student nurse reflective essay on communication

Communication in Nursing Practice: Gibbs’ Reflective Cycle Essay

Introduction, description, action plan, reflective conclusion.

Communication is a fundamental element in nursing practice. This element can possibly determine patients’ satisfaction and even the outcomes of their treatment (Lotfi et al., 2019). The situation described in the paper will exemplify the potential role of communication, which is why it will serve as a Gibbs Reflective Cycle nursing example. The cycle will help to assess the situation and extract lessons from it.

The model is a widely-recognized and crucial learning instrument, allowing individuals to extract lessons from life experiences. The pattern helps one to consider previous experiences, reevaluate them in the light of new knowledge, and implement the freshly obtained insight to improve future practice (Markkanen et al., 2020). The cycle is composed of six stages (description, feelings, evaluation, analysis, conclusion, and action plan), on which the reflection regarding the personal experience will be based (Markkanen et al., 2020). The paper’s principal objective is to outline a challenging situation from personal practice using Gibbs’ Reflective Cycle. The problematic situation is an encounter with a patient suffering from an infected diabetic foot ulcer and in need of amputation. Overall, the paper aims to critically analyze the situation and transform it into a learning opportunity useful in improving my future practice as a wound care specialist.

The situation concerns a 40-year-old patient with diabetes and an infected foot ulcer who was admitted to the hospital where I was working at the moment. The patient had a long history of diabetes, from which he suffered since he was ten years old. A multidisciplinary team examined the patient and established that he needed an amputation. As I approached the patient to get a consent form, I noticed that he looked upset. Given the described situation, it might be suggested that a communication dilemma here is of ethical character, in particular – it is the delivery of the bad news. By applying the model, the provided Gibbs Reflective Cycle example communication will demonstrate what actions were undertaken to resolve the mentioned dilemma.

The incident that will be analyzed is an outstanding Gibbs Reflective Cycle nursing example, which happened several years ago when I began working as a wound care nurse. A 40-year-old diabetic patient with an infected diabetic foot ulcer was admitted to the hospital. He had a long history of diabetes, suffering from the condition for three decades. A multidisciplinary team examined and communicated with the patient; it was established that he needed a below-knee amputation. The group stated their decision and left, and I had to retrieve the consent form. While retrieving the record, I perceived that the patient looked exceedingly sorrowful and depressed. Nevertheless, I did not know whether I needed to intervene in the situation and left.

Although I worked for many years in nursing before the incident, I became a certified wound care nurse relatively recently before it took place. At the moment, I saw the situation as irreparable, so I was not sure whether I should have tried to console the patient. I felt anxious and, to an extent, powerless when faced with the man’s grief. I thought that words or an empathic response would not be able to mitigate his sadness. Additionally, I was also somewhat startled that the multidisciplinary team did not handle the conversation more delicately and left rather abruptly. Overall, I did not feel confident enough to handle the situation and was unsure whether my intervention would be appropriate.

I frequently returned to the incident, trying to understand what should have been done instead. Retrospectively, I believe that it helped me to reevaluate the role of therapeutic communication in my profession. Prior to the incident, I did not perceive preoccupation with patients’ emotional well-being as my duty as a nurse. I believed that administering medications and treatment, performing tests, recording medical history, educating patients, et cetera, was all that was required of me. Nevertheless, I did not fulfill another vital function in the described situation. To understand that a holistic approach to care presupposes therapeutic communication, I had to experience the case (2). As a nurse, showing empathy and consoling patients is a critical function that is sometimes overlooked. Furthermore, the incident demonstrates a lack of cooperation between the nursing staff and the team since communication was needed to ensure that the emotional impact of amputation on the patient was alleviated.

Some medical professionals find the process of delivering bad news challenging and feel psychologically unprepared (Van Keer et al., 2019). A lack of skills in this aspect can negatively affect patients: they might undergo extra stress, have lower psychological adjustment, and have worse health outcomes (Biazar et al., 2019; Matthews et al., 2019). Furthermore, the way the news is handled can impact patients’ understanding of the situation and adherence to treatment (Galehdar et al., 2020). Given the adverse effects, multiple protocols and approaches to communicating bad news and dealing with its consequences were developed. This situation is analyzed in detail in a ‘Gibbs Reflective Cycle example essay pdf’ that focuses on these communication challenges in healthcare.

In the patient- and family-centered approach, the process occurs based on the patient’s needs as well as their cultural and religious beliefs (Hagqvist et al., 2020). Upon communicating the information, a medical professional is supposed to assess their understanding and show empathy (Hagqvist et al., 2020). In an emotion-centered approach, a medical professional is supposed to embrace the sadness of the situation and build the patient-medical professional interaction on empathy and sympathy (Hagqvist et al., 2020). Yet, the patient- and family-centered approach seems more effective since excessive empathy can be counter-productive and impede information exchange.

Managing patients’ reactions is the final and particularly vital step in communicating bad news. Nurses are commonly involved in handling emotional responses, which entails several responsibilities:

• Additional emotional support should be given to those who cannot accept the information (Galehdar et al., 2020).
• Nurses can find more related information and share it with patients (Rathnayake et al., 2021).
• Nurses are supposed to improve the situation if bad news has been delivered poorly (Dehghani et al., 2020).

In the case of amputation, heightened emotional attention should be given to the patient, as limb loss is a life-altering procedure. Such patients commonly undergo the five stages of grief (denial, anger, bargaining, depression, and acceptance) and are prone to developing anxiety, depression, and body image issues (Madsen et al., 2023). Hence, upon delivering the news regarding amputation, it is vital to provide a patient with community resources for dealing with emotional and psychological implications.

Currently, I understand more in-depth that delivering and handling the consequences of bad news is an inescapable reality of the nursing profession. The incident allowed me to notice the aspects of my professional development that necessitate more attention and improvement. Hence, I strive to be more empathetic in my clinical practice and not undervalue the role of patient-nurse communication. I attempt to provide psychological and emotional support to patients and console them to the best of my ability and knowledge, especially if a patient has just received traumatic news. Due to the incident, I comprehended better that a patient’s emotional well-being can be dependent on my actions. I also stopped presuming that other medical professionals provide the necessary emotional support. Moreover, I understand that I am not powerless when faced with a patient’s sorrow.

Consequently, I will not neglect the importance of patient-nurse communication for patients’ health outcomes and mental well-being. I will offer hope where it is appropriate and encourage and validate patients’ emotions to help them deal with traumatic information (Font-Jimenez et al., 2019). In the future, I will use verbal and non-verbal communication clues to show that I care and, generally, be more empathetic (Font-Jimenez et al., 2019). I will not prevent my insecurities from fulfilling my nursing duties, nor will I allow the feeling of hopelessness to affect my clinical practice. Furthermore, I will rely on evidence-based approaches to handle bad news effectively and facilitate its delivery to patients.

Additionally, I will be more mindful in my nursing practice. Gibb’s reflective cycle will assist me in attaining this objective. I will continue to apply it to the situations occurring at work in order to think systematically as well as analyze and evaluate them. Furthermore, Gibb’s reflective cycle will enhance my ability to learn from my experience. The model will help me to refine my communication skills and make patient-nurse interactions more intuitive and productive (Markkanen et al., 2020).

The situation allowed me to understand the actual value of therapeutic communication in nursing. Now, I understand the need to exercise it in my clinical practice, which is a realization that I further explored in a ‘Gibbs Reflective Cycle example essay pdf.’ Learning to provide emotional support and manage the consequences of bad news is an essential quality for nurses, influencing health outcomes and satisfaction from a visit. Additionally, I become more conscious of my own emotions and the way they can prevent me from acting in a patient’s best interests. Overall, the proper tactics of delivering bad news and assisting patients in handling them became a higher priority in my clinical practice.

To conclude, this reflection featured an episode from my practice in which I analyzed a communication situation using Gibbs’ Reflective Cycle. It showed that I need to concentrate on my abilities to resolve the communication dilemma of the delivery of bad news. The above discussion also demonstrated how the implementation of an appropriate and significant evidence-based model – Gibbs’ Reflective Cycle – may result in better patient outcomes.

Biazar, G., Delpasand, K., Farzi, F., Sedighinejad, A., Mirmansouri, A., & Atrkarroushan, Z. (2019). Breaking bad news: A valid concern among clinicians . Iranian Journal of Psychiatry, 14 (3), 198–202. Web.

Dehghani, F., Barkhordari-Sharifabad, M., Sedaghati-kasbakhi, M., & Fallahzadeh, H. (2020). Effect of palliative care training on perceived self-efficacy of the nurses . BMC Palliative Care, 19 , 63. Web.

Font-Jimenez, I., Ortega-Sanz, L., Acebedo-Uridales, M. S., Aguaron-Garcia, M. J., & de Molina-Fernández, I. (2019). Nurses’ emotions on care relationship: A qualitative study . Journal of Nursing Management, 28 (8), 2247-2256. Web.

Galehdar, N., Kamran, A., Toulabi, T., & Heydari, H. (2020). Exploring nurses’ experiences of psychological distress during care of patients with COVID-19: A qualitative study . BMC Psychiatry, 20 , 489. Web.

Hagqvist, P., Oikarainen, A., Tuomikoski, A.-M., Juntunen, J., & Mikkonen, K. (2020). Clinical mentors’ experiences of their intercultural communication competence in mentoring culturally and linguistically diverse nursing students: A qualitative study . Nurse Education Today, 87 , 104348. Web.

Lotfi, M., Zamanzadeh, V., Valizadeh, L., & Khajehgoodari, M. (2019). Assessment of nurse–patient communication and patient satisfaction from nursing care . Nursing Open, 6 (3), 1189-1196. Web.

Madsen, R., Larsen, P., Carlsen, A. M. F., & Marcussen, J. (2023). Nursing care and nurses’ understandings of grief and bereavement among patients and families during cancer illness and death – A scoping review . European Journal of Oncology Nursing, 62 , 102260. Web.

Markkanen, P., Välimäki, M., Anttila, M., & Kuuskorpi, M. (2020). A reflective cycle: Understanding challenging situations in a school setting . Educational Research, 62 (1), 46-62. Web.

Matthews, T., Baken, D., Ross, K., Ogilvie, E., & Kent, L. (2019). The experiences of patients and their family members when receiving bad news about cancer: A qualitative meta-synthesis . Psycho-Oncology, 28 (12), 2286-2294. Web.

Rathnayake, S., Dasanayake, D., Maithreepala, S. D., Ekanayake, R., & Basnayake, P. L. (2021). Nurses’ perspectives of taking care of patients with Coronavirus disease 2019: A phenomenological study. PLoS ONE, 16 (9), e0257064

Van Keer, R. L., Deschepper, R., Huyghens, L., & Bilsen, J. (2019). Challenges in delivering bad news in a multi-ethnic intensive care unit: An ethnographic study . Patient Education and Counseling, 102 (12), 2199-2207. Web.

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How to Write a Nursing Reflective Essay (Guide for Nurse Students)

If you are a nursing or medicine student, you are aware that you will come across or have already come across assignments requiring you to write a nursing reflection essay. At first, such a task always appears challenging, but given the understanding of the steps, things flat out, and you can write reflective essays and get better grades.

Reflective practice is highly encouraged in nursing. Reflection entails making sense of situations, events, actions, and phenomena in the workplace.

As a nursing student, you will be asked to write a reflective essay on your clinical placement, practicum, shadowing experience, shadow health DCE activities, personal nursing philosophy, why you want to become a nurse, nursing program, ethical dilemma, knowledge, skills, and abilities, systems, and processes.

The easiest way to complete the reflective essay assignment is by first determining what reflective writing entails, its significance, its steps, and some of the best tips that form the core of this ultimate guide.

Basics of Reflective Writing in Nursing

Reflective writing is an analytical writing practice where the writer describes a real or imaginary event, scene, phenomenon, occurrence, or memory, including their takeaway. It entails the critical analysis of an experience, including recording how it has impacted you and what you intend to do with the new knowledge or how to act when such an occurrence recurs.

As you document the encounter, you can use first-person pronouns and write subjectively and objectively. This means that you can decide to either use personal experiences alone or support these experiences using citations from scholarly sources.

When writing a reflective essay in nursing, you must recount the events and give critical detail of how the events shaped your knowledge acquisition. Reflection helps nursing students develop skills in self-directed learning, which is directly associated with high motivation and improved quality of care .

In most cases, reflection occurs on what went well and what went wrong. It could be a successful operation, a thank you note from a patient, a patient who regained their health faster, or a new nursing care plan that worked. However, it can also be about adverse events such as death, postoperative complications, death of an infant at birth, dissatisfied patient, medical error, or a failed procedure.

As a nursing student, when you learn to reflect on situations, you grow to become a professional nurse who diligently does their noble duty.

When writing a reflective essay, you begin by setting the scene (explaining what, where, how, and who-the situation), detailing how you felt (emotional state), why it happened (making sense of the situation), critical review and development of insights, a note on what was learned, and strategies to address future recurrence.

Your professor may ask you to write a nursing reflective paper about various topics in your course or your experience working in a group, how you solved a problem, a healthcare issue, or clinical practice. Consider the following example of a reflective statement in nursing; in my clinical practices, I realized I focused more on the technical aspects but failed to explain what it was doing to improve their health. I would like to understand more about listening to patience and their concerns to better care for them.

As you will notice later, these reflective stages are structured into different reflective models and frameworks that we will explore in-depth. So, with the understanding of what comprises reflective writing and its importance in nursing, let's now get solid on the structure.

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Structure of a Reflective Essay in Nursing

A reflective essay is an analytical writing piece describing and evaluating encounters or experiences. When asked to write one, you should know that an excellent reflective essay consists of different parts, just like a typical academic essay. It comprises the cover or title page, introduction, body paragraphs, conclusions, and a references page.

The title page contains information about the assignment. If you are writing the reflective essay in APA, include these on the title page:

• Title of the reflective essay
• Course code and name
• Instructors name
• Name of your institution
• Date of submission

When writing in Harvard format, the title or the cover page will consist of the following:

• Title of the essay in title case and the page number (upper right margin),
• Title of the essay in CAPS,
• Name of class or course,
• Name of the instructor,
• Name of your school,
• City and state where your school is located and,
• The date of submission.

Introduction

The introduction begins with an attention grabber or a hook sentence to attract readers' attention. It should then explain the essay's purpose and signpost the ideas that will come later in the essay. The introduction also has a thesis statement at the end of the paragraph- the last sentence. The thesis is concise, clear, and relatable and should reflect your position.

Body Paragraphs

The body paragraphs of a reflective essay can be three or more, depending on the length of the essay. Essentially, the body comprises 80% of the total word count.

The first paragraph is where you describe the situation, including the events, why they occurred, how they occurred, and those involved.

The second paragraph entails your personal feelings or reaction to the situation and how it made you feel.

The third paragraph can include making sense of the situation. You have to think about why things happened the way they did. You should also critically review and develop insights based on the situation. Finally, think of the factors that could have influenced the situation.

The next paragraph should explain how the event or situation will change your practice, approach, decisions, perspective, or perception. This is where you evaluate the experience by detailing the knowledge and skills you took from the experience.

The last body paragraph should entail a critical reflection on the learning opportunities. First, describe the situation and what it made you learn. Next, elaborate on how you intend to make yourself better poised to address such situations.

Mostly, you should structure the body of your essay as per the preferred nursing reflective model.

After everything else falls into place, you need to summarize the information you presented in the essay. Then, finally, restate your thesis and have a call to action to bring a sense of closure to your readers.

Steps for Writing a Nursing Reflection Essay � The Guide

When assigned to write a reflective essay for your nursing class, here are the surefire steps to get you to success.

Read the instructions

The first step after receiving an assignment is to begin reading the instructions. as you read, note what your instructor or professor expects in the paper you will submit for marking.

Reading instructions helps you to get informed on the scope of the paper, word count, number of references and pages, and the formatting style to use.

Besides, you also get to plan your paper with the deadline highlighted in the instructions.

You need to get a conducive environment where you can start writing.

The first step of writing is to brainstorm about situations during your clinical hours when you were shadowing a Nurse Practitioner or one you have read about.

Assess whether the situation or scenario you have thought, encountered, or chosen can help you write a reflective essay that meets the requirements.

Research and Plan

After choosing a scenario, the next step is researching the best reflective model.

You can use your class text, the instructions, the college library, course readings, and online nursing journals to get articles and resources with information about specific reflective models.

Select the best reflective model and take notes on the steps it entails.

As you research, write down notes on how to address your paper based on your selected framework or model of reflection . Additionally, research nursing journal articles with information you can use when critically analyzing a situation.

Plan how you will handle the paper as well. For instance, as you research, develop a thesis statement that grounds your entire paper, then draft an outline on how to develop the thesis.

Write an Outline

Outlining is a crucial aspect of writing. It helps you envision how you will meet the objective of writing a reflective essay. As an essential part of the essay writing process, outlining helps create a good flow of ideas and can come in handy in helping you overcome writer's block. Your outline should comprise the following:

• The hook or attention grabber
• Thesis statement
• Main points of each body paragraph (topic sentence, evidence, examples, illustrations, etc.)
• Conclusion (restated thesis and call-to-action)

With the outline done, you should take a break and resume writing your first draft of the nursing reflection essay. Writing with an outline helps avoid mistakes and also helps you write faster.

Describe the Experience

Once you have identified the relevant experience, begin describing it chronologically.

Describe the experience that prompted you to consider nursing your ideal career goal. Think of this experience's key elements, such as the setting, patient demographics, and significant events that impacted you.

Show how these events changed your perspective on life. Ensure you are as descriptive as possible to paint a clear picture for readers.

Consider the following questions to come up with a good description:

• What happened?
• Was there someone involved? If yes, what part did they play?
• Where did the event take place?
• What actions did you take?

Set the context of this experience by giving relevant background information. Ensure you are objective and pay attention to the facts.

Provide a Reflection

Talk about your feelings and thoughts concerning the particular experience you went through. You have to be honest and open up about your initial expectations and challenges you faced at each stage of the experience. The following questions can help you come up with a good reflection:

• What was I trying to achieve?
• What prompted me to act the way I did?
• Are there any consequences for my actions? If yes, what are they?
• How did I feel about this event as it was happening?
• How did those around me react to it?
• How do I know how those around me felt about it?

Analyze the Experience

Description of an experience is essential, but so is analysis. You have to move beyond the surface and give a critical analysis of your experience.

State your actions, and your overall experience will give insights into your experience. Think of how the experience has impacted your actions, feelings, and thoughts.

Give an Evaluation

Evaluate the skills and knowledge you got from the experience. Show how you can apply these skills and knowledge in your nursing practice. Also, state the actions and interventions you took during the nursing experience.

State whether you achieved the desired outcome and if there are any specific areas that you need to improve on.

Talk about how you built or improved skills like communication, teamwork, and critical thinking.

As you evaluate the experience, identify what you believe to be your strengths and weaknesses in the nursing experience. What have you learned from the experience? State the areas where you excelled and what abilities contributed to your success.

Talk about how those you were with during the clinical experience complimented you. Similarly, acknowledge your weaknesses.

What kind of mistakes did you make, and how did you improve them? Talk about the tasks that drain you most during the experience.

Illustrate Learning

Demonstrate elements of deeper thought and reflection levels. This is a great point to include nursing theories in your reflection essay to support analysis of your experience.

Relate your experiences to the theoretical frameworks you were taught in class. This is effective learning and will demonstrate your ability to apply knowledge to real-life nursing situations.

Doing this will also show that you can effectively deduce different things from observations made during the reflection process.

Ensure you also demonstrate a change in perspective, as this will prove that you learned something from the experience.

Write Your Conclusion

Conclude by summarizing your points and highlighting the lessons learned.

The lessons you reached as part of your reflection should support your overall conclusion.

Also, restate your thesis statement.

Come Up with an Action Plan

Now that you have learned from your reflection develop an action plan for future nursing practice.

This part should contain all the details you have learned and actions needed to improve when faced with a similar situation. Consider the following questions:

• What would I change if faced with a similar situation?
• How can I develop the necessary skills needed to face this situation?
• How can I act differently in a similar situation?  

Ensure you identify areas to improve and set realistic goals to enhance your nursing skills. Discuss how you intend to seek additional education, training, or mentorship to address your shortcomings.

Finally, end the essay with a happy note so readers know you learned something from the experiences.

Proofread, Edit, and Polish

After doing your first draft, take a break to relax and get out of the writing mood - it helps you to become objective.

You can then resume reading out loud to yourself, make necessary tweaks, and ensure that every part you include meets the rubric requirements.

Edit for grammar, punctuation, tenses, voice, spelling, and use of language. You should also proofread the essay to adhere to the style, organization, and presentation requirements.

Ensure that all the in-text citations are accounted for in the reference list and are up-to-date. You are good to go when you have an essay that meets all the instructions.

Finally, you can submit the paper for grading.

Writing is not everyone's cup of tea. For that reason, you can hire a nursing reflection essay writer from our website to assist you in crafting a top-grade paper. In addition, we have nursing writers whose forte is writing various nursing papers.

Choosing the suitable Reflective Model or Framework

As you can see above, many reflective models are used for your reflective essay. We have not exhaustively listed and expounded on all of them. Other reflective models and frameworks you can also consider when writing a reflective essay in nursing include:

• Bouds Reflective Model
• Brookfield Reflective Model
• Pender's Health Promotion Model
• Roper Logan and Tierney Model
• Driscoll Reflective Model
• The Johari window model

Note that most nursing instructors will often suggest the models they prefer for you to use in your essay.

For example, in most nursing reflective essays. Whichever the case, readily available information expands on each model to make it easier to write a reflection essay on a specific aspect of nursing education or practice.

Read the assignment rubric and instructions to understand the specific model. If it is unclear, ask for clarification from your instructor early enough.

Tips for Writing a Good Nursing Reflective Essay

As you try to figure out how to write a nursing reflective essay, keep the following tips in mind.

Choose the Right Topic

If the instructions from your professors involve choosing a topic for the reflective essay, you must select one that is meaningful to you.

This will ensure you can easily write and easily develop relevant elements about the topic. Therefore, take time to pick a topic that you find interesting.

As you write, ensure you stay on topic, whether sharing a one-off event or a recurrent story.

Use the Right Tone

A reflective essay is more personal, unlike other types of academic essays. This means you don't need a strict or formal tone.

Since this is about your experiences, use personal pronouns such as I and Me.

Be Vulnerable

You must be extremely vulnerable to learn how to write a reflective essay in nursing.

Be open about your thoughts, feelings, and beliefs about something you went through that sparked an interest in nursing.

It's okay to share mistakes or things you did wrong that eventually led you to this career path.

Choose the Right Focus

A reflection essay is all about narrating your experience during the nursing experience.

While including other people in your experience is okay, please let them not be the center of your reflection.

This is your essay, so you should be the focus of attention.

Keep it Brief

A good nursing reflection essay should be between 300 and 800 consciously written words. Because of this length, you must only write relevant information about your reflection. Refrain from lengthy reflections, as they make it difficult to pass your points across.

Convey Your Information Wisely

Even though a nursing reflection essay is about your personal experiences, it doesn't mean you should reveal everything about yourself. Ask yourself whether something is appropriate before including it in your paper.

Mistakes to Avoid When Writing a Reflection Essay in Nursing

A good reflection essay involves reflecting on your nursing studies and practices throughout school and career to demonstrate your competence. For this reason, there are certain mistakes you should be aware of when writing an essay.

Not including a Personal Story

Like food tastes bland without salt, so does a reflection essay without a personal story. At the center of a reflection essay is You. This means the essay should focus on your personal story that led you to want a nursing career. A lot of times, students miss out on this instead of talking about their story. You need more than just the personal qualities you think will be a great fit for the nursing program; you must also share a story that shows how well you contributed to nursing care.

Failing to Share Your Experience

You will lose points when you fail to include nursing-related experiences in your reflection essay. Mentioning that you want to be a nurse is great, but failing to show specific events that led to the desire will cost you a great point.

Plagiarizing Your Essay

Plagiarism is a serious academic offense because it is considered taking other people's ideas and using them as your own without crediting the author. So, provide relevant citations and references for any ideas that aren't your own. Also, an AI will not write your essay as a human writer would. 

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Sample of a Nursing Reflective Essay 

The following is a sample of a nursing Reflective essay using Gibb's Model of Reflection. Use this sample to guide you when writing your own.

Introduction  Communication is an important element in healthcare practice as it determines patient satisfaction and treatment outcomes. This essay will focus on reflecting on an experience I went through with a 40-year-old diabetic patient who also had a foot infected with an ulcer. When I approached the patient to sign the consent form, I noticed that he wasn't happy because of the news given to him about his health. I concluded that there must be a communication dilemma. I will reflect on the experience using Gibb's Model of Reflection. Using this model, I will identify and discuss the actions taken to resolve the issue. Description  This incident happened a few months ago when I was working as a wound nurse in a Methodist hospital in my hometown. I was part of a care team handling the case of a 40-year-old male patient with diabetes and an infected diabetic foot ulcer. After careful examination, a team comprising various specialists concluded that his leg needed amputation below the knee. After making this decision, the team left, and I was asked to give the patient a consent form to sign. When I came back from retrieving the form, I noticed the patient looked sorrowful because of the news given to him. Feelings  As soon as I saw the patient, I knew what he was going through. He perceived the situation to be irreparable, but I wasn't sure whether to console the patient or not. I was powerless and couldn't imagine what he was going through. At the same time, I was startled that the team left without showing any compassion. They could have handled the situation more delicately. I, on the other hand, could have relayed the information better. I wasn't sure whether my approach would be acceptable or appropriate. Evaluation  I always go back to that particular situation and wonder whether I could have acted better. The situation helped me better understand the importance of good communication in patient care, particularly in therapeutic care. Before the incident, I didn't acknowledge the role of nurses play in caring for patient's emotional needs. I realized nurses must show compassion and console patients in their low moments.  Analysis  Most healthcare professionals do not know how to deliver bad news to patients. They find the process extremely challenging and always feel psychologically unprepared. This has a negative impact on patients and could lead to bad health outcomes. Furthermore, how information is relayed could impact a patient's adherence to treatment. Because of these effects, multiple protocols and approaches were developed to help with communicating bad news to patients. One of the approaches that was proposed is emotion-centered. This proposes that a healthcare provider acknowledges how sad the patient is and builds a professional relationship based on empathy and sympathy. Action Plan I now understand the essence of communicating bad news with compassion. The experience allowed me to look closely at different aspects of my professional development that needed more improvement. Thus, I plan to be more empathetic and speak up in support of patient's emotional and psychological well-being, especially when presented with traumatic news about their health. Additionally, I now understand I am not powerless when dealing with a sorrowful patient. I believe I have learned from my experience, and I'm not able to communicate well with patients any more. Conclusion  The experience allowed me to value good communication in nursing and the need to incorporate it into daily nurse-patient interaction. Nurses must learn how to deliver bad news and manage patient's sorrow. This has been and will continue to be my biggest priority in patient care. References Street Jr, R. L., Makoul, G., Arora, N. K., & Epstein, R. M. (2009). How does communication heal? Pathways linking clinician–patient communication to health outcomes. Patient education and counselling, 74(3), 295-301. Buckman, R. (1992). Breaking bad news: why is it still so difficult? BMJ: British Medical Journal, 304(6842), 886. Ptacek, J. T., & Eberhardt, T. L. (1996). Breaking bad news: a review of the literature. The Journal of the American Medical Association, 276(6), 496-502.

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The Effect of Reflection on Nurse-Patient Communication Skills in Emergency Medical Centers

Bahman pangh.

1 Department of nursing, Faculty of Nursing and Midwifery, Golestan University of Medical Sciences, Gorgan, Golesatn, Iran

Leila Jouybari

2 Department of Family and Community Medicine, Faculty of Medicine, Golestan University of Medical Sciences, Gorgan, Golestan, Iran

Mohamad Ali Vakili

3 Department of Community Health Nursing, Nursing Research Center, Golestan University of Medical Sciences, Gorgan, Golestan, Iran

Akram Sanagoo

Aysheh torik.

4 Department of Women Affairs, Gomishan Government Office, Golestan, Iran

Introduction: Reflection is formed through deep reflection on the event or a certain clinical position. The aim of this study was to determine the effect of reflection on nurse-patient communication skills of nurses working in emergency departments.

Methods: This interventional study was conducted on intervention and control groups and with a pretest-posttest design. 142 nurses working in the emergency departments of hospitals affiliated to Golestan University of Medical Sciences were enrolled in the study in 2015, and randomly divided into two groups. During eight weeks of the study, the intervention group was asked to write their clinical experiences with regard to communication issues with their patients. Before the intervention, the communication skills of both groups were compared using a questionnaire. Data analysis was performed, using independent t-test, paired t-test, Mann-Whitney and Wilcoxon tests.

Results: Of the 142 nurses, 122 nurses had full participation. In the intervention group the mean scores of verbal communication skills, non-verbal communication skills, general communication skills and communication skills based on patient safety were statistically significant, but there was no significant difference in the control group.

Conclusion: The results showed that eight weeks of reflection by nurses is an effective intervention in dimensions of communication skills. We therefore suggest that a reflective writing be encouraged as a vital tool for improving communication competency among emergency department nurses.

Introduction

Communication skills are taught to nurses in the educational environment and are an important part of educational programs, but there are many concerns about communication weaknesses and lack of communication skills. 1 Some nursing experts believe that appropriate communication skills are the cornerstone of all nursing care activities, 2 resulting in improved patient care and professional development and personality growth of the nurses. 3

Effective communication has positive effects on the patients, including improved vital signs, decreased pain and anxiety, increased satisfaction, improved treatment outcomes, and enhanced participation in treatment programs. 4 The emergency room is the busiest and most serious part of any hospital. 5 And smooth and organized management of this department can save the lives of many patients. Therefore, in this environment, nurses should be equipped with different capabilities and skills to withstand the pressure and tension, among which communication skills are one of the most important. 6 Many qualitative and quantitative studies have evaluated the nurse-patient relationship. 7 In a study about nursing care in emergency units, communication has been introduced as one of the elements of care in the emergency room. Therefore, special attention should be paid to effective communication between nurses, patients, their companions, and other care providers in the emergency units. 6 Studies conducted in Iran show that the nurse-patient relationship is not quite effective and is even reported to be weak at times. 8 , 9

The art of reflection encourages the person to search for and evaluate solutions in equivocal and complicated situations. 10 The experience of utilizing the reflection process in a clinical setting causes a sense of ownership towards the created knowledge in nurses, because they achieve this knowledge through focusing on their own experience, using creative methods. 11 The process of reflection starts when the person refers to his/her own experience and recollects what has occurred, reconsiders the experience, and reevaluates it. 12 This effective strategy also improves critical thinking and problem-solving skills in nurses. 13 Reflection is regarded as a proof of professionalism and is used as a skill related to clinical performance and professional behavior. 14 Reflective thinking in recent years has been considered as a learning strategy for nursing students while not being used by novice nurses in practice. 15 Studies have suggested that reflective thinking as a skill should be learned and used continuously. 16 , 17 In general, nurses should know how to have reflection on their clinical performance and practice it regularly.Evidence suggests that nurses may not be able to recognize the effects of reflection thinking on their professional development. 18 It seems there are some organizational barriers to hinder the use of reflective thinking. 19 , 20 The study by Asselin and Fain on the effectiveness of a continuing education program using individual narratives and group discussion showed that many of the participants couldn’t complete the process of reflection process. 21 Kim and colleagues in their study about the effects of a work-based critical reflection program for novice nurses recommended doing similar research with larger and more diverse samples.

Considering the effect of reflection on enhancing clinical activities and the importance of communication skills in advancing the therapeutic objectives and patient satisfaction and because patients are in a state of suspension and abeyance in emergency units, the best of the staff should be employed in these wards. Since university students have been the main target group of the studies conducted in Iran, and there has been no empirical evidence on the outcomes of reflective thinking among nurses in the emergency department, in this research we aimed to evaluate the effect of reflection on nurse-patient communication skills in emergency units.

Materials and methods

This single-blind, randomized, controlled clinical trial was conducted in nurses working in Sayyad Shirazi and Panj-Azar educational hospitals and west healthcare centers (Aqqala Al Jalil Hospital, Bandar Torkaman Imam Khomeini Hospital, Kordkuy Amir-Al-Momenin Hospital, and Bandar-e Gaz Shohada Hospital) with two parallel arms in 2015. The protocol of the study was approved by the ethics Committee of Golestan University of Medical Sciences (code: R.GOUMS. REC. 1394.73) and registered in the Iranian Registry of Clinical Trials (IRCT201501277821N1). The inclusion criteria were a minimum of 6 months’ experience in the emergency units, holding B.Sc or M.Sc. Degrees in nursing, and a negative history of acute stressful events in the past six months (death of fist-degree relatives, use of drugs related to psychotic disorders).

Leaving the emergency units or working in other units for any reason during the study, acute physical or mental crisis during the study (death of relatives, divorce, hospitalization), and incomplete recording of the reflection notebook (less than 4 reflections) were regarded as the exclusion criteria of the study. The participants were given information on the protocol and aims of the study, data anonymity, and confidentiality of the results. Informed consent was obtained from all the participating nurses. The sample size of the study was calculated, using the following formula, considering a study conducted by Hemmati Maslakpak et al., 22 With regards to the above study and an estimate of 80-80% for desirable verbal and non-verbal communication in ICU nurses of Urmia (Iran), an increase of at least 20% in desirable verbal communication was expected to occur after the study. Therefore, considering P1=0.75 and P2=0.95, confidence interval of 95%, and power of 90%, 62 nurses were required in each group (a total of 124 nurses); however, all nurses were included in the study to increase the precision of the study. The participants were allocated to the intervention or control group, using random blocks with block sizes of 4 and 6 and an allocation ratio of 1:1. For allocation concealment, the type of intervention was written on a piece of paper, placed in dark envelopes and numbered sequentially.

The allocation sequencing was done by a person who was not involved in the recruitment, data collection, and analysis. If a participant met the inclusion criteria, his/her name was written on the envelope. The envelopes were opened by the researcher to allocate the participants to either the intervention or control group.

The census method was used to invite all eligible nurses (142 out of 158) who met the inclusion criteria to participate in the study. A random number table generated by the SPSS software was again used to allocate the nurses to intervention and control groups. After obtaining informed consents and before the intervention, the nurse-patient communication skills questionnaire developed by Hemmati Maslakpak et al., 22 was completed by the nurses in both groups. In their study the average content validity index (0.887) and reliability coefficient of the questionnaire (alpha-coronbach = 0.96) were confirmed.‏ In the present study the total Cronbach's alpha coefficient‏ of questionnaire was 0.919 and for different dimensions were as verbal: 0.884, non-verbal: 0.848, and patient-based safety skill: 96.03, which indicates an acceptable homogeneity.

The participants in both groups were requested to complete the questionnaire once more after eight weeks. Special notebooks were designed based on the Gibb’s reflective cycle, and were given to the intervention group for reflective writing. Code 0 was assigned to the control group (n=71) and code 1 was given to the intervention group (n=71). Blinding: This study was a single-blind trial; in other words, the research assistant who collected the questionnaires was not aware of the allocation. After coordination with the nursing office of the afore-mentioned health centers, the schedule of the rotating shifts of the nursing staff of emergency units was obtained and then a briefing session was held about the process of work. The participants completed the nurse-patient communication skills questionnaire. Nurses in the intervention group practiced reflection at least once a week for 8 weeks. Since the purpose of this study was not to analyze the participants' notes in detail, the handwritten notes were only checked for relevance in relation to the communication skills with patients. There was no specific guideline to determine the length of reflective writing and national and international studies have reported different periods, so their average was used in this study. In reflection, based on the Gibb’s model, although there is no need to require the participants to adopt a certain framework, the following guide may help a person organize their thoughts and feelings:

• What happened?
• What were your reactions and feelings?
• What was good or bad about the experience?
• What did you learn from this situation?
• What else could you do?
• What will you do if it occurs again? 23

According to the Gibb’s reflective cycle, the participants were asked to reflect on their clinical experiences and write their best and worst experience of communication with the patient and their companions, the most difficult moment, and the best moment. No intervention was applied in the control group. The participants completed the nurse-patient communication skills questionnaire before the study and also at the end of eight weeks, and then they were asked to complete the questionnaire. The collected data included demographic (age, sex, ethnicity, marital status) and occupational characteristics (work experience, type of employment, position, ward).

The questionnaire had three sections including verbal and non-verbal communication skills (21 questions) and patient safety-related communication skills (27 questions). The questions were scored, using a 5-point Likert scale as always (5 points), often (4 points), sometimes (3 points), rarely (2 points), and never (1 point).According to the total score, the verbal and non-verbal communication skills were categorized as weak (score: 21-48), moderate (score: 49-76), and good (score: 77-105), and patient safety-related communication skills were categorized as weak (score: 18-41), moderate (score: 42-65), and good (score: 66-90). A higher score indicated a better communication performance. The Cronbach’s alpha was 0.96 for the whole questionnaire, 0.87 for verbal communication section, 0.92 for non-verbal communication section, and 0.95 for patient safety-related communication section. 22 The SPSS software, version 13 (IBM, Armonk, NY, USA) was used for analysis. The Kolmogorov-Smirnov and Shapiro-Wilk tests were applied to evaluate data normality. To determine the difference between quantitative variables in each group, independent t-test and paired t-test were used if the data were distributed normally and Mann-Whitney and Wilcoxon tests were used if the data distribution was not normal. P- values less than 0.05 were considered significant

The present study was conducted from September 2015 until January 2016. Of 158 eligible nurses, 142 met the inclusion criteria of whom 71 were allocated to the intervention group and 71 were allocated to the control group. Finally, the data of 122 participants were analyzed ( Fig. 1 ). The mean age of the participants was 29.97 (6.14) years, with 64.5% of the nurses in the control group and 60% of the nurses in the intervention group being female. There was no significant difference in demographic characteristics between the two groups ( Table 1 ).

Flow chart of the participants through each

a Mean (SD), b Mann–Whitney U, c Chi square, d n (%), e Chi-square for trend, f Fisher's exact test

The Shapiro-Wilk test was used to evaluate the normal distribution of quantitative continuous variables. Age, total work experience in hospitals, work experience in the emergency units, and nurse-patient communication skills had a non-normal distribution (P>0.05). A significant difference was observed in the score of verbal communication skills before and after the intervention in the intervention group (P<0.001) while the difference was not significant in the control group (P<0.418).

The difference in the score of non-verbal communication skills before and after the intervention was significant in the intervention group (P<0.001) while no significant difference was observed in the control group (P<0.413).

Moreover, there was a significant difference in patient safety related communication skills before and after the intervention in the intervention group (P<0.001); however, the difference was not significant in the control group (P<0104).

In general, a significant difference was seen in the total score of communication skills before and after the intervention in the intervention group (P<0.001) while no significant difference was observed in the control group (P<0.872) ( Table 2 ).

a Mann–Whitney U, b Wilcoxon

The main findings of this study show that the reflective writing had a positive effect on the nurses’ clinical communication abilities. A significant difference was observed in verbal, non-verbal, and patient safety-related communication skills before and after the intervention while the difference was insignificant in the control group.

This study assessed the effect of reflection on communication skills of clinical nurses for the first time in Iran. Most national studies on reflection, such as those conducted by Sedaghti et al., 24 Abedini et al., 25 and Dehghany et al., 26 have mainly been of observational types. Moreover, most of the studies investigating the nurses’ communication skills were descriptive or related to reflection in the students. The results of the present study are in line with previous research findings according to which work-based critical reflection program or reflective journaling by hospital nurses (through fellowship program) improved critical thinking skills, communication abilities, and job performance. 27 , 28

Fukui et al., showed that communication skills training improved the patients’ quality of life and increased the nurses’ job satisfaction. 29 With regards to weak communication skills in clinical environments and their potential effects on the nurses, interventions are required to enhance these skills. It seems that the traditional teaching methods are not effective enough. A study by Heaven et al., revealed that despite the effectiveness of educational workshop, it was comparatively less effective in clinical environment, indicating the need for more clinical supervision and intervention in practice. 29

Reflection enables the learners to search for their roles and responsibilities in an interdisciplinary context and enhance their verbal and teamwork skills. In the present study, among the three types of skills, verbal skills had the highest mean score after the intervention. Verbal communication skills are behaviors such as greetings, introducing to patients, and using open questions. It seems that the nurses had the highest score in their verbal skills because such behaviors are common in the practice.

The reflective writing helped nurses pay more attention to such apparently simple behaviors. Consequently, reflective thinking promoted positive social behaviors in communicating with their patients.

These findings are consistent with the results of a study by Lestander et al., in which the participants stated that their verbal communication skills with patients improved after three reflection sessions (two individual sessions and one group session), leading to their increased efficacy in the nursing profession. 30 A study by Pai et al., showed that simulated learning opportunities with feedback, debriefing, and guided reflection enhanced critical thinking, clinical judgment, verbal communication skills and caring skills. Therefore, self-reflection may play an effective role in improving the nurses’ verbal communication skills. 31 In that study, the participants also stated that reflective thinking helped them to use proper phrases to encourage patients to express their feelings or to try to provide training in plain and intelligible language. In a study by Abedini et al., on the effectiveness of reflection in clinical education, most of the students believed that reflection increased their communication and social skills. 25 Therefore, verbal skills are an important part of nurse-patient communication skills and accurate identification of factors affecting verbal skills is required to improve them. The results of the present study also showed the high score of non-verbal communication skills (such as proper eye contact with the patient, body gesture and head movements or listening to the patient) of the nurses working in the emergency rooms. In a study by Thomas et al., the majority of patients needed non-verbal communication. 32

Heinerichs et al., assessed the effect of non-verbal communication skills through videotaping and debriefing of clinical skills. The results showed non-verbal communication skills improved in 96% of the students and 98% of the students mentioned non-verbal communication skills as a proper means of communication. 33 Although, in the present study, before and after the intervention, the non-verbal communication skills of the nurses increased in the intervention and control groups, this difference was only significant in the intervention group, which could be due to the rethinking and contemplation of nurses in their daily experiences of communicate with patients. The results of the present study also showed that nurses had good patient safety-related communication skills. Similarly, the results of a study by Hemmati et al., showed that from the perspective of the nurses, patient safety was in a good level for most patients hospitalized in the intensive care units of educational hospitals. 22 However, some studies have reported contradictory results regarding patient safety. 33 , 34 The domain of patient safety-related communication skills has a direct association with clinical competency of the nurses and their professionalism, 27 which was significantly enhanced through reflection in our study. Pearson et al., noted that reflection by surgical residents improved their medical performance, communication, and professionalism. 35 Moghadami et al., evaluated the effect of reflection on nurse-patient communication skills in nursing students, but found no significant difference in the students’ therapeutic communication skills between the two groups. Although clinical reflection was associated with an increase in the mean score of therapeutic communication skills, the difference was not significant. 36 It is important for all nurses to possess communication abilities; therefore, those nurses working in the emergency unit are not exempt from this requirement. So, it is critical to help them improve their communication verbal and non-verbal abilities and patient safety through reflective writing, which is an easy and non-expensive approach.

The present study had certain limitations. Since the previous studies had not suggested a specific period for performing the narrative writing, a period of “eight weeks” was considered for the intervention based on the available evidence,. So it has to be admitted that a decrease or increase in this period could have been accompanied by other consequences not found in the present study. Due to mandatory rotating work shifts, the communication between the intervention and control groups was inevitable and there was a possibility of transmission of intervention into the control group. However, the fact that the participants had been selected from different hospitals (teaching hospitals, governmental hospitals), and from different cities of the same province can be considered as a strength of this research. Suggestions for further studies: It is suggested that in the future studies, the effect of group oral reflection on communication skills of nurses working in emergency units be investigated. Also, the effect of reflective narration on the patients’ safety and clinical errors and the other core clinical competencies can be studied. Exploring the effect of self-reflective narration through e-mail sounds interesting too. Implication for nursing: Every health care system should equip its nurses with good communication skills. Since reflective thinking leads to the development of critical thinking, it is expected that better decisions can be made by nurses in relation to patients, and better communications with patients can thus be established. It is, thus, recommended nurses’ administrators incorporate reflective writing into in-service training and use that as a tool for making sense in emergency units, learning and art in care practices.

The reflective writing not only had a positive effect on verbal, non-verbal and general communication skills, but also helped nurses to have better communication skills based on patient safety. In other words, reflection enables the nurses to support the patients more effectively in each stage and have a more prominent role in the health despite limitations in resources and the high work load. For these reasons, such a program could be considered an important tool for improving communication competency among nurses in emergency units. This educational approach emphasizes health, hopefulness, and positive thinking; therefore, it is consistent with the philosophy of nursing care and may be used in different situations like routine clinical care.

Acknowledgments

The authors wish to thank the education development center and deputy of Research, Golestan University of Medical Science, as well as the officials and emergency wards’ staff of the hospitals for their participations. This article was derived from a master thesis of at Golestan University of Medical Sciences, Gorgan, Iran.

Ethical issues

None to be declared.

Conflict of interest

The authors declare no conflict of interest in this study.

Citation: Pangh B, Jouybari L, Vakili MA, Sanagoo A, Torik A. The effect of reflection on nurse-patient communication skills in emergency medical centers. J Caring Sci 2019; 8 (2): 75-81. doi: 10.15171/jcs.2019.011 .

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Students' experience of the challenges of using assertive communication

Claire Keates

Senior lecturer, Adult nursing, University of Hertfordshire, Hatfield

View articles · Email Claire

Assertive communication is a skill that many nurses, particularly nursing students, find challenging. This article describes the findings of phenomenological study that set out to explore third-year student nurses' experiences of using assertive communication in the clinical setting. A narrative enquiry approach reviewed six reflective written accounts of their experiences. In addition, seven students took part in an in-depth semi-structured group discussion of their clinical experiences. Data were analysed using a hybrid interpretive phenomenological analysis and discourse analysis framework. Three key themes emerged: a sense of responsibility/duty and a sense of failure when this is not upheld, the importance of mentors in promoting self-confidence and self-esteem, and a sense of belonging on placement. The students responded well to positive role models and were able to identify negative role models. Accurate, constructive feedback and support was important to help students reflect appropriately.

Nursing has historically been a submissive profession within health care. Today, changes in healthcare policy, the evolving nursing role and negative healthcare events publicised in the media, have made it essential for contemporary nurses to be leaders within the clinical environment, using assertive communication styles in their exchanges with patients, relatives and other healthcare staff. Individuals in leaderships positions motivate others, set clear goals and make decisions, using listening skills and articulating clearly. The Nursing and Midwifery Council (NMC) (2018a ; 2019 ) standards consider that leadership principles, such as assertiveness, are an integral component in the delivery of high-quality care and there is an expectation that students will engage with this from the start of their education.

The Willis Commission (2012) recognised that nurse educators and qualified nurses are in a unique position to lead nursing as a competent and compassionate workforce. Nursing students must be proficient in recognising, challenging and reporting poor care, working as equal partners alongside other health professionals ( NMC, 2018b ). This is consistent with Cumming and Bennett's (2012) position that leadership must exist at every level, with each individual viewing themselves as a leader who role models compassion in day-to-day care and who is committed to speaking up when things are wrong.

Nurses need to use firm, polite, assertive communication to address unsafe care at the time it occurs (Care Quality Commission, 2011). Hudek (2012) emphasised that assertiveness is integral to the creation of working environments within which, regardless of hierarchical position and profession, all team members are active, respected participants in discussions. Assertiveness is key for every nurse in all aspects of everyday nursing communication, although Johns (2013) stated that nurses find certain situations challenging, such as managing conflict. Nursing students need to perceive themselves as leaders, with a responsibility to use skills such as assertiveness effectively. The all-too-familiar perception, ‘I'm just a student nurse’, must be challenged and students need to develop their abilities to use assertiveness as a strategy to facilitate communication in delivering high-quality care.

In line with the nursing governing body's standards of proficiency ( NMC, 2018a ) students are required to demonstrate specific skills, knowledge and attributes, including skills relating to leadership, management and team working. Historically, there has been a heavier focus on leadership skills within the final stages of nursing programmes. However, despite the fact that leadership skills and communication skills are intrinsically linked, there has been insufficient emphasis placed on this link in previous nursing curricula. Universities and clinical areas need to better prepare students by supporting the development of key leadership skills ( Edwards et al, 2018 ; Fuster Linares et al, 2020 ), including assertiveness, as a strategy to facilitate the delivery of high-quality care.

What is assertiveness?

Assertiveness is the ability to express ones' rights, thoughts and feelings without denying the rights of others, creating equality in relationships ( Alberti and Emmons, 2017 ). In health care, it allows nurses to express their opinions confidently and without using aggressive, passive or manipulative behaviours ( Bishop, 2013 ). It is important to emphasise that assertiveness is not a means for individuals to 'get their own way’, but rather a communication strategy that encompasses respect and openness to create balance, with recognition of what needs to be done in order to then act accordingly with fairness and empathy ( Malik et al, 2014 ). Assertiveness is a key nursing skill and an attribute that underpins effective clinical leadership ( Stanley, 2014 ; West et al, 2014 ). However, nurses have been criticised for lacking assertiveness skills, not always knowing how to achieve the delicate balance between speaking up, being aggressive or avoiding confrontation ( Oxtoby, 2015 ).

Healthcare cultures

Healthcare cultures are complex, embedded with beliefs and behaviours of what is considered normal or acceptable by each professional group such as nurses ( Fook and Askeland, 2007 ). To understand the use of assertiveness by nurses it is important to consider the historical beliefs and behaviours of the profession and the ensuing changes.

The historical attributes required of a ‘good’ nurse included loyalty, a commitment to ‘aid the physician’, obedience and servility ( Begley, 2010:525 ). This created a culture within which nurses were not encouraged to use assertiveness or to challenge figures of authority. A lack of assertiveness could be a cultural issue that reaches beyond the nursing profession's view of itself, and is influenced by those who work alongside nurses, as well as by public expectation.

Study outline

The NMC (2018a) has retired the term ‘mentor’ in favour of using the terms ‘practice assessors’ and ‘supervisors’ to describe nurses who support student education in practice. However, the article uses the term ‘mentor’, as this was the term used by study participants.

The rationale for this qualitative study stemmed from concerns that nursing students do not perceive themselves as leaders, with a responsibility to use skills such as assertiveness effectively. Full ethical approval for the study was granted as part of the author's master's project from the university ethics committee.

The study set out to explore the experiences of third-year student nurses of using assertive communication in clinical practice, with the aim of considering the following questions:

• How do student nurses understand the use of assertive communication in their clinical practice?
• What challenges do student nurses encounter when using assertiveness?
• What clinical support do student nurses receive in their use of assertiveness?

The study design consisted of analysing the accounts and perceptions of assertive communication of two cohorts: a group of students who had written reflective accounts and a second group that agreed to participate in a group discussion. The study consisted of three stages ( Table 1 ):

• Stage 1: analysis of students' reflective accounts, to identify issues relating to students' use of assertiveness in a clinical situation
• Stage 2: identification of emerging themes from the accounts,
• Stage 3: discussion of the issues identified in the previous two stages.

The reflective account cohort had completed the course within the preceding 12 months, and no longer had student status: they were sent an email to explain the purpose and framework of the study, facilitating informed consent. This also limited any concerns relating to coercion or power relationships between participant and researcher, which could have been seen as a risk to their studies ( Royal College of Nursing (RCN) (2011) .

An opt-out approach to consent was used to create a pool of potential participants. From these, six narratives were selected using simple random sampling, based on the lottery method, which ensured that all documents had an equal and independent chance of being selected ( Cohen et al, 2007 ). The six narratives were deemed to be a reasonable sample size to provide enough data to identify similarities and differences of views.

All students whose work had met the pass mark were considered. Although the higher graded work may have presented a higher level of academic clarity, there is a documented link between students who perform at a high academic level and high levels of reflexivity and emotional intelligence ( Beauvais et al, 2011 ), and consequently a higher capability in managing social interactions ( Por et al, 2011 ). This carries the risk that study subjects are naturally more comfortable with using assertive behaviours, and subsequently only considering these narratives could misrepresent the cohort as a whole.

Documents that had not met the minimum pass requirement were disregarded on the grounds that they were more likely to have not followed the assignment remit or have significant academic writing issues.

The second cohort of students consisted of seven students, who were invited to take part in a group discussion to explore the issues raised that emerged from the reflective narratives. Participants were identified using purposeful sampling, selecting a cohort that met the criteria for the study ( Krueger, 1998 ), and who had been taught a session on assertiveness as part of their timetabled final-year studies. This ensured they had received the same academic input as the students who had provided reflective accounts in the other phase of this study. A face-to-face explanation of the study was followed up with information sent by email.

The discussion group were expected to manage themselves in a professional manner ( NMC, 2018b ); the ground rules, which involved promoting all participants' engagement and ability to share freely without threat to their confidentiality, and a definition of assertiveness, were displayed on posters at the discussion table, to keep the group focused on the topic. The definition of assertiveness provided to the students described it as:

‘… being able to express yourself with confidence without having to resort to passive, aggressive or manipulative behaviour … It requires listening and responding to the needs of others without neglecting your own interests or compromising your principles … An assertive response is invariably the preferable one, and leads to win-win situations where both parties feel good about themselves.’

Bishop, 2013:1

Data collection

An empirical social science research approach was adopted, supported by the collection of data relating to the students' direct experiences within the context of their social world of nursing ( Punch, 2014 ). The study considered how adult nursing students understand and interact within the clinical world around them, allowing explanation, description and analysis of the meaning of the students' experiences of assertive communication.

The six reflective accounts selected had been written and submitted as part of students' final year assessment on the nursing degree programme and related to their experiences of using assertive communication in clinical practice.

The seven students selected for the group discussion took part in an in-depth semi-structured group discussion to uncover honest, rich and detailed information about their’ experiences of using assertiveness. Open-ended questions within a fluid questioning structure were employed to help them narrate their experiences, ensuring that all viewpoints were represented through the active participation of all students.

As part of the group discussion, the participating students were asked to identify on sticky notes examples of when nurses need to be assertive and rank these on an ‘easy-to-hard’ continuum. This visual approach encouraged the students to discuss their opinions and experiences in practice, increasing their voice within the research and adding to participant reflexivity ( Butler-Kisber and Poldma, 2010 ).

The application of researcher reflexivity, as a nurse and educational practitioner, was important both during, as well as after, the group discussion and contributed to the overall development and analysis of data. As the group discussion unfolded, reflexivity drew out threads and listened to both what was and was not said ( Johns, 2013 )

Findings and discussion

Elements of interpretive phenomenological analysis (IPA) and discourse analysis were employed to handle the data. IPA explores how individuals interpret and make sense of their social and personal world and experiences ( Smith and Osborn, 2003 ) and allowed examination of the students' perceptions of their clinical practice experiences. Discourse analysis identified themes and ideas while being sensitive to the language the participants used to add meaning to their stories ( Punch, 2014 ). Clear identification of the descriptive words used, and application of reflection was used to give consideration to the themes identified.

The reflective accounts were read multiple times within each of the three stages of the amalgamated IPA and discourse analysis framework ( Table 1 ). The documents were annotated while considering key reflective questions (see study outline) to promote trustworthiness.

Following transcription of the group discussion, the same analysis framework was employed as had been applied to the written reflections, with two additional criteria.

• Consideration of the emotion displayed within the participants' stories by noting their tone and voice, which would have been absent from the written format, in order to understand how their feelings and hopes affected the way they reacted, or may react in the future
• The transcribed narrative was emailed to the group for agreement of its authenticity.

The themes and issues that emerged within the written narratives and the discussion group were considered and are discussed in parallel. To give context and clarity to the students' stories, the written narratives are summarised in Table 2 . For the purpose of ethical consideration and anonymity, identifiable details relating to the students, patients and trusts have been removed.

Assertiveness linked to responsibility

Sense of responsibility/duty.

All the narratives discussed the sense of responsibility students felt while in clinical placement. The concept of ‘my duty of care’ was replicated across the documents and expressed explicitly through phrases such as ‘protect our service users’, ‘safeguard my patients’, ‘patient choice and safety’ and ‘make the safety of my patient my first priority’. There were also implicit references to the students' perceived duty to use assertiveness:‘I had to be assertive’ and ‘as a nurse I must …’ This could arise from the expectation that nurses today need to use assertiveness to raise patient safety concerns ( Begley, 2010 ; NMC, 2018a ; 2018b ; 2019 ).

Responsibility as a theme emerged late within the group discussion process, prompted by the researcher out of interest because it had featured so significantly in the written reflections. One of the group retold her experience of speaking up about a mentor's poor practice. She described how her practice assessment document and the verification of her hours were subsequently, as she described it, ‘held ransom’ by her mentor, making her feel that her learning and assessment experience were significantly threatened. This issue was cited by Levett-Jones and Lathleen (2009) , who identified that students felt the relationship with their mentor – and potential learning opportunities – were jeopardised when they confronted issues relating to patient safety. According to Duffy et al (2012) , students regularly experience fear regarding the impact that whistleblowing on poor practice could have on their assessments.

The group openly discussed concerns about speaking up; increased stress, alienation from other nurses, failing a placement and concerns about future placements and employment, mirroring issues identified by Ion et al (2016) . All seven of the group stated that they would speak up if they were aware of poor practice, regardless of ramifications for themselves, in order to ensure patient safety. However, some responded more emphatically than others, raising questions about how honest students can really be within the discussion, if they feel uneasy in terms of whether the researcher may have concerns about their fitness for practice.

Workplace rules

Students were able to reconcile the need to use assertiveness more easily when rules were in place and needed to be followed. Student 2 talked extensively about ward visiting rules. The ward's rules and protocol appeared to offer the student permission to be assertive:

‘I felt I was applying good nursing practice by maintaining the protocols of the ward and this made me feel confident.’

The concept of rules supporting the use of assertiveness was described within the group discussion when they explored the topic of carrying out medication rounds. Wearing a red tabard when administering medication was understood as a clearly defined rule, making others aware that the person wearing it is administering medications and it is their sole focus to promote safe medications management. Tomietto et al (2012) appeared to partially support this, stating that when a nurse wore a tabard the number of interruptions from other staff members actually increased, but the nurse carrying out the medication round had more authority to delegate these more swiftly.

Feelings of failure

Where poor practice was witnessed, students addressed this out of a sense of duty, which granted them permission to be assertive. However, they still found this an anxious and unpleasant experience. Student 1 described feelings of ‘failure’, despite the fact the poor practice had occurred when she had not been not in the room. She alluded to feeling that had she been more assertive at an earlier opportunity she could have headed this off.

Larijani et al (2010) found links between higher levels of assertiveness and lower levels of anxiety. Had the student felt able to seize an earlier opportunity to address the issue, she may not have felt so guilty about the ensuing care. Feelings of failure and guilt can reduce a student's feelings of worth, which undermines self-esteem.

Assertiveness linked to mentors

All students, from both the narratives and discussion group, acknowledged and described the central role of mentors in the overall quality of their clinical practice experience, positive or negative. The group discussion highlighted the multiple roles of mentors across a range of learning needs. The main roles identified were role modelling, reflection support and providing feedback, which are discussed below.

Role modelling

Student 2 described how she was able to approach a situation using assertive communication based on previously observing her mentor demonstrating this skill in a confident and compassionate manner that had led to a positive clinical outcome. Nurses should act as role models for their students, which includes promoting safe and effective practice. A mentor who demonstrates both professional values and clinical skill presents a powerful and influential learning mechanism for students ( Keeling and Templeman, 2013 ). Hudek (2012) and Siviter (2013) suggested that students must actively seek out role models who demonstrate appropriate use of assertiveness. However, students do not choose the mentors to whom they are allocated on clinical placement.

Poroch and McIntosh (1995) identified that a large proportion of ‘traditional nurses’ do not use assertiveness effectively. The group discussion agreed with this in part, with comments that they felt that more recently qualified staff demonstrated higher levels of assertiveness than those who had been nursing longer. When offered a tentative hypothesis that this might be a result of graduate education, they thought that it was more to do with newly qualified nurses still feeling they could make a difference, and reflected the fact that those who had been qualified longer were more worn down and resigned to ‘the way it is’.

Due to the nature of working so closely with others in a highly emotive environment, nurses are susceptible to burn-out, a state of emotional exhaustion, cynicism and negative attitudes towards oneself ( de Souza Pereira et al, 2015 ). This undermines a nurse's self-esteem and confidence and can have a negative impact on their ability to use and role model assertiveness ( Poroch and McIntosh, 1995 ). This suggests that nursing students need role models who demonstrate the use of assertive communication and have the capacity to maintain and protect this skill, demonstrating resilience to maintain a healthy perspective, self-esteem and self-confidence.

If, while on placement, nursing students are encountering a variety of nurses with a range of skills, they need to be able to differentiate the practices they wish to emulate themselves and those they wish to avoid. Keeling and Templeman (2013) found that nursing students are able to use negative role-modelling experiences to enhance their own practice. Student 4 alluded to previous poor experiences and appeared to have been able to process these and facilitate improvement in their own practice.

Reflection support

All students in both cohorts identified reflection as an integral part of their practice. However, within the written narratives the ability to reflect independently varied between students. Student 1 described a situation with which she had felt uncomfortable and, when reflecting on this, considered her options, and then returned to the situation to implement her decision to speak up, exemplified through the process of both reflection-on-action, a cognitive process to review and understand her actions, and reflection-before-action to plan her next steps before taking them ( Greenwood, 1998 ).

Student 4 had a more reflective approach and appeared to have responded to the situation more intuitively. She mentioned a previous occasion when she had a bad experience of speaking up. This experience, her demonstration of high self-confidence and a strong sense of the right thing to do, allowed her to respond instinctively using reflection-in-practice. This is not simply thinking about her actions while being assertive, but responding in the way she did because her previous reflection had shaped her ‘way of knowing’ ( Johns, 2013 ). Her active approach was indicative of self-mentoring, where she had extracted learning and guided herself through the decision-making process ( Law and Chan, 2015 ).

Student 5 reflected on the skills she had used, or felt that she had not used, when discussing the arrangements for a large family visiting a dying relative. Her reflection disclosed feelings of failure, anxiety and limited communication skills. At this point, the student felt she had failed at being assertive, focusing on the negative aspects of the situation and, in doing so, decreased her self-confidence and self-esteem – this leads to decreased ability to be assertive ( Wadensten et al, 2009 ; Larijani et al, 2010 ). The student identified that she would have benefited from discussing the situation with her mentor afterwards.

Kaihlanen et al (2013) posited that the student–mentor relationship must be allowed time to use reflection as a learning opportunity. The student appears to have felt let down by her mentor and, perhaps, had she been afforded reflective opportunities before, during and after the episode of speaking up, as proposed by Law and Chan (2015) , she may have felt more prepared, learnt positively from the experience and may have come away with a more balanced view of the situation. From an outsider's perspective she appeared to have taken all the blame for the poor outcome, and it is possible that some of this could have been apportioned to the family. Absorbing the burden and emotion of the situation without support could lead to the aforementioned phenomenon of burnout, decreasing her confidence and stunting her learning.

Providing feedback

The need for mentor feedback was demonstrated, in positive and negative descriptions of experiences, by all students, from both the narratives and the discussion group. Two in particular stood out, and provide insight into the mentor's and wider clinical environment's impact on supporting students in using assertive communication. Student 3 spoke honestly about the anxiety she had experienced when addressing a senior physiotherapist:

‘Despite my fears and concerns, I managed to step forward and affirm my views and advocated [for the patient].’

At first the terms ‘fears’ and ‘concerns’ might sound passive, but the use of ‘despite’ and ‘managed’ are used positively and the student's narrative highlights pertinent moments that allowed her to overcome these issues. But the most significant part of the story is not of the student speaking up to the physiotherapist, but that a ward manager from whom the student had sought advice had then said ‘thank you’ to the student.

The manager could have said ‘well done’, which would have validated the student's clinical concerns, making her feel validated as a competent clinician. By saying ‘thank you’ the manager also validated her as a member of the ward team. Feeling clinically competent and having a sense of belonging to the team boosted the student's sense of safety, self-esteem and confidence, and her feelings of empowerment then enabled her to communicate assertively with the physiotherapist, albeit she had had to force herself to do this.

Also significant is the fact that the student felt there was a hierarchy in place when addressing the physiotherapist. ‘Would not listen to me as I was a student nurse and was not qualified or as senior as her’, and yet she still felt compelled to communicate assertively. This suggests that empowering students is the key to diminishing the issues students experience relating to using assertiveness when there is a hierarchy, be it real or perceived.

Student 6 had a less positive experience of feedback from her mentor team. It is important to consider the relative truth of the reflective account. Because this was written as an assessed piece of work, the student may have wished to present herself in a positive light to her academic tutors. However, two issues should be considered.

• At face value, the story may be accurate
• On the other hand the story may not be accurate. However, if the student believes this is what happened, there is potential for her to feel confused about the events and the ensuing reflection.

The student's reflection described what appeared to be a competent decision to alert the GP of a deteriorating patient. She was then called to the nurse in charge to discuss her actions. Although not explicit, from the tone of the ongoing reflection, she appears to have been reprimanded or challenged about her decision to get urgent medical attention. The student acknowledged that she had felt very scared working autonomously with such an unwell patient, yet also had concerns about overstepping her student limitations, being ‘too confident’ and finally reflected for the future:

‘I will ensure openness, teamwork and act in a professional manner.’

According to Keeling and Templeman (2013) , there is a direct link between theory and clinical practice, and self-esteem. Should the student subsequently have felt conflicted about the theory of using assertiveness and its practical use, her self-esteem would have been lowered. Using clinical skills and knowledge effectively is a significant part of the ability to be assertive and, in undermining this, the nurse in charge may have diminished the student's self-esteem and self-confidence, and affected her capacity to use assertiveness in future.

As with Student 3, the interactions are with the nurse in charge, but in this reflective account the student identified that her mentor was on holiday. Although all registered nurses have a responsibility to support student learning ( NMC, 2018a ), the absence of this student's mentor is significant. There was a consensus within the group discussion that, when a student was unsure of something, they should wait to speak to their mentor. The mentor was seen as the go-to person and, on the whole, as someone who was more willing to support a student's questions. Ferguson (2011) stated that newly qualified nurses place a high value on mentors who answer questions and provide extra information and support. Perhaps if the mentor of student 6 had been more accessible, the student would have felt more able to make her case and reflect more holistically on a frightening and challenging experience.

Mentorship in summary

The degree to which students require support with reflection to create a valuable learning experience varies. The mentor is in an ideal position to support the reflection-in-action process. However, reflective learning can be supported by anyone within the learning context of the student ( Law and Chan, 2015 ). Therefore consideration should be given to the reflective support structures available for students. Students must have clear and accurate feedback from their mentors and mentoring teams to help give structure and meaning to the reflective process.

Assertiveness linked to student safety

The group discussion agreed with the description of a less positive experience of mentorship, as contributed by student 6, and included a frank discussion around not wishing to be ‘too known’ and making sure they ‘fitted in’. These are common concerns for students, as reported by Levett-Jones and Lathleen (2009) , whose study used the phrase ‘don't rock the boat’, with Mooney (2007) suggesting that fitting in makes the individual more highly thought of by the team. The discussion group was unanimous that it takes them 2 minutes from walking onto a ward to gauge the environment and make a decision about how they intend to handle themselves. Timmins and McCabe (2005) described the notion that nurses change their behaviours to meet the expectations made of them.

The group said they noticed when there was a ‘clique’ culture on a ward and identified the relationships on the ward and there was a general feeling that, if anyone upset the dominant female, they literally upset the whole ward.

It is not uncommon, as described by Timmins and McCabe (2005) , for assertiveness levels to drop in an attempt not to upset the ward equilibrium. Even the students within the discussion group who described themselves as comfortable in terms of using assertiveness agreed that on ‘some wards I am more myself … where I feel comfortable … and there isn't a clique’, suggesting that some ward cultures do not look favourably on students who practise assertive communication.

The discussion group highlighted common fears of using assertiveness to speak up, such as being viewed as a troublemaker ( Mooney, 2007 ). The group went as far as to say that they did not want to be ‘hated on the ward’ for ‘standing up’. They also expressed fears of ‘getting it wrong and looking stupid’, and some worried that this may have ramifications for their assessment of skills or the placement as a whole, a sentiment described by Duffy et al (2012) .

A summary of the study findings is presented in Table 3 .

Implications for practice

A number of ways in which mentors can support students to use assertiveness, and enable them to feel more able to cope with the feelings of perceived and, in some cases real, hierarchy are suggested in Table 4 . Students need multiple opportunities to reflect accurately and holistically on their own clinical practice and the practice of others, to help them develop confidence, understanding, self-awareness and competence ( Contreras et al, 2020 ). A by-product of this is their understanding of, and ability to be assertive. Structures supporting reflection that provide nursing students with these opportunities are needed not simply to develop students' awareness of the use of assertiveness, but also to ensure that they learn how to support their own reflective processes for future development outside nurse education.

Johns (2013) suggested that sharing similar experiences within peer group reflective supervision helps not only individuals to learn from each other but also makes them stronger as a group. The use of assertiveness by nurses within the healthcare environment needs to be addressed culturally. The use of peer reflection and reflective debate could support students to use reflective action, whereby they are empowered to promote a sense of social justice for nursing students among health professional peers ( Akinbode, 2013 ; Hutchinson, 2015 ). Students therefore benefit from opportunities to reflect that are incorporated as standard into their studies, which should extend beyond opportunistic one-to-one sessions with mentors and self-directed reflection.

As a new nursing curriculum is implemented across the country, it is pertinent to consider how the issues raised can be addressed. Structured in-class reflection could promote a sense of belonging and of value, and encourage students to have the confidence to speak up in a safe environment. A process such as this could provide the reflecting student with elevated self-esteem as they experience being listened to ( Akinbode, 2013 ) and achieve learning for both the reflector and the supporters, by allowing attitudes and beliefs to be challenged and understood ( Ekebergh, 2007 ), gaining an appreciation of how others think and reason ( Moon, 2010 ).

Students feel more able, or willing, to use assertiveness where there is a clear sense of duty, such as the responsibility to protect patient safety in the NMC (2018b) Code, or where there are clear rules set out by the clinical environment. Students are able to learn from both positive and negative examples of professionalism. However, their future practice benefits from being able to identify a nurse as a role model, who not only demonstrates assertive communication, but also the attributes that maintain and protect this communication skill: resilience, compassion, reflexivity and high levels of self-esteem and self-confidence.

Students need reflection opportunities and honest, accurate, clear feedback to help them make sense of their experiences and to promote their self-esteem and self-confidence as a nurse. Mentors, or practice assessors and supervisors, are in an ideal position to support reflection as a structured and conscious process. It is also beneficial for students to discuss their experiences with their peers within the university environment. This process should help students to identify and process any feelings of guilt or concern within their practice, as well as help them identify what they have done well. Developing students' self-esteem and self-confidence will increase a sense of empowerment, which is necessary for students to assert their thoughts effectively.

Students need to be, and to feel, safe at a basic level before they will feel able to engage in assertive communication. This safety includes having a relationship with their mentor and feeling that they are part of the team, within which they can share their thoughts, feelings and ideas.

• Students who feel welcomed, safe and confident in their clinical environment will experience greater empowerment to use assertive communication
• Students need accurate and honest feedback to understand their clinical experiences and may need support to reflect on and understand how they can use this to be a more confident practitioner
• Students need role models who demonstrate not simply assertive behaviours, but also resilience, self-esteem, self-confidence and reflective processes

CPD reflective questions

If you are a qualified nurse:

• Consider how nursing students are welcomed into your clinical environment. How are they supported to be part of the team?
• How could you empower students by using reflection?

If you are a student:

• How do you feel about speaking up and sharing your opinion? Why do you feel this way?
• Think of a nurse with whom you have worked who you consider a role model. What is special about them?

Home — Essay Samples — Nursing & Health — Nursing — Nursing and Effective Communication

Nursing and Effective Communication

• Categories: Effective Communication Nursing

About this sample

Words: 514 |

Published: Jan 25, 2024

Words: 514 | Page: 1 | 3 min read

Benefits of Effective Communication in Nursing

Works cited.

• Barton, G., Bruce, A., & Schreiber, R. (2018). Teaching nurses teamwork: Integrative review of competency-based team training in nursing education. Nurse education in practice, 32, 129-137.
• Kourkouta, L., & Papathanasiou, I. V. (2014). Communication in nursing practice. Material socio-medica, 26(1), 65.
• The Importance of Effective Communication in Nursing (2022). The University Of St. Augustine for Health Sciences. Retrieved from, www.usa.edu/blog/communication-in-nursing/

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In the ever-evolving field of nursing, understanding the metaparadigm is essential for providing effective and holistic care to patients. Fawcett's Metaparadigm Summary offers a comprehensive framework that encompasses the core [...]

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