. In addition, many educators incorporate this approach into the classroom activities to enhance students’ engagement. In this regard, Aul and Johnston [ 37 ] explored the experiences of undergraduate nursing students during the oncology course. The authors created barcodes consisted of one review question using a web-based, QR code generator tool. The authors printed the barcodes on an index card and then the cards were strategically taped throughout the classroom and the hallways outside of the classroom. Sixty-seven students were instructed to circulate around the room to scan the codes with their smartphones to find a range of oncology review questions. Afterward, the students should present and discuss the answer to the scanned questions. The authors found that barcode scanning is an attractive method for increasing SE and performance of nursing students. At present, the efficacy of barcode scanning to increase the engagement of nurse students is under research and currently, there is no experimental research that examined the effectiveness of this method.

2. Collaborative strategies

Collaborative learning is defined as a set of instructional methods to encourage students to work together to achieve a common learning goal. It involves mutual intellectual works by students themselves or students and educators. In this approach, students themselves are responsible for group governance and education output [ 38 ]. We found 10 articles discussing the importance of using collaborative strategies in promoting nursing students’ engagement.

1) Team-based strategies

a. Team-based learning: Team-based learning (TBL) is a shared learning and teaching approach, which is frequently used by health sciences educators in their preclinical and clinical programs to foster self-directed learning [ 39 ]. In nursing education, Dearnley et al. [ 40 ] reviewed the outcomes of TBL in nursing education programs to explore the experiences of nursing students regarding the TBL. They discussed that there is a great body of evidence, which supports TBL, as collaborative teaching and learning strategy, for sustaining and enhancing students’ engagement [ 40 ]. In an exploratory, descriptive study, Oldland et al. [ 41 ] explored the perceptions of nursing students regarding the role of TBL in shaping their professional clinical behaviors. Authors found that TBL can maximize students’ participation in the learning activities, develop active and deep learning, and raise teamwork performance, which in turn can enhance the students’ engagement in both academic and clinical settings [ 41 ].

b. Interdisciplinary partnership: Many schools across the world have been implementing partnership projects between students and the school’s staff in order to increase students’ engagement in academic learning activities. Bramble et al. [ 42 ] implemented a participatory action research to develop a “3-month mentorship partnership intervention” between nursing students and a group of academics as a mentor. They found that interdisciplinary partnership could increase students’ academic engagement and success; however, the acquisition of mutual trust and security were the main issues for developing mentorship capacity [ 42 ].

c. Collaborative testing: Quizzing has become a popular method of assessing learning and retention of knowledge as well as a mean of engaging students. In collaborative testing, students work together in small groups to complete quizzes before they select their final answer. Therefore, an important aspect of collaborative testing is the peer interaction, education, and collaboration during discussing each question. In nursing, Burgess and Medina-Smuck [ 43 ] used a collaborative testing approach using quizzes during maternal-infant course in the undergraduate nursing program. During this course, four multiple-choice quizzes were electronically administered. The outcomes were perception and attitude of students regarding collaborative testing strategy. Seventy-eight percent of students described this method as helpful and enjoyable in supporting their learning of the course material. Authors concluded that this strategy provided a structured method to enhance students learning and retention of course contents [ 43 ]. At present, no experimental research has evaluated the effectiveness of this technology in terms of SE.

d. Faculty-student interaction: D’Souza et al. [ 44 ] highlighted and summarized the important roles of nursing educators to promote nursing students’ engagement in the clinical environment. The suggested that to increase students’ academic engagement, nursing educators should: (1) involve students in teaching strategies, (2) balance student’s clinical activities with clinical assignments, (3) provide wide range of clinical activities, (4) appreciate the individual difference, (5) provide them with multidimensional resources, (6) group students for reflective activities, (7) create an atmosphere to enable students to learn, and (8) continuously supervise their activities. Authors found that when students and faculty actively share learning opportunities with each other, students are motivated to be more engaged in the new clinical learning environment.

e. Crossword puzzles solving: Raines [ 45 ] incorporated two models of crossword puzzles, as a cooperative learning activity, into nursing courses to promote students’ engagement and their critical thinking. Students worked in two phases of individually and in a small group. In the first model, which was designed for simple courses, students should solve the clues and in the second one, they should construct the content for the crossword puzzle (advanced courses). This process forces the students to actively engage and share their thinking and reasoning process with each other. The author found that these methods can actively engage students, promote their decision-making process, and help them to solve the problems [ 45 ].

2) Service-based strategies

Service-based learning involves learning that takes place outside the classroom in a structured way between the learner and a service, and seeks to achieve common goals. It is a kind of partnership that bridges academic and community needs. This type of learning is mostly done in the community, but it can also be used in clinical settings [ 46 ]. It is believed that service-based learning is one of the most effective strategies for students’ engagement because it has the potential to positively engage learners into the real-life situations and encourage the learner to be an active learner [ 46 , 47 ]. In this regard, Hart [ 46 ] provided a three-step framework, called “ABCs of service-learning,” that indicated the process of establishing and evaluating a service–learning project. The main components of this project are taken from the nursing process. In this project, A stands for “assessment and evaluation of community and educational needs,” B stands for “be flexible and engaging,” and C stands for “collaboration and celebration.” The authors claimed that service-learning project has the distinctive potential for engaging students because it can capture the learners’ attention, develop their partnerships and collaboration [ 46 ].

3) Peer-based strategies

Peer assessment (PA) refers to a process whereby students evaluate the learning or task performance of their peers and conversely, their learning are evaluated by their peers [ 48 ]. Although a few studies have focused on PA as a strategy for enhancing students’ engagement in academic learning, some nursing authors agree that PA can actively engage nursing students in their learning activities by enhancing the confidence of students in judging about their own work/performance. In addition, PA can encourage them to reread their own assignment in light of their peers’ feedback [ 49 , 50 ].

3. Simulation-based techniques

This category includes two strategies of “Simulation with Manikins and Tag” team simulation.

1) Simulation with manikins

Manikins have been long used in nursing education since they can provide safe and repeatable conditions for practicing. In this regard, Power et al. [ 51 ] simulated five separate case studies during ten teaching weeks. They aimed to explore student perspectives (n=9) of the use of vignettes to increase engagement with manikins. Authors through thematic analysis and group discussion found that manikins are an effective procedure for increasing SE. Authors believed that if the appropriate educational scenario is selected in this learning method, the instructors will be able to actively engage nursing students in the learning process and to promote their decision-making skills [ 51 ].

2) Tag team simulation

The word “tag team” refers to a combination of two or more people who have formed a team to meet similar goals. The tag team is a small group, so the participation of the members in that team is maximal and active. In nursing programs, simulations are regularly led in large groups, with few students playing an active role and most observing. In contrast, tag team simulation (TTS) as an innovative educational strategy emphasizes the active engagement of both participants and observers in the simulation scenario. This method is inspired by the principles of theater and allows learners, as actors, to take responsibility for the actions and outcomes in a real context. Levett-Jones et al. [ 52 ] provided a TTS with pain scenario for 444 second-year nursing students. Satisfaction with Simulation Experience Scale was used to evaluate the active engagement and satisfaction of observers and participants. The mean satisfaction score was not different between participants and observers (4.63 versus 4.56, p=0.16). This indicated that TTS is an effective approach for ensuring observers’ and participants’ active involvement during group-based simulations. Authors showed that TTS could promote the active engagement of learners and enhance their satisfaction with the simulation experience [ 52 ].

4. Research-based strategies: Q methodology

Q methodology is a mixed-method approach for conducting research that focuses on individuals’ preferences and subjective attitudes. Participants can express and share their viewpoints within the group [ 53 ]. In nursing, Judge et al. [ 54 ] incorporated Q methodology into a nursing education course about “substance abuse in school.” The basis for using this method was that if students’ attitudes and preferences are recognized and fulfilled, their participation and engagement in educational activities will be enhanced. The authors aimed to promote students’ engagement and enhance their learning of evidence-based practice. Nursing students (n=35) participated in a 2.5-hour session to create a mock Q study on their opinions about substance abuse education. The outcome was the overall opinions of students regarding the characteristic of Q methodology and the class format. At the end of the study, most students expressed favorable opinions. Authors found that Q methodology can provide a means to extract the participants’ opinion around a given topic and thus provide a way to keep students as active and engaged learners [ 54 ].

5. Miscellanea learning strategies

We found three articles discussing uncategorized learning strategies in promoting nursing students’ engagement.

1) Active learning

Undoubtedly, active learning is one of the key strategies for enhancing students’ engagement within the nursing educational programs. Active learning is a student-centered approach in which requires students to participate and cooperate in the teaching and learning process [ 55 ]. Many of the discussed educational strategies in the current review can be classified as an active learning strategy. In general, the available evidence about the effectiveness of active learning in nursing education shows that this cooperative educational strategy has a potential to promote nursing students’ engagement in the academic and clinical learning activities [ 9 , 55 ]. In contrast, some studies have shown that in the absence of active learning, academic engagement is not created. Popkess and McDaniel [ 9 ] examined the relationship between pre-college students’ inputs and academic engagement levels among baccalaureate students in nursing (n=1,000) and non-nursing professions (n=2,000). The National Survey of Student Engagement instrument was used to measure engagement on five subscales with a total of 41 items. Their findings showed that nursing students scored significantly higher (mean=58.71) on some aspects of academic engagement than other professions (mean=55.22 or 56.14). However, they were less engaged in active and collaborative learning than other majors [ 9 ].

2) Homework completion

Although many studies have shown that homework, as an active learning approach, can increase the academic performance of students, this learning activities has received little attention in nursing education [ 56 ]. Salamonson et al. [ 56 ] described the relationship between academic engagement (homework completion, lecture attendance) and academic performance in nursing students (n=126) who were enrolled in a pathophysiology subject. Students spent about 6 hours per week studying. The mean percentages of lecture attendance and homework completion were 67.5% and 48.9%, respectively. Authors found that active learning activities such as homework completion are one of the best way to engage students. As well, it is a strong positive predictor of academic performance and success for nursing students [ 56 ].

Engaging nursing students in academic environments and clinical settings is a challenging issue for nursing educators, worldwide. In recent years, many nurse researchers have investigated various educational strategies to explore and develop the best ways to increase nursing students’ academic engagement. Results of these efforts are the creation of new teaching strategies or modification of the techniques used by other disciplines. Accordingly, our main goal of this review study was to provide a set of useful tools for promoting nursing students’ academic engagement. In this review, we summarized the teaching strategies that nursing educators used to sustain or enhance the academic and clinical engagement of nursing students and eventually, we highlighted the gap for further research. We organized the teaching strategies into five categories based on the similarities of concepts and teaching techniques that educators had used: the main categories were technology-based strategies, collaborative strategies, simulation based strategies, research based strategies, and miscellanea learning strategies. Many of the training strategies had been created innovatively or derived from other disciplines such as management, technology, art, and theater. But the role of today technologies such as Internet in creating educational strategies was more prominent than the other [ 57 ]. Generally, in many of the strategies used, students’ academic engagement increased, but the main problem was that the tools used to measure the degree of engagement were mostly self-reported or subjective. In other words, due to the lack of experimental educational studies in nursing regarding the SE (only 6 quasi-experimental studies), we could not judge the strengths and weaknesses of the extracted strategies. Therefore, regarding the optimal strategy to sustain and promote nursing SE, further experimental study is needed. Moreover, given that the effectiveness of these techniques has been evaluated in the small number of studies, more experimental research is recommended.

Another important point is that educational strategies were mostly used in the classroom, and few were able to be transferred to clinical settings. Therefore, because more than half of nursing education takes place in clinical settings, the findings of these studies do not support the role of these strategies in increasing the academic engagement of nursing students in clinical education. In contrast, previous studies have shown that nursing students have greater motivation, both internally and externally, to learn clinical activities; therefore, they are more engaged in these activities [ 44 , 58 ]. However, there are limited studies on the clinical engagement of nursing students and there is a need for further research in this area. It is necessary that nursing instructors sustain and enhance the academic and clinical engagement of nursing students using innovative educational strategies in order to increase the level of students’ knowledge and abilities and improve the quality of clinical services provided.

Based on the results of this review, among the strategies discussed in this review, the use of technology, particularly the response system and online learning, was more common among nursing educators, which is in line with today advances in smart technologies. Students of new technologies’ era (‘digital native’ learners) are constantly engaged with the updated smart technologies [ 57 ]. In addition, online learning has witnessed a noticeable growth within healthcare education, nowadays [ 18 , 25 , 36 , 57 ]. Accordingly, if nursing educators want to maintain and enhance the students’ academic and clinical engagement, they should equip themselves more with innovative technologically-driven learning techniques.

Active learning was the foundation of most educational strategies used to enhance students’ academic engagement. In this regard, several studies in different fields of study have shown that any teaching method that can actively engage the student in learning process, can promote academic engagement and ultimately academic achievement of students [ 55 , 59 ]. Among the educational strategies reviewed in this study, strategies based on online technologies and simulation were more attractive to students and made their participation more active in the learning process. Accordingly, as a practical point of this study, if nursing teachers want to improve students’ academic engagement, they need to use attractive teaching methods that are based on the latest technologies of today world, such as smartphones and online discussion systems; however, at present little is known about the methods of promoting academic engagement in clinical activities.

1. Limitations and strengths

Our main limitation was that the number of experimental studies that accurately assessed the effectiveness of a particular teaching strategy on students’ engagement was limited. Some educators evaluated an innovative method in a limited group of nursing students without using a particular research plan and some others discussed the advantages and disadvantages of particular teaching strategies. These factors limited our conclusion about the effectiveness of a particular technique. Notwithstanding, the collection presented in this review can be used as a starting point for future research that to evaluate the effectiveness of an educational intervention on the academic engagement of nursing students. One of the strengths of our study is that we only considered the studies that were conducted in the field of nursing.

2. Conclusion and directions for future research

The main goal of this review study was to provide a set of useful tools for promoting nursing students’ academic engagement. In this review, we organized the teaching strategies into five categories based on the similarities of concepts and teaching techniques that educators had used. The main categories were technology-based strategies, collaborative strategies, simulation-based strategies, research-based strategies, and miscellanea learning strategies. Among these educational strategies, technologies- and simulation-based strategies were more attractive to students and made their participation more active in the learning process. At present, little is known about the methods of promoting academic engagement in clinical activities. Further experimental research is needed to confirm or disprove the effectiveness of the methods discussed in this paper. We did not find a unique strategy to enhance academic engagement in clinical education activities. One of the possible reasons for this is that learning in clinical settings particularly requires maximum engagement in clinical learning activities. It is recommended that future researchers design and test unique strategies for improving academic engagement in clinical settings.

Acknowledgments

This review was not funded by any companies, research grants, or funds.

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Author contributions

Study conception and design: MGH, HKM; data analysis and interpretation: MGH, HKM, AH; drafting the article or revising it critically for important intellectual content revisions for important intellectual content: MGH, HKM, AH; and final approval of the version to be published: MGH, HKM, AH.