Nursing in today's complex health care environment is a challenging task. The definition and scope of nursing practice require that nurses protect patients, promote and optimize their health and abilities, aid in the prevention of illness and injury, ease suffering, collaborate in diagnosis and treatment plans, and demonstrate "advocacy in the care of individuals, families, communities, and populations."1 Nursing students need to be prepared to make decisions, solve problems, and be patient advocates. They should be empowered to address dangerous shortcuts, incompetence, and disrespect demonstrated by colleagues. They must be committed to reducing errors, improving quality of care, and promoting a work environment where all members are valued and engaged.
Unfortunately, few nursing students feel empowered and prepared to confront physicians, nurses, and educators when these controversial situations arise.2 Many lack the communication skills to influence and skillfully collaborate for their patients. Little information is available to the nursing student on how to best advocate for a patient when a nurse thinks a health care provider or another nurse is not providing care in the best interest of the patient or if some portion of the plan of care is misunderstood. It is important, therefore, for nurse educators to provide students with skills to effectively advocate for patients. This begins with giving students a tool to advocate for themselves. In other words, if they believe something is wrong, students need a tool to "speak out." With a dedicated framework, students can build confidence in their ability to advocate for themselves and their patients.
The purpose of this study was to implement and evaluate the effectiveness of using a communication competency educational program, derived from a portion of the TeamSTEPPS curriculum, in an associate degree in nursing (ADN) program to improve self-advocating behaviors in students, thus providing a framework for patient advocacy communication. Many health care settings use the TeamSTEPPS curriculum to enhance communication and teamwork in practice.3 This study introduced some of the competencies supported by the TeamSTEPPS curriculum into a nursing classroom to determine if this training had an impact on students' ability to advocate for themselves and their patients.
Theoretical Framework
The theoretical framework for this study was from Malcolm Knowles' Adult Learning Theory or andragogy. Knowles' andragogical model is based on 6 core assumptions about adult learners: the need to know, the self-concept of adults to be responsible for themselves, the previous experiences of the adult learner, the learner's readiness to learn, the orientation that the learning is task centered or problem centered, and the adult learner's motivation to learn.4 This framework was well suited to guide this study with a focus on the educational component incorporated within the research. The students were taught the scope and standard of nursing practice, which illustrated the need to be patient advocates. The learners' self-concept and previous experiences enhanced their ability to see the value of obtaining the skills of effective communication in professional nursing. In addition, introducing the communication techniques, including role-play scenarios and group discussions, enabled students to see the problem-centered focus of the educational presentation. The impact of effective communication skills on their ability to promote self-advocacy and patient advocacy in their nursing careers was effectively demonstrated, lending value to the educational experience.
Literature Review
Literature regarding patient advocacy, self-advocacy, and communication guided this study. All 3 are interrelated and essential for the professional nurse. Patient advocacy is considered a fundamental responsibility of the professional nurse.1 Nurses support a patient's rights and wishes in the complex health care environment. Speaking up for quality patient care is central to advocacy. Nurses are expected to identify and act upon situations that impact patients' rights or negatively affect their best interests.5 Advocacy also has been described as the power to remove barriers and enable patients' involvement and decision making about their plan of care.6 In addition, researchers described educational reform needed to include interventions that build proficiency in communication, advocacy, and other important nursing skills.7 To adequately perform advocacy functions, nurses need communication skills and tools to voice their opinions and those of their patients.8
Self-advocacy is the act of supporting one's own interests. Nurses should strive to uphold their principles and integrity, preserve safety, and advance personal and professional growth.9 One of these duties to self includes the responsibility to participate in a respectful, open dialogue with all individuals involved and to express individual opinions. All opinions should be considered, even if the opinion voiced does not become an aspect of the final plan of care.9 For the student, self-advocacy is described as the responsibility to consistently work in safe environments where they are competent to practice and prepared for their assignments.10 The environment should be conducive for students to learn and if necessary, to voice any safety or practice concerns without retribution. There is also the expectation that students should not accept or allow behaviors that threaten the safety of themselves or patients.10 The Quality and Safety Education for Nurses competencies specifically outline under teamwork and collaboration the requirement of professional nurses to proclaim their opinion and perspectives in patient care conferences.11
Communication is a method of conveying concise, critical information. The Agency for Healthcare Research and Quality (AHRQ), during the development of the TeamSTEPPS curriculum, identified the importance of communication in complex health care environments. In addition, the importance of effective communication has been outlined in the data published by The Joint Commission related to sentinel events. The second leading cause of sentinel events, behind human factors, is communication failures. The failures can be oral, written, or electronic and can occur among nurses, physicians, administration, and even patients.12 Conflict resolution skills are a critical communication element in working with other health care professionals. Research indicates that including additional communication competency training in nursing programs should prepare students to effectively advocate for themselves and their patients.13
Methods
Design and Sample
This study was a quasi-experimental, 1-group, pretest-posttest designed to determine the effects of a communication competency educational program on nursing students' self-advocacy skills. The convenience sample was of approximately 138 sophomore ADN students. All students were enrolled in a single course, Health Care Concepts III. In addition, students were participating in patient care assignments during the study time frame.
Instrument
Permission was obtained to use the Nurse Workplace Scale (NWS) survey designed by DeMarco et al. The NWS scale measures behaviors and beliefs that are counterproductive to self-advocacy and oppress a nurses' ability to effectively advocate and contribute to the health care system.14 The survey consists of 12 brief statements that ask how often the respondent has experienced the possible behaviors, feelings, or beliefs. Choices are selected based on a Likert-type scale of 1 never to 5 always. Examples of the survey questions are (a) prefaced statements with phrases such as "I know this is a really stupid question," (b) "constantly compared yourself with others," and (c) "complained about a problem to your fellow workers but did nothing to confront the person you believe is causing the problem."14 The students were instructed to reflect on their role as a nurse when answering the questions. The NWS was not altered from its original form. The reliability and validity of the NWS instrument were substantiated in an earlier study. In that study, the Cronbach's [alpha] was .81.14
Implementation
The survey instrument was completed by nursing students, followed by a communication competency educational program derived from portions of the TeamSTEPPS communication and collaboration curriculum, then accentuated by group discussions. TeamSTEPPS was developed by the Department of Defense Patient Safety Program in collaboration with the AHRQ with a focus on skills and concepts that "provide specific tools and strategies for improving communication and teamwork, reducing chance of error, and providing safer patient care."3 Three TeamSTEPPS components were included in the communication competency educational program: the assertive statement, the 2-challenge rule, and the CUS (concerned, uncomfortable, safety) technique. The assertive statement involves 5 steps: "open the discussion; state the concern; state the problem-real or perceived; offer a solution; [and] obtain an agreement."3 This process involves being firm and respectful, persistent, and persuasive and providing evidence to support advocacy. The 2-challenge rule was originally developed to guide pilots in preventing disasters when those making decisions experience a problem or lapse in judgment.3 In the health care setting, the 2-challenge rule emphasizes the nursing advocacy role by ensuring that a concern expressed to another health care provider has been heard and understood and then requires the challenge to be acknowledged. Finally, the CUS technique provides signal words for verbal communication that engage attention.3
The communication competency educational program included PowerPoint slides, video presentations, group discussions, and role-playing scenarios. The students were reminded in the educational program of the professional responsibility for patient and self-advocacy supported by standards of practice and ethical guidelines. The PowerPoint slides in the TeamSTEPPS curriculum outlined the patient care issues that could occur if health care professionals were not prepared to advocate for a patient's safety or voice their own concerns. The video presentations in this program displayed scenarios of communication ineffectiveness. Group discussions after the videos allowed participants to make suggestions for improvements to solve the problems identified. Providing a period of 2 weeks between the educational intervention and final survey allowed for the students to apply their new knowledge to clinical practice situations.
Two weeks after the communication competency educational program, the survey instrument was completed again by the students. All students participated in the communication competency educational intervention; however, those students who chose not to participate in the surveys were excluded from data collection. Institutional review board approval was obtained before data collection.
Data Analysis
Demographic data were analyzed with descriptive statistics. To determine if there were differences in self-advocacy behaviors and beliefs in nursing students after the educational program, the data from the survey instrument were analyzed using a paired-sample t test. The independent variable in this project was the communication competency educational program, and the dependent variable was total scores on the self-advocacy instrument.
Results
Demographics
At the initial survey and communication competency educational program (time 1), 100 surveys were distributed and 75 were returned, resulting in a 75% response rate. At time 2, 62 (82.7%) of these students completed the survey. The decrease in responses may have occurred as a result of absence or attrition. A total of 61 participants answered both surveys, yielding an overall completion rate of 81.3% (61/75). Most of the participants were female, between the ages of 26 and 34 years, and white; spoke English as their primary language; had some college credit or an associate degree; and were not the first in their family to attend college.
Differences in Self-advocating Beliefs and Behaviors
The paired-sample t test was used to analyze the difference between the group mean scores at time 1 (preintervention) and time 2 (2 weeks after intervention). The NWS instrument measures non-self-advocating beliefs and behaviors so a decrease in score represents an improvement in self-advocacy behaviors. There was a statistically significant decrease in NWS scores from time 1 (mean [SD], 29.10 [7.44]) to time 2 (mean [SD], 27.25 [6.33]; t60 = 2.76, P = .008, 2 tailed). The mean decrease in the NWS scores was 1.85, with a 95% confidence interval ranging from 0.51 to 3.19. Cohen d resulted in d = 0.71, or medium effect. A power analysis was conducted using G*Power.15 A post hoc comparison or post priori test found that this study had a 78% chance of detecting a significant effect at the P < .05 level.
Discussion
Without adequate communication skills to address concerns, advocacy is threatened. This study demonstrated that communication competency training significantly decreased nursing students' non-self-advocating beliefs and behaviors as measured by the NWS with a medium effect. The communication competency educational program, with an emphasis on the TeamSTEPPS assertive statement, 2-challenge rule, and signal words for verbal communication that engage attention provided nursing students with a tool to enhance their self-advocacy skills.
Several implications for nursing leadership, especially in nursing education, were derived from this study. The fundamental duty of professional nurses to advocate for patients and themselves is well established in the literature, by practice guidelines, and by educational competencies. Therefore, it is the responsibility of nurse educators to provide students with the best available tools to enhance patient and self-advocacy skills. Implementing a communication competency educational program and specifically focusing on communication, advocacy, and assertion skills provides a foundation for learning.3 Nursing programs that provide students with formal training in communication can guide the process of communicating concerns to affect patient safety. In addition, using experiential training techniques such as video presentations, role-play scenarios, and group discussions builds on Knowles' Adult Learning Theory for enhanced engagement and retention.
Implementation of a communication competency educational program can be accomplished in several ways. A single lecture using the 3 components of the TeamSTEPPS curriculum could be implemented. Active learning techniques such as video presentations, available from TeamSTEPPS, and group discussions can enhance knowledge and skill retention. The lecture and active learning components can be leveled to the experience of the student and incorporated throughout the nursing curriculum. Perhaps the most engaging way to facilitate communication skills would be to expand the practice into experiential scenarios in the simulation laboratory. Role-play of scenarios of controversial situations with other health care providers would require students to apply their communication skills to benefit patient advocacy.
Recommendations for Additional Research
In this study, the convenience sample was from 1 community college. Replicating the study in other schools and regions and with different levels of prelicensure students would be beneficial for comparison. In addition, collecting follow-up data with longer intervals between surveys could determine if the significant self-advocacy results were maintained over time.
Initiating a longitudinal study with the educational content leveled to the academic progression of the student, advancing from fundamental to advanced communication strategies, would reinforce the material and perhaps produce a larger effect. In addition, incorporating a qualitative component then completing a mixed-method project design could contribute insights into the development of advocacy skills in nursing students.
Conclusion
Nursing students must be prepared to advocate for their patients and themselves. This requires communication skills to influence and skillfully collaborate in crucial situations. Students had a statistically significant decrease in non-self-advocating beliefs and behaviors after participation in the communication competency educational program, as indicated by their scores on the NWS survey. The results supported providing communication competency education to nursing students and the positive impact on students' ability to advocate for themselves and their patients. Using Knowles' Adult Learning Theory by clearly outlining the value of the education to the student's professional practice and incorporating experiential techniques of learning were instrumental in the positive results. Providing communication competency education to nursing students positively impacts the students' ability to advocate and should influence their delivery of health care.
References