Nurse Education in Practice 50 (2021) 102928

Contents lists available at ScienceDirect

Nurse Education in Practice

journal homepage: [Link]/locate/issn/14715953

Acceptability and efficacy of a communication skills training for nursing

students: Building empathy and discussing complex situations
Kerry M. Cannity *, Smita C. Banerjee, Shira Hichenberg, Angelina D. Leon-Nastasi,
Frances Howell, Nessa Coyle, Talia Zaider, Patricia A. Parker
Memorial Sloan Kettering Cancer Center, 641 Lexington Ave., 7th Floor, New York, NY, 10022, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Nurses must demonstrate effective communication across complex interpersonal domains, as emphasized by
Nursing education numerous professional healthcare organizations. However, formal communication skills training has been only
Communication modestly integrated into baccalaureate nursing programs, and of those studied systematically, there are notable
Empathy
methodological concerns. The current study focused on application of a well-researched communication program
End-of-life care
(Comskil) to student nurses completing summer internships at a comprehensive cancer center as part of their
clinical education. The Comskil training program for student nurses is an in-person, day-long training that in­
cludes three sections: responding empathically to patients; discussing death, dying, and end-of-life goals of care;
and responding to challenging family interactions. Student nurse participants provided strongly favorable per­
ceptions of the program, with 90% indicating that they agreed or strongly agreed with all perception items. A
significant pre-to post-training improvement in self-reported confidence was observed (p < .01). Additionally,
pre- and post-training observational coding of standardized patient assessments indicated significant improve­
ments in usage of the following skill categories: total skill use, information organization, and empathic
communication (p < .001). Overall, these results suggest that communication skills training for student nurses is
a feasible, acceptable, and effective way of increasing confidence and skills usage in complex clinical scenarios.

According to the American Association of Colleges of Nursing, skills are linked to improved disease prevention efforts, treatment
nursing program graduates are expected to demonstrate skill across a adherence, and satisfaction for patients (Charlton et al., 2008; Howick
variety of complex interpersonal domains (problem solving, leadership, et al., 2018; Taghizadeh et al., 2018). Many student nurses express
interprofessional collaboration, autonomy, integrity) – most notably anxiety or lack of confidence in their ability to communicate with pa­
communication, which is referenced across many of their “essentials of tients (Fisher, 2002; Szpak and Kameg, 2013). Students identified
baccalaureate education” (American Association of Colleges of Nursing, numerous barriers to effective communication, including reluctance to
2008). Despite increasing emphasis within academic and research engage with patients or families, difficulty initiating or maintaining
frameworks in the United States and internationally (International conversation, feeling devalued or inadequate, feeling frightened or
Council of Nurses, 2008; Sharon et al., 2019), formal communication anxious about engaging in advanced or complex conversations (e.g.
training for nursing students has been modestly integrated into bacca­ discussing death and dying), and continuing to worry about their per­
laureate programs, often without systematic examination of their effi­ formance after the interaction has ended (Kav et al., 2013; Lin et al.,
cacy (Gutiérrez-Puertas et al., 2020; Windsor et al., 2012). 2017).
Poor communication is identified as a barrier to effective care across Numerous methods have been suggested to improve patient care
many areas of nursing (Banerjee et al., 2016; Beckstrand et al., 2012; through nurse education, including simulated clinical experiences
Gillett et al., 2016) and may lead to adverse patient outcomes, including (Coleman and McLaughlin, 2019), training with standardized patient
lower satisfaction, reduced adherence to treatment recommendations, interactions (Kameg et al., 2014; MacLean et al., 2017), peer instruction
and poorer health outcomes (Burgener, 2020; Charlton et al., 2008). and mentoring (Moscaritolo, 2009), mindfulness practice (Ponte and
Conversely, decreased provider anxiety and improved communication Koppel, 2015), and communication skills training (Banerjee et al.,

* Corresponding author.
E-mail address: cannityk@[Link] (K.M. Cannity).

[Link]
Received 7 January 2020; Received in revised form 9 November 2020; Accepted 16 November 2020
Available online 19 November 2020
1471-5953/© 2020 Elsevier Ltd. All rights reserved.
K.M. Cannity et al. Nurse Education in Practice 50 (2021) 102928

2017). Of these, training in communication skills is one of the most second critique regarding unstandardized outcome measurement, we
widely applied and studied, as it has begun to be integrated into pre- and employed self-report measures which have been consistently used for
post-graduate medical and nursing education (Berkhof et al., 2011; program evaluation and participant self-ratings during the Comskil
Bylund et al., 2011; Kruijver et al., 2000). Communication skills pro­ research program. In addition, we utilized SPAs for role-plays, as well as
grams designed for nursing and nursing students have focused on pre- and post-training assessments – coupled with an empirically vali­
effectively gathering and imparting information and communicating dated observational coding system (Banerjee et al., 2017; Bylund et al.,
empathically (Banerjee et al., 2017; Call, 2016). Typically, such pro­ 2011, 2017). Pilot data from this project was presented previously
grams involve a combination of activities, including didactics, role (Cannity et al., 2019), and this paper represented an expansion and
playing, modelling, simulated patient experiences, and recording and deeper analysis of those findings.
critique of interactions (Alhassan, 2019; Shorey et al., 2018). We hypothesized that the Comskil training program for nursing
However, there are some notable challenges in implementing and students would have high levels of acceptability and result in significant
measuring efficacy of these programs. First, the range of topics covered increases in confidence between pre- and post-training and increased
is narrow [e.g. asking before telling, gathering and imparting informa­ frequency of good communication skills, including empathy, question­
tion, clarifying goals and expectations, empathic communication ing, agenda setting, information organization, and checking.
(Rosenzweig et al., 2007; Zavertnik et al., 2010)] and inconsistent across
H1. Participants would report favorable perceptions of the communi­
programs and learner populations. In some cases, the content of the
cation skills training program. These perceptions would be observed
training is not specified (Gutiérrez-Puertas et al., 2020). Few nursing
overall and for each training component.
programs include training on complex and highly emotional situations,
such as responding to difficult patients or families, handling requests for H2. Participants would report improved confidence in communicating
unwarranted treatment, and discussing death and end-of-life care with oncology patients from pre-to post-training. This improvement
(Bloomfield et al., 2015; Ferrell et al., 2016), though these components would be observed overall and for each training component.
frequently are featured in physician and registered nurse communica­
H3. Participants would demonstrate improved communication skill
tion skills programs (Arnold et al., 2017; Banerjee et al., 2017; Bylund
usage in SPAs from pre-to post-training.
et al., 2011). A second problem in implementing nursing student
communication skills training is unstandardized or idiosyncratic mea­
surement of outcome measures (Alhassan, 2019). Numerous methods 1. Methods
have been developed by individual institutions to assess program
acceptability and efficacy, but few have been accepted across in­ The research design was a single-arm pre-post study. This study
stitutions or across the field (MacLean et al., 2017). Frequently, partic­ received exemption by the institutional review board of the hospital
ipant satisfaction with the training program and self-reported skill usage (IRB #: X13-028).
are the main outcome measures, often assessed through questionnaires
developed by individual investigators or institutions (Mullan and Kothe, 2. Sample and setting
2010; Rosenzweig et al., 2007), although some studies use pre-existing
measures of related constructs (problem solving, motivation to learn: 158 nursing students completing a clinical rotation at a large cancer
Yoo and Park, 2015). Additional measurement techniques used include center in the northeastern United States participated in the Comskil
participants’ final grade in an academic course as a “quantitative” or training as a part of their clinical education. Students attended work­
observation measure (Mullan and Kothe, 2010) or qualitative or narra­ shops from July 2015 through June 2018, and all nursing students
tive responses to assess participants’ experiences (Davies, 2016). In completing rotations at this hospital during this period were required to
addition, researchers may not provide adequate psychometric data on attend this training.
their measures to allow for comparison across studies (MacLean et al.,
2017). 3. Methods and variables
Given that the goal of such training programs is to improve
communication skills and behavior change, the gold standard of mea­ 3.1. Comskil training
surement appears to be objective evaluation of standardized patient
assessments (SPAs: Bloomfield et al., 2015; Ryan et al., 2010; Schlegel Students participated in a one-day, three-topic workshop, which
et al., 2012). SPAs are structured interactions with a trained professional included didactics, role plays, video feedback, and pre- and post-SPAs.
(often an actor) in realistic clinical scenarios. Benefits of assessing par­ With input from senior nursing staff, this program was tailored to pro­
ticipants using this method include standardization of clinical scenarios vide training for communication encounters previously identified as
and providing direct observation of communication skills, while draw­ particular areas of concern for oncology nurses: responding empathic­
backs include that the interaction may seem stilted or artificial to the ally to patients; discussing death, dying, and end-of-life goals of care;
participants and does not provide a direct measure of patient outcomes and responding to challenging family interactions (Banerjee et al., 2016,
(Gerzina and Stovsky, 2020; Kruijver et al., 2000). Numerous studies 2017).
have found that SPAs are efficacious in both training and assessment of Each section began with a 30-min didactic which described the goals
communication skills in nursing students (Bloomfield et al., 2015; Hsu of the component, current literature on the skill, specific techniques for
et al., 2015; Ryan et al., 2010; Schlegel et al., 2012); however, this participants to use, and a short video demonstrating the techniques.
strategy has not been universally implemented in nursing programs Students also received a workbook with this information and additional
(MacLean et al., 2017; Ross, 2012). suggestions and resources. Following this, students were divided into
We sought to address these methodological concerns through groups of three for breakout role-play sessions lasting approximately 90
tailored application of a well-studied communication skills training min, which in most cases were co-facilitated by a communication
program (Comskil; Bylund et al., 2011) to a population of nursing stu­ specialist – an individual with an advanced degree in psychology or
dents with goals of increasing confidence and efficacy in communica­ communication – and a nurse with significant clinical experience and
tion. To address the limited variety of topics covered in nursing training in facilitation of communication training. When possible, stu­
communication skills training programs, we developed the program dents were grouped based on placement settings (e.g. urgent care,
after conducting a detailed needs assessment of communication chal­ intensive care, outpatient). During role plays, students completed brief
lenges for oncology nurses (Banerjee et al., 2016) and in consultation interactions with trained actors simulating patients, based on vignettes
with experts in the fields of nursing and communication. To address the developed by nursing experts. For example, during the end-of-life

2
K.M. Cannity et al. Nurse Education in Practice 50 (2021) 102928

section, students were asked to role play a meeting with a patient to Table 1
discuss her understanding of her cancer status and interest in care op­ Participant ratings of course effectiveness and confidence by module.
tions such as hospice. Students then receive verbal feedback from peers, Item from Program Evaluation Agree or Strongly Agree
facilitators, and the actor, and they reviewed video footage of the N (%)
interaction. Module Module Module Overall
Program effectiveness was assessed based on the Kirkpatrick model 1 2 3
(Kirkpatrick and Kirkpatrick, 2006), a widely used means of program Before this module, I felt 54 29 24 22.6%
evaluation (Bos–van den Hoek et al., 2019; Konopasek et al., 2017). This confident about this task. (34.1%) (18.4%) (15.2%)
model recommends evaluating programs on four levels: 1) the reaction Now that I have attended this 145 116 126 81.7%
of participants to the program, 2) evaluation of the participants’ module, I feel confident in my (91.8%) (73.4%) (79.8%)
ability to perform this task.
learning, 3) changes in behavior based on the program, and 4)
I feel confident that I will use the 154 152 146 95.3%
completion of the program’s objectives. Because this is an efficacy study, skills I learned today. (97.4%) (96.2%) (92.4%)
we concentrated on the first two levels. Participants’ reactions were The skills I learned today will 154 153 146 95.6%
evaluated through self-reported perceptions of the communication skills allow me to provide better (97.5%) (96.9%) (92.4%)
training program. These measures were administered by program as­ patient care.
The module/workshop prompted 155 153 146 95.8%
sistants not directly involved in the research team. Evaluation of me to critically evaluate my (98.1%) (96.8%) (92.4%)
participant learning was assessed through self-reports of their confi­ own communication skills.
dence and completion of pre- and post-SPAs. The experience of video 142 142 137 88.8%
feedback/large group role play (89.8%) (89.9%) (86.7%)
was helpful to the development
4. Measures
of my skills.
The skills I learned were 152 152 N/A 96.2%
4.1. Perception of course effectiveness reinforced through the (96.2%) (96.2%)
feedback I received in the small
Following completion of each component, participants were asked to group.
The small group/fishbowl 157 153 139 94.7%
rate the effectiveness and applicability of the skills taught. Items were facilitators were effective. (99.3%) (96.9%) (88.0%)
rated on a five-point Likert scale ranging from one (Strongly disagree) to
five (Strongly agree) with eight questions assessing the effectiveness of Note: Module 1 = responding empathically to patients; Module 2 = discussing
death, dying, and end-of-life goals of care; Module 3 = responding to challenging
the course. Example items include “The skills I learned today will allow
interactions with families. Overall scores represent mean percentage across
me to provide better patient care,” “The module prompted me to criti­
modules.
cally evaluated my own communication skills,” and “The experience of
video feedback was helpful to the development of my skills.” In addition,
participants were asked to rate the degree to which specific components Table 2
(didactic teaching, exemplary videos, and role plays) aided in their Participant ratings of course effectiveness by component.
learning. These three items were measured on a three-point Likert scale
Item from Program Somewhat Aided My Learning or Aided My Learning a
from one (Did not aid my learning at all) to three (Aided my learning a lot). Evaluation Lot
N (%)
4.2. Self-report of communication skill usage Module 1 Module 2 Module 3 Overall

Didactic teaching 149 162 147 94.5%

Participants’ uptake of skills was assessed through two methods: self- (94.3%) (96.2%) (93.1%)
reported pre- and post-training confidence in the specific communica­ Exemplary video 163 152 158 95.6%
tion skills and through observational coding of videotaped standardized (96.9%) (96.2%) (93.7%)
patient interactions. Self-reported confidence was assessed on a five- Role play/fishbowl 156 154 156 98.3%
experience (98.7%) (97.4%) (98.7%)
point Likert scale ranging from one (Strongly disagree) to five (Strongly
agree). One item measured retrospective pre-training confidence in Note: Module 1 = responding empathically to patients; Module 2 = discussing
communication skill usage (Before this module, I felt confident about this death, dying, and end-of-life goals of care; Module 3 = responding to challenging
task), and two items assessed post-training confidence (Now that I have interactions with families. Overall scores represent mean percentage across
attended this module, I feel confident in my ability to perform this task; I feel modules.
confident that I will use the skills I learned today).
example, within the Empathic Communication domain, one discrete
4.3. Observational coding of communication skill usage skill is Validate. This skill is defined as the provider making an explicit
statement which conveys to the patient that it is appropriate to be
Additionally, participants’ uptake of skills was measured through experiencing or feeling the way they are. These include statements such
observational coding of pre- and post-training SPAs. Students completed as, “I’m sorry you have been feeling so anxious,” or “This is so over­
8-min video-recorded SPAs during which they interacted with a trained whelming.” See Banerjee et al. (2017) for a comprehensive explanation
actor portraying a patient during a standardized, structured clinical of the coding system.
scenario. These interactions were coded by two independent, trained
coders – blinded as to whether the scenarios were pre- or post-training – 4.4. Reliability assessment
using the Comskil coding manual developed by Bylund and colleagues
Bylund and colleagues (2011). Two research assistants were trained by the co-authors in using this
The Comskil coding system (CCS) was developed to assess usage of a coding system until they were proficient based on coding of “gold-
variety of effective communication strategies in medical scenarios. The standard” training videos. Coders were blind to whether videos were
coding system was created for use with physician interactions and has pre- or post-training. Both research assistants started with coding the
been adapted for use with nursing and nursing students (Banerjee et al., same designated subset of videos (10% of the 316 standardized patient
2017). Verbal communication skills are operationalized into 20 discrete assessment videos = 32), followed by independently coding 45% of the
skills across five domains (See Table 3 for a list of the skills and do­ remaining videos each. Coding for the 32 videos was checked by the
mains). Nonverbal communication is not coded in this system. For second author for inter-coder agreement to assess coder drift from the

3
K.M. Cannity et al. Nurse Education in Practice 50 (2021) 102928

Table 3 6.1. Perception of course effectiveness

Student nurses’ pre- and post-training skills usage results.
Skills Pre- Post- t (df = 156) See Table 1 for frequency statistics of participant ratings of course
Training Training effectiveness. Based on self-report, participants generally rated the
M (SD) M (SD) Comskil course as highly helpful, with 90% endorsing agreement or
Agenda setting 0.07 (.28) 0.14 (.37) − 2.14* strong agreement with the efficacy of the course overall. In addition,
Declare agenda 0.05 (.21) 0.1 (.31) − 2.72** over 90% of participants agreed or strongly agreed that the responding
Invite agenda 0.01 (.08) 0.03 (.16) − 1.35 empathically and discussing death, dying, and end-of-life goals of care
Negotiate agenda 0.01 (.08) 0 (.00) 1.00
Take stock 0.01 (.16) 0.01 (.08) 0.45
components were useful. Further, for the challenging family interactions
Checking 0.32 (.70) 0.42 (.75) − 1.16 component, over 90% of participants reported that the skills learned
Check understanding 0.26 (.58) 0.24 (.51) − 0.76 were useful and prompted critical evaluation of their skills and over 85%
Check preference 0.06 (.33) 0.10 (.45) − 1.02 of participants agreed or strongly agreed that the large-group role-
Questioning 5.09 (2.48) 4.74 (2.31) 1.81
playing format was effective for skill development. When considering
Ask open questions 3.62 (2.03) 3.33 (1.90) 2.17*
Clarify 0.15 (.41) 0.27 (.57) − 1.70∧ each aspect of the training individually (didactic learning, exemplary
Restate 0.07 (.30) 0.14 (.37) − 1.78∧ video, small-group role-play, large-group role-play), more than 90% of
Endorse question asking 0.19 (.46) 0.23 (.56) − 0.46 participants reported that these techniques somewhat or strongly aided
Invite questions 0.9 (1.14) 0.73 (.87) 1.67 in their learning (See Table 2).
Information organization 0.33 (.53) 0.56 (.63) − 4.07***
Preview 0 (.00) 0.01 (.08) − 1.00
Summarize 0.01 (.08) 0.01 (.11) − 0.58 6.2. Confidence
Transition 0 (.00) 0.01 (.11) − 1.42
Review next steps 0.3 (.51) 0.51 (.55) − 3.88*** See Table 1 for frequency statistics of participants’ self-reported
Empathic communication 2.47 (2.34) 4.10 (3.05) − 6.47***
confidence. Based on self-report, most participants (78%) reported
Encourage expression of feelings 0.58 (.90) 0.90 (.93) − 4.08***
Acknowledge 0.57 (.93) 0.80 (1.09) − 3.10** that before training, they were ambivalent or not confident about their
Validate 1.05 (1.35) 1.57 (1.45) − 4.06*** communication skills. Following training, more than 80% reported that
Normalize 0.14 (.44) 0.34 (.62) − 4.02*** they agreed or strongly agreed that they feel confident in their
Praise patient efforts 0.15 (.44) 0.30 (.66) − 3.52*** communication abilities. Within the empathy component, 66% of par­
All skills 8.28 (3.57) 10.00 (4.10) − 4.69***
ticipants described themselves as unsure or not confident before the
∧
p ≤ .10, *p ≤ .05, **p ≤ .01, ***p ≤ .001. training, while 90% reported that they were confident or strongly
confident at using those skills after training. Similarly, before the dis­
CCS. Inter-coder agreement was assessed by checking coders’ percent­ cussing death, dying, and end-of-life goals of care component, 82% of
age agreement on 15-s blocks of the standardized patient interaction. We participants reported that they were ambivalent or not confident about
continued with coding only when the coders achieved a minimum of communicating, while after this component, 73% reported that they
70% agreement. All disagreements were resolved by the second author. were confident or strongly confident in their communication skills. The
See Banerjee et al. (2017) for a comprehensive explanation of the reli­ challenging family interactions training showed the greatest percentage
ability assessment process. change in self-reported confidence from pre-to post-test, with 85% of
participants describing themselves as unsure or not confident before­
5. Data analysis hand and 80% agreeing or strongly agreeing that they were confident in
their skills following the training.
Participants were rated to have found the training acceptable if they A paired-samples t-test indicated that overall, participants’ post-
indicated that they “agreed” or “strongly agreed” with questions training self-reported confidence in communication abilities was sta­
assessing the efficacy and usefulness of each component of the program. tistically significantly higher than before training [t(472) = − 30.12, p <
Self-reported improvement in confidence in communication was .01]. This finding held true across all components: responding
assessed using paired-samples t tests. Despite using Likert-scale data, empathically [t(157) = − 15.59, p < .01], discussing death, dying, and
parametric tests were used for this self-report data as the data did not end-of-life goals of care [t(156) = − 20.40, p < .01], and challenging
violate any assumptions of normality and to prevent loss of richness of family interactions [t(157) = − 18.29, p < .01].
data (De Winter and Dodou, 2010). Observational coding of SPAs was
used to measure skill usage, with the total number of each skills used as 6.3. Communication skill usage
the unit of measurement. Paired-samples t tests were used to assess
change in skill usage from pre-to post-training. Due to the multiple See Table 3 for descriptive statistics and t values of participants’ pre-
comparisons required for data analysis (1 overall skill index, 5 skill and post-testing communication skill usage. Before the training, par­
categories, 20 specific skills), a Bonferroni correction was applied ticipants demonstrated an average of 8.28 skills per interaction (range:
(0.05/25 = 0.002), and we utilized p ≤ .001 as the threshold for sta­ 1–20; SD = 3.57). Following training, participants demonstrated an
tistical significance. average of 10.00 skills (range: 2–23; SD = 4.11), a statistically signifi­
cant increase from pre-to post-training [t(156) = − 4.69; p < .001).
6. Results Participants also demonstrated a statistically significant increase in skill
usage across five of the 20 skills (review next steps, encourage expres­
87% of the sample identified as female, and 13% identified as male. sion of feelings, validate, normalize, and praise patient efforts) and
The sample had an average age of 23.7 (SD = 3.70). 84% of the sample across two of the five domains (information organization and empathic
was white/Caucasian, 9% Latino, 4% Asian/Asian-American, 1% black/ communication). There was not statistically significant change in the
African-American, and 1% two or more races/ethnicities. Participants other discrete skills or overall scores in the agenda setting, checking, or
attending this workshop were in their final year of their bachelors questioning domains.
nursing education.
7. Discussion

This study demonstrated the acceptability and efficacy of a one-day

training program to improve communication skills in student nurses

4
K.M. Cannity et al. Nurse Education in Practice 50 (2021) 102928

practicing within an oncology setting. Specifically, our first hypothesis rotations in a cancer center likely will take jobs across settings after they
was supported, such that participants rated the overall training and all graduate, taking their communication skills training with them. The
three components as highly effective, based on self-report. Participants applicability of oncology-based communication skills training for
also reported that each method of teaching skills (e.g. video examples, nursing students and nurses in other settings is an important area for
small-group role play) was highly effective. Our second hypothesis also future research.
was supported; participants reported improved confidence in their It also would be important to assess long-term maintenance and
communication skills overall and within each training component. growth in communication abilities following the training. This is vital
Finally, from pre-to post-training, participants demonstrated overall because very few studies assess the durability of communication skills
increased skill usage in SPAs, as predicted in our third hypothesis. training (e.g. Webster, 2014) despite the necessity of these skills across
Greater skill usage was observed within the information organization the career lifespan of nurses (Banerjee et al., 2017). The current study
and empathic communication domains, as well as in five discrete skills evaluated the acceptability and efficacy of this training program using
(review next steps, encourage expression of feelings, validate, the first two levels of Kirkpatrick and Kirkpatrick’s (2006) triangle of
normalize, and praise patient efforts). However, no significant increase program development. Future research also should focus on levels three
in skills occurred in the other three communication domains (agenda and four – evaluating generalization to real-world clinical practice and
setting, checking, or questioning) or within the other specific skill whether the training program influences patient outcomes. Further, it
categories. would be beneficial to evaluate how communication skills training af­
This program addressed previously identified limitations of previous fects personal factors for providers, such as empathy and burnout
communication skills trainings in nursing students (Gutiérrez-Puertas (Moore et al., 2018).
et al., 2020) through inclusion of a variety of methods of teaching and
feedback (didactic, video exemplars, small- and large-group role-play). 8. Implications for nursing
We consistently receive feedback from participants about the value of
using SPAs within the learning process, consistent with the emphasis on While the importance of communication skills is emphasized in both
standardized patient interactions in the literature (Ryan et al., 2010). nursing education and nursing practice guidelines, (Jenerette and
We also were able to systematically assess change in skill usage through Mayer, 2016; American Association of Colleges of Nursing, 2008),
use of the Comskil observational coding system, which provides a standardized, implementable training to facilitate such skills has only
rigorous and generalizable format to conduct evaluation of communi­ recently begun to be researched systematically (Banerjee et al., 2017;
cation skills training program (Bylund et al., 2011). Rosenzweig et al., 2007; Zavertnik et al., 2010). There were notable
Some limitations of the current study should be noted. We employed similarities in communication skill uptake among student nurses when
a single-arm research design, and there was not a control condition to compared to practicing nurses receiving similar training (Banerjee et al.,
allow for comparison of training and assessment. This study was con­ 2017). Both student nurses and practicing nurses demonstrated signifi­
ducted at one cancer center in the northeast United States, which may cantly increased use of skills overall and within the empathic commu­
limit generalizability to other settings and geographical areas. In addi­ nication domain. Only student nurses showed significant increases in the
tion, student nurses recruited to this site may be homogenous in some information organization category and the clarify and validate skills,
demographic factors (race/ethnicity, level of education, previous while only practicing nurses demonstrated a significant increase in the
experience) when compared to other samples of students. Self-report acknowledge skill. Notably, across nearly all communication domains
data was used to assess participants’ confidence in communication and discrete skills, student nurses showed greater amounts of skill use
abilities, as well as for perception of course effectiveness. Though self- during post-training standardized patient assessments. It may be that
reported measures of confidence generally are considered to be reli­ nursing students are more used to receiving and integrating instruction
able, it may be difficult to determine their validity (Stankov et al., 2015). into their practice, as they still are in training and may have more
The current study utilized self-report measurement and observational changeable patterns of communication with patients. Alternatively,
coding [assessing the first and second levels of the Kirkpatrick model of practicing nurses may have evolved more parsimonious methods of
program evaluation (2006)], but this limits generalizability of the re­ communication through their experience – requiring fewer comments to
sults to other settings and leaves open the question of the durability of maintain high levels of effective communication.
these findings over time. Our minimum standard for inter-rater agree­ However, it also is important to note that research shows nurses’ and
ment for the observational coding of communication skills was some­ nursing students’ level of empathy for their patients decreases the longer
what low (70% or higher). While we believe that it is important to they work (Ferri et al., 2015; Ward et al., 2012). It should not be
educate student nurses in communication skills at the beginning of their assumed that experience in nursing necessarily equates to effective pa­
career – where there may be exponential growth as they gain experience tient communication, given the notable institutional and individual
– these results cannot be easily compared to those of other medical barriers nurses report (Beckstrand et al., 2012), as well as their
professions or even post-graduate nurses. expressed need for communication skills training in challenging aspects
Given the limitations of the current study, future directions in this of patient interactions (Banerjee et al., 2016). Further, numerous studies
area of research should include completion of randomized controlled have highlighted the beneficial aspects of effective communication for
trials to evaluate the efficacy of this training program compared to the both patient and provider outcomes (Charlton et al., 2008; McCabe and
typical nursing education. However, it is notable that there is not a clear Timmins, 2013). Communication skills training such as Comskil can be
standard, given the wide variability in the types and methods of an important tool in maintaining empathy and effective patient care
communication skills training programs for student nurses (Gutiérrez-­ across the nursing career span. (Kruijver et al., 2000; Ward, 2016).
Puertas et al., 2020). Notably, this research was conducted at a cancer
center, and the sample was made up of student nurses completing 9. Conclusion
clinical rotations within this hospital. Further, some examples and
prompts used within Comskil training and SPAs are related to cancer. Our study has demonstrated the applicability and initial efficacy of a
This leaves open the question of whether these results are applicable to communication skills training program for student nurses. Given the
student nurses working in other settings or with other patient pop­ significant communication challenges this population faces (Kav et al.,
ulations. Studies in other settings suggest that good communication, 2013), as well as the lack of standardized methods to conduct research
trust in one’s provider, empathy, and willingness to address difficult on these programs, we demonstrated how an existing communication
topics may be just as important as in oncology settings (Curtis et al., skills training program (Banerjee et al., 2017) may provide high quality
2013; Dwamena et al., 2012). In addition, nursing students completing instruction and practice across several complex communication

5
K.M. Cannity et al. Nurse Education in Practice 50 (2021) 102928

domains. Our hope is that well-researched communication skills training communication skills training program for graduate medical trainees in Qatar. Int. J.
Med. Educ. 8, 16–18. [Link]
programs can be applied on a large scale to nursing education programs
Bylund, C.L., Brown, R.F., Bialer, P.A., Levin, T.T., Lubrano di Ciccone, B., Kissane, D.W.,
for the benefit of student nurses and their current and future patients. 2011. Developing and implementing an advanced communication training program
in oncology at a comprehensive cancer center. J. Canc. Educ. 26, 604–611. https://
[Link]/10.1007/s13187-011-0226-y.
Author Statement Call, L., 2016. A Structured Literature Review Regarding Teaching Communication Skills
to Pre-licensure Nursing Students. Doctoral dissertation. Western University of
Kerry M. Cannity:Performed the experiments, analyzed and inter­ Health Sciences.
Cannity, K.M., Banerjee, S., Hichenberg, S., Leon-Nastassi, A., Howell, F., Coyle, N.,
preted the data, wrote the paper
Zaider, T., Parker, P.A., 2019. Acceptability and efficacy of a communication skills
Smita C. Banerjee:Conceived and designed the experiments; per­ training for nursing students: Building empathy and discussing complex situations.
formed the experiments; analyzed and interpreted the data; contributed In: Symposium Presented at the 40th Annual Meeting for the Society of Behavioral
Medicine, Washington, DC.
reagents, materials, analysis tools or data; wrote the paper
Charlton, C.R., Dearing, K.S., Berry, J.A., Johnson, M.J., 2008. Nurse practitioners’
Shira Hichenberg:Conceived and designed the experiments; per­ communication styles and their impact on patient outcomes: an integrated literature
formed the experiments; wrote the paper review. J. Am. Acad. Nurse Pract. 20, 382–388.
Angelina D. Leon-Nastasi:Performed the experiments; wrote the Coleman, D., McLaughlin, D., 2019. Using simulated patients as a learning strategy to
support undergraduate nurses to develop patient-teaching skills. Br. J. Nurs. 28,
paper 1300–1306.
Frances Howell:Performed the experiments; wrote the paper Curtis, J.R., Back, A.L., Ford, D.W., Downey, L., Shannon, S.E., Doorenbos, A.Z., et al.,
Nessa Coyle:Conceived and designed the experiments; performed the 2013. Effect of communication skills training for residents and nurse practitioners on
quality of communication with patients with serious illness: a randomized trial.
experiments; wrote the paper J. Am. Med. Assoc. 310, 2271–2281.
Talia Zaider:Conceived and designed the experiments; performed the Davies, J., 2016. Using the real world to develop nurses’ skills. Nurs. Times 112, 23–24.
experiments; wrote the paper De Winter, J.C., Dodou, D., 2010. Five-point Likert items: t test versus Mann-Whitney-
Wilcoxon. Practical Assess. Res. Eval. 15, 1–12.
Patricia A. Parker:Conceived and designed the experiments; per­ Dwamena, F., Holmes-Rovner, M., Gaulden, C.M., Jorgenson, S., Sadigh, G., Sikorskii, A.,
formed the experiments; analyzed and interpreted the data; contributed et al., 2012. Interventions for providers to promote a patient-centred approach in
reagents, materials, analysis tools or data; wrote the paper clinical consultations. Cochrane Database Syst. Rev.
Ferrell, B., Malloy, P., Virani, R., 2016. Celebrating the success of an AACN partnership.
J. Prof. Nurs. 32, 1–4. [Link]
Funding Ferri, P., Guerra, E., Marcheselli, L., Cunico, L., Di Lorenzo, R., 2015. Empathy and
burnout: an analytic cross-sectional study among nurses and nursing students. Acta
Biomed. 86 (Suppl. 2), 104–115.
This research did not receive any specific grant from funding Fisher, J.E., 2002. Fear and learning in mental health settings. Int. J. Ment. Health Nurs.
agencies in the public, commercial, or not-for-profit sectors. 11, 128–134.
Gerzina, H.A., Stovsky, E., 2020. Standardized Patient Assessment of Learners in Medical
Simulation. StatPearls [Internet].
Ethical approval Gillett, K., O’Neill, B., Bloomfield, J.G., 2016. Factors influencing the development of
end-of-life communication skills: a focus group study of nursing and medical
This study received exemption by the institutional review board of students. Nurse Educ. Today 36, 395–400. [Link]
nedt.2015.10.015.
Memorial Sloan Kettering Cancer Center (IRB #: X13-028). Gutierrez-Puertas, L., Marquez-Hernandez, V.V., Gutierrez-Puertas, V., Granados-
Gamez, G., Aguilera-Manrique, G., 2020. Educational interventions for nursing
students to develop communication skills with patients: a systematic review. Int. J.
Declaration of competing interest Environ. Res. Publ. Health 17, 2241.
Howick, J., Moscrop, A., Mebius, A., Fanshawe, T.R., Lewith, G., Bishop, F.L., et al.,
2018. Effects of empathic and positive communication in healthcare consultations: a
None.
systematic review and meta-analysis. J. R. Soc. Med. 111, 240–252.
Hsu, L.L., Chang, W.H., Hsieh, S.I., 2015. The effects of scenario-based simulation course
References training on nurses’ communication competence and self-efficacy: a randomized
controlled trial. J. Prof. Nurs. 31, 37–49. [Link]
profnurs.2014.05.007.
Alhassan, M., 2019. Nursing and midwifery students’ communication skills training: a
International Council of Nurses, 2008. Nursing Care Continuum Framework and
systematic review. Journal of Advances in Medicine and Medical Research 1–10.
Competencies. Geneva, Switzerland.
American Association of Colleges of Nursing, 2008. The Essentials of Baccalaureate
Jenerette, C.M., Mayer, D.K., 2016. Patient-provider communication: the rise of patient
Education for Professional Nursing Practice. Washington, DC.
engagement. Semin. Oncol. Nurs. 32, 134–143. [Link]
Arnold, R.M., Back, A.L., Baile, W.F., Edwards, K.A., Tulsky, J.A., 2017. The Oncotalk/
soncn.2016.02.007.
Vitaltalk model. In: Kissane, D.W., Bultz, B.D., Butow, P.N., Byland, C.L., Noble, S.,
Kameg, K.M., Szpak, J.L., Cline, T.W., Mcdermott, D.S., 2014. Utilization of standardized
Wilkinson, S. (Eds.), Oxford Textbook of Communication in Oncology and Palliative
patients to decrease nursing student anxiety. Clinical Simulation in Nursing 10,
Care, second ed. Oxford University Press, Oxford, U.K., pp. 363–368
567–573.
Banerjee, S.C., Manna, R., Coyle, N., Penn, S., Gallegos, T.E., Zaider, T., Krueger, C.A.,
Kav, S., Citak, E.A., Akman, A., Erdemir, F., 2013. Nursing students’ perceptions towards
Bialer, P.A., Bylund, C.L., Parker, P.A., 2017. The implementation and evaluation of
cancer and caring for cancer patients in Turkey. Nurse Educ. Pract. 13, 4–10. https://
a communication skills training program for oncology nurses. Translational
[Link]/10.1016/[Link].2012.05.010.
Behavioral Medicine 7, 615–623. [Link]
Kirkpatrick, D., Kirkpatrick, J., 2006. Evaluating Training Programs: the Four Levels.
Banerjee, S.C., Manna, R., Coyle, N., Shen, M.J., Pehrson, C., Zaider, T., Hammonds, S.,
Berrett-Koehler Publishers, San Francisco.
Krueger, C.A., Parker, P.A., Bylund, C.L., 2016. Oncology nurses’ communication
Konopasek, L., Rosenbaum, M., Encandela, J., Cole-Kelly, K., 2017. Evaluating
challenges with patients and families: a qualitative study. Nurse Educ. Pract. 16,
communication skills training courses. Oxford Textbook of Communication in
193–201. [Link]
Oncology and Palliative Care 399.
Beckstrand, R.L., Collette, J., Callister, L., Luthy, K.E., 2012. Oncology nurses’ obstacles
Kruijver, I.P., Kerkstra, A., Francke, A.L., Bensing, J.M., van de Wiel, H.B., 2000.
and supportive behaviors in end-of-life care: providing vital family care. Oncol.
Evaluation of communication training programs in nursing care: a review of the
Nurs. Forum 39, E398–E406. [Link]
literature. Patient Educ. Counsel. 39, 129–145.
Berkhof, M., van Rijssen, H.J., Schellart, A.J., Anema, J.R., van der Beek, A.J., 2011.
Lin, M.-F., Hsu, W.-S., Huang, M.-C., Su, Y.-H., Crawford, P., Tang, C.-C., 2017. “I
Effective training strategies for teaching communication skills to physicians: an
couldn’t even talk to the patient”: barriers to communicating with cancer patients as
overview of systematic reviews. Patient Educ. Counsel. 84, 152–162. [Link]
perceived by nursing students. Eur. J. Canc. Care 26, e12648. [Link]
org/10.1016/[Link].2010.06.010.
10.1111/ecc.12648.
Bloomfield, J.G., O’Neill, B., Gillett, K., 2015. Enhancing student communication during
MacLean, S., Kelly, M., Geddes, F., Della, P., 2017. Use of simulated patients to develop
end-of-life care: a pilot study. Palliat. Support Care 13, 1651–1661. [Link]
communication skills in nursing education: an integrative review. Nurse Educ. Today
10.1017/S147895151500022X.
48, 90–98. [Link]
Bos–van den Hoek, D.W., Visser, L.N., Brown, R.F., Smets, E.M., Henselmans, I., 2019.
McCabe, C., Timmins, F., 2013. Communication Skills for Nursing Practice, second ed.
Communication skills training for healthcare professionals in oncology over the past
Macmillan International Higher Education, New York.
decade: a systematic review of reviews. Curr. Opin. Support. Palliat. Care 13, 33–45.
Moore, P.M., Rivera, S., Bravo-Soto, G.A., Olivares, C., Lawrie, T.A., 2018.
Burgener, A.M., 2020. Enhancing communication to improve patient safety and to
Communication skills training for healthcare professionals working with people who
increase patient satisfaction. Health Care Manag. 39, 128–132.
have cancer. Cochrane Database Syst. Rev. 7, CD003751. [Link]
Bylund, C.L., Alyafei, K., Anand, A., Al Marri, A., Omer, W., Sinha, T., Alam, W.,
14651858.CD003751.pub4.
Abdelrahim, H., Al-Khal, A., 2017. Implementing and tailoring a Western-developed

6
K.M. Cannity et al. Nurse Education in Practice 50 (2021) 102928

Moscaritolo, L.M., 2009. Interventional strategies to decrease nursing student anxiety in undergraduate nursing students: a quasi-experimental study. Nurse Educ. Today 61,
the clinical learning environment. J. Nurs. Educ. 48, 17–23. 120–126.
Mullan, B.A., Kothe, E.J., 2010. Evaluating a nursing communication skills training Stankov, L., Kleitman, S., Jackson, S.A., 2015. Measures of the trait of confidence. In:
course: the relationships between self-rated ability, satisfaction, and actual Measures of Personality and Social Psychological Constructs. Academic Press.
performance. Nurse Educ. Pract. 10, 374–378. [Link] Szpak, J.L., Kameg, K.M., 2013. Simulation decreases nursing student anxiety prior to
nepr.2010.05.007. communication with mentally ill patients. Clinical Simulation in Nursing 9, e13–e19.
Ponte, P.R., Koppel, P., 2015. Cultivating mindfulness to enhance nursing practice. Am. Taghizadeh, R., Shakhaei, S., Sadagheyani, H.E., Motaarefi, H., 2018. The effects of
J. Nurs. 115, 48–55. teaching communication skills to nursing students on the quality of care for patients.
Rosenzweig, M., Clifton, M., Arnold, R., 2007. Development of communication skills Asian J. Pharm. 12, S1252–S1255.
workshop for oncology advanced practice nursing students. J. Canc. Educ. 22, Ward, J., 2016. The empathy enigma: does it still exist? Comparison of empathy using
149–153. [Link] students and standardized actors. Nurse Educat. 41, 134–138.
Ross, L., 2012. Interpersonal skills education for undergraduate nurses and paramedics. Ward, J., Cody, J., Schaal, M., Hojat, M., 2012. The empathy enigma: an empirical study
J. Paramedic Pract. 4, 655–661. [Link] of decline in empathy among undergraduate nursing students. J. Prof. Nurs. 28,
Ryan, C.A., Walshe, N., Gaffney, R., Shanks, A., Burgoyne, L., Wiskin, C.M., 2010. Using 34–40. [Link]
standardized patients to assess communication skills in medical and nursing Webster, D., 2014. Using standardized patients to teach therapeutic communication in
students. BMC Med. Educ. 10, 24. [Link] psychiatric nursing. Clinical Simulation in Nursing 10, e81–e86.
Schlegel, C., Woermann, U., Shaha, M., Rethans, J.J., van der Vleuten, C., 2012. Effects Windsor, C., Douglas, C., Harvey, T., 2012. Nursing and competencies—a natural fit: the
of communication training on real practice performance: a role-play module versus a politics of skill/competency formation in nursing. Nurs. Inq. 19, 213–222.
standardized patient module. J. Nurs. Educ. 51, 16–22. [Link] Yoo, M.S., Park, H.R., 2015. Effects of case-based learning on communication skills,
01484834-20111116-02. problem-solving ability, and learning motivation in nursing students. Nurs. Health
Sharon, F.B., Farmer, S., Nunn-Ellison, K., Ard, N., 2019. International nursing program Sci. 17, 166–172. [Link]
accreditation. Int. J. Nurs. Educ. Scholarsh. [Link] Zavertnik, J.E., Huff, T.A., Munro, C.L., 2010. Innovative approach to teaching
0075. communication skills to nursing students. J. Nurs. Educ. 49, 65–71. [Link]
Shorey, S., Kowitlawakul, Y., Devi, M.K., Chen, H.-C., Soong, S.K.A., Ang, E., 2018. 10.3928/01484834-20090918-06.
Blended learning pedagogy designed for communication module among