Nurse Education Today 33 (2013) 823–827

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Nurse Education Today

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An evaluation of nursing students' communication ability during

practical clinical training
Jianfei Xie a, b, Siqing Ding b, Chunmei Wang a, Aizhong Liu a,⁎
a
The School of Public Health, Central South University, Changsha, 410008, China
b
Third Xiangya Hospital, Central South University, Changsha, 410008, China

a r t i c l e i n f o s u m m a r y

Article history: Objectives: To investigate communication abilities and other influential factors on nursing students at the
Accepted 21 February 2012 beginning of clinical practical session.
Methods: A cluster sample of 312 nursing students from 22 nursing colleges or universities was recruited.
Keywords: Communication ability of these participants was evaluated by 4 questionnaires for demographic data, clinical
Nursing student communication behavior, treatment communication skills and interpersonal communication skills at the
Communication
beginning of clinical practical session.
Education
Clinical practice session
Results: The stability and accuracy of the questionnaires were established with an overall content validity
index of 0.78, the Cronbach's Alpha index ranged from 0.872 to 0.951, and the letter index fluctuates from
0.85 to 0.89. Results demonstrated that 88.1% of the nursing students require extra training in clinical com-
munication behavior, treatment communication skills, and interpersonal communication skills. The Pearson
analysis revealed significantly positive correlations between communication abilities and the students'
educational level, clinical training experience, living circumstances and number of siblings.
Conclusion: Most nursing students need communication skill training. Multiple factors, including educational
level, living circumstances, number of siblings, and training experience significantly affect nursing students'
communication abilities. Our study suggested a need to widely establish a communication course or clinical
communication training program to improve nursing students' communication skills.
© 2012 Elsevier Ltd. All rights reserved.

Introduction It is widely accepted that a nurse's communication ability is an im-

The practice of nursing utilizes constant communication between
nurse, patient, patient's family, nurse's co-workers, supervisors, and
many others (clinical communication). Good communication is es-
sential in establishing trust between nurses, patients, as well as
their family members which forms the foundation of good healthcare
(Reader et al., 2007). In contrast, breakdown in communication neg-
atively affects patient care, causes stress, and may lead to other prob-
lems (Fallowfield et al., 2001). For example, poor communication can
lead to misunderstandings, frustration, medical disputes, errors, and
poor patient outcomes, which may lead to death in the worst case
scenario (Leonard et al., 2005; Meyer and Arnheim, 2002). Recent
studies demonstrated that the majority of medical disputes are not
caused by failures of medical technology, or healthcare practitioners.
Conversely, they are usually caused by miscommunication between
patients and doctors, or some patients' prejudice towards the nursing
service (Zhang, 2007).
⁎ Corresponding author at: School of Public Health, Central South University, 110
Xiangya Road, Changsha, 410008, China. Tel.: +86 731 8480 5465; fax: + 86 731
8480 5454.
E-mail address: lazroy@live.cn (A. Liu).
portant factor for good clinical practice. However, communication
skill training has been somewhat neglected in some countries (Liu
et al., 2007). In these countries, nurses have considerable needs for
communication skills training because of the lack of relevant educa-
tional and training programs and the shortage of resources (Liu et
al., 2007). Nursing students generally only receive instruction on
communication techniques from lecture-based teaching without any
hands on training. Currently, there is no study that evaluates whether
there is a lack of the communication skill training among nursing stu-
dents during early practical sessions. Despite the students' lack of
communication training prior to the practical session, most nursing
students will graduate, become full time nurses, and practice clinical
work. Therefore, the practical clinical session becomes the last chance
for nursing students to learn communication skills prior to exiting
their program of study. However, clinical learning is random and
does not guarantee every student similar opportunities or experi-
ences to learn when to communicate with physicians, when to com-
municate with patients, and when to report or how to convey the
information that is obtained (Krautscheid, 2008). In addition, mis-
takes made by nursing students may not be corrected on time by an
experienced nursing supervisor due to the large number of students
in the unit and variable needs of different patients. Thus, although a

0260-6917/$ – see front matter © 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2012.02.011
824 J. Xie et al. / Nurse Education Today 33 (2013) 823–827
ward-based training of clinical communication skills is crucial, estab-
lishment of an educational program for communication training prior
to the practical session might be more important for nursing students.
Among the communication skills used in nursing, treatment com-
munication is one of the most important and aims to solve some of
the main problems through effective communication with patients
(Swinny and Brady, 2010), such as expressing support, providing
information, giving feedback, giving patients hope, and helping
them deal with anxiety, etc. (treatment communication) (Elizabeth,
2006). Interpersonal communication is a process to communicate
one person's ideas, thoughts, and feelings to another person. However,
treatment communication was not isolated from clinical communica-
tion and interpersonal communication skills. In this study, clinical
communication, treatment communication skills, and interpersonal
communication skills of nursing students at different educational
levels was evaluated by questionnaires at the beginning of the clinical
practical session. Our study will provide information for the governor
to make changes to the educational policy and the program director to
design courses for communication training.
Materials and Methods
Setting and Sampling
This study was conducted in September, 2010 in Changsha, in the
third affiliated teaching hospital of Central South University. A total of
312 nursing students were recruited before the practical session of
their registered nursing program for this study using group sampling.
These nursing students were registered in nursing programs in 22
colleges or universities. The study was approved by the Ethics Com-
mittee of Central South University. The signed informed consent
forms were obtained from all subjects who participated in the
study. The communication abilities were investigated by question-
naires at the beginning of the practical session.
Questionnaires
A total of four questionnaires were used in this study.
1) Basic information questionnaire collected demographic data in-
cluding age, sex, educational level, living circumstances (urban
or countryside), sibling number, previous experience in communi-
cation skill training, etc.
2) Clinical communication behavior questionnaire included 9 items:
communication with schoolmates, teachers, patients' family
members, patients, nurses, valid persons, doctors, invalid persons
and self-evaluation. The valid and invalid persons were deter-
mined by a questionnaire before this study. Nursing students
were asked what age group of people is easiest to communicate
with and what age group of people is most difficult to communi-
cate with. People in the age group that were easy to communicate
with were defined as “valid persons”, whereas people in the age
group that were hard to communicate with were defined as
“invalid persons”. Each item had 5 Likert-type scales. Higher
scores indicated better communication behavior.
3) Treatment communication ability questionnaire was made by re-
ferring to the SEGUE framework (Makoul, 2002), clinical commu-
nication behavior scale (Steyn et al., 1999), and Liverpool
Communication Ability Assessment Scale (Humphris and Kaney,
2001). The overall questionnaire contained 9 items and 43 sub-
scales. The 9 items included: sharp listening, effective transfer of
information, participation, establishing harmonized relationships,
preparation for communication, effective improvement, process
control, ending communication work, and self-evaluation. Each
of the 43 subscales had 5 Likert-type scales: 1.0 for strongly
disagree, 2.0 for disagree, 3.0 for unable to determine, 4.0 for the
agreements, 5 for agreement with attentive.
4) The interpersonal communication ability questionnaire included
items: support attitude, negative feedback, and communication
skills and 20 scales with 5 rates. The higher score represented
stronger ability.
Procedures
The research team was composed of 1 director, 1 vice physician-
in-charge, 16 nursing managers and 1 teaching secretary. The team
members were responsible for getting signed informed consent
forms and explaining the research goal and purposes before the nurs-
ing students completed the survey. To increase the accuracy of the
questionnaires, all questionnaires were anonymously filled and col-
lected right after interview. The average time for each interview
(not anonymous) was 15–25 min.
Statistic Analysis
All information from the questionnaires was entered into a com-
puter according to the serial number. Both descriptive and inferential
statistics were used for data analysis by using SPSS 17.0 software. A
p b 0.05 was considered statistically significant.
Results
Reliability and Validity Assay
The questionnaires were evaluated by two experts and a content
validity index of 0.78 was established. The Cronbach's Alpha index
was from 0.872 to 0.951. These questionnaires were pre-tested with
20 nursing students. All participants expressed that the question-
naires were easy to understand. To analyze the reliability of the ques-
tionnaires, the pre-test was conducted for two times with a 2-week
interval and showed a reliability of 0.85 to 0.89. Generally, a reliability
of 0.75 or 0.80 indicated good stability.
Basic Characteristics of the Participants
312 sets of questionnaires were used and 311 effective question-
naires were received. The basic characteristics of participants are
shown in Table 1. A significantly higher ratio of students comes
from one-child (69.8%) families, having no standardized training
(86.5%) before clinical practice, and will require communication
training (88.1%).
An Overall Evaluation of Nursing Students' Communication Abilities
The average scores of clinical communication behavior, treatment
communication ability, and interpersonal communication ability
were 3.77 ± 0.35, 4.29 ± 0.34, and 3.85 ± 0.40, respectively. Among
the 9 items of clinical communication behavior questionnaire, the
students thought that the best way was to discuss with peers and
the worst way was to communicate with unfamiliar persons.
Among the 9 items of treatment communication ability question-
naire, nursing students behaved best in attentive listening and
worst in subjective overall appraisal. Among the 20 items of interper-
sonal communication ability questionnaire, nursing students ranked
highest in support attitude: “when communicating with people, I
will defend their sense of self-respect and self-value”, but they ranked
lowest in negative feedback: “even if I do not approve of someone's
point of view at all, I still try to show interest in it”; “I often try to
give advice to people whose behavior needs to change”; “I often
point out inconsistencies in people”. Pearson correlation analysis
demonstrated a significant correlation between nursing students'
 J. Xie et al. / Nurse Education Today 33 (2013) 823–827 825

Table 1 Table 3
Characteristics of the participants (n = 311). Influence of educational levels on clinical communication behavior and treatment com-
munication ability (n = 311).
Characteristics Number %
Variable Education M ± SD t Value P Value
Age (year)
19–21 231 74.3 Self-evaluation of College 3.71 ± 0.51 − 3.132 b 0.05
22–24 80 25.7 communication behavior University 3.88 ± 0.37
Establishing harmonized College 25.97 ± 2.56 − 2.133 b 0.05
Gender relationship University 26.71 ± 2.27
Male 7 2.3 Process control College 4.04 ± 0.70 − 2.666 b 0.05
Female 304 97.7 University 4.29 ± 0.67
Overall evaluation of treatment College 3.69 ± 0.65 − 3.573 b 0.05
Educational background communication University 3.94 ± 0.43
Middle school-college 75 24.1 Communicate with doctors MS–college 3.16 ± 0.61 − 2.142 b 0.05
high school-college 165 53.1 HS–college 3.35 ± 0.59
4-year university 55 17.7 Self-evaluation of MS–college 3.86 ± 0.57 2.454 b 0.05
5-year university 16 5.1 communication behavior HS–college 3.62 ± 0.67
Transfer effective information 4-year 26.22 ± 2.16 − 3.575 b 0.05
Sibling number university
Single child 217 69.8 5-year 28.44 ± 2.16
Non-single child 94 30.2 university

MS: middle school; HS: high school.

Living circumstance
Urban area 190 61.1
Rural area 121 38.9

Standardized training
Table 4
Yes 42 13.5
Influence of the number of siblings in the nursing students' family and the living
No 269 86.5
circumstance on communication abilities (n = 311).

Communication-training needs Variable Number of M ± SD Living M ± SD

Yes 274 88.1 siblings
No 37 11.9
Clinical communication One-child 3.72 ± 1.62 Urban 3.81 ± 0.68#
behavior ≥1 sibling 3.80 ± 1.62 Rural 3.72 ± 0.59
Treatment communication One-child 4.04 ± 0.52⁎ Urban 4.37 ± 0.76#
clinical communication behavior scores, treatment communication ability ≥1 sibling 4.33 ± 0.59 Rural 4.15 ± 0.78
ability scores, and interpersonal communication ability scores Interpersonal One-child 3.82 ± 0.41 Urban 3.99 ± 0.56#
(Table 2, ps b 0.01). communication ability ≥1 sibling 3.91 ± 0.35 Rural 3.78 ± 0.56
⁎ p b 0.05 vs. ≥1 sibling.
#
The Influence of Educational Level on Nurses' Communication Abilities p b 0.05 vs. rural.

As shown in Table 3, the education al level significantly affected

the clinical communication behavior and treatment communication
ability. Nursing students registered for college nursing program
with high school education behaved significantly better than students
registered for college nursing program with middle school education.
Also, students (high school education) registered in a 5-year universi-
ty nursing program behaved better than students (high school educa-
tion) registered in a 4-year university nursing program. Similarly,
significant differences in the influence of the educational level on
the students' interpersonal communication ability were also observed
between nursing students having middle school and high school edu-
cation and between students registered for 4-year and 5-year univer-
sity nursing programs.
The Influence of Number of Siblings, Living Circumstances, and Previous
Training Experience on Nursing Students' Communication Abilities
We found that the students who are a single child had significant
differences in treatment communication ability (p b 0.05), but had no
differences in clinical communication behavior score and interper-
sonal communication ability (ps > 0.05) compared to the students
who have more than one siblings (Table 4)
We analyzed the influence of students' living circumstance (urban
or rural) on their communication abilities (Table 4). Students that
lived in an urban environment before they registered for the nursing
program exhibited significantly better abilities in clinical communica-
tion behavior, treatment communication ability, and interpersonal
communication ability compared to the students that lived in rural
environments (ps b 0.05).
There are 269 nursing students (86.5%) that have never enrolled
in any standard communication skill training programs. We found
that some of the participants never even received standard training
in communication skills through lectures or seminars. Students with
communication training via lectures exhibited significantly better
communication abilities than students with no communication train-
ing at all (Table 5, ps b 0.05).

Table 2
Correlation between nursing students' communication abilities.

Communication abilities Correlation and p value Treatment communication Clinical communication Interpersonal communication
ability scores behavior scores ability scores

Treatment communication ability scores Correlation coefficient 1 .315⁎⁎ .618⁎⁎

P .000 .000
Clinical communication behavior scores Correlation coefficient .315⁎⁎ 1 .248⁎⁎
P .000 .000
Interpersonal communication ability scores Correlation coefficient .618⁎⁎ .248⁎⁎ 1
P .000 .000
⁎⁎ p b 0.01.
826 J. Xie et al. / Nurse Education Today 33 (2013) 823–827
Table 5
Comparison of overall score by different training experiences (n = 311).
Variable Standardized M ± SD t Value
training
Clinical communication behavior Yes 3.89 ± 0.57 2.258
No 3.67 ± 0.59
Treatment communication ability Yes 4.34 ± 0.72 1.717
No 4.12 ± 0.78
Interpersonal communication Yes 3.93 ± 0.54 1.514
ability No 3.79 ± 0.56
Discussion
One of the most important components of a quality healthcare es-
tablishment is quality nurses. Not only are nurses the first to interact
with patients in a clinical setting; but also they take care of patients
during their entire stay. Thus, it is important for nursing students to
be prepared and assessed on communication competency prior to
exiting their program of study. In this study we demonstrated that
most nursing students require improvement in their communication
skills in clinical communication behavior, treatment communication
ability, and interpersonal communication ability. To our knowledge,
only a few studies have addressed the communication issues in nurs-
ing students in all of the above three aspects. Our study also identified
factors that negatively affect the nursing students' communication
abilities and highlighted the need to establish a course in nursing pro-
gram or a clinical training program to improve students' communica-
tion skills.
The notable finding in this study is that most nursing students
need communication skill training while communication skill train-
ing prior to clinical practice session significantly increased nursing
students' communication abilities. Only a few of the nursing pro-
grams have designed a communication curriculum. Even so, the con-
tent of these courses emphasizes interpersonal communication
theories, but ignores hands on clinical communication training. How-
ever, clinical communication is very different from everyday commu-
nication; it emphasizes more on the interaction effect of interpersonal
communication, appraisal communication and treatment communi-
cation (Fitzpatrick et al., 1992). Our study also revealed that clinical
communication behavior, treatment communication ability, and in-
terpersonal communication ability correlated with each other
(Table 2). This suggests a clear need to improve the content of the
current communication curriculum of our schools. Moreover, most
colleges and universities have not yet adopted the communication
curriculum. Therefore, most nursing students were not trained in
any communication skills before they were ushered into clinical prac-
tice because of the high demand for nurses. Previous studies demon-
strated that nurses' communication skills could be developed and
consolidated under the integrated communication skills training
model (Liu et al., 2007). In addition, clinical placements are not only
important in the learning processes of nursing students (Berntsen
and Bjork, 2010), but also directly influence nurses' attitudes, skills,
knowledge and abilities to deal with various problems (Henderson
et al., 2007). Therefore, clinical practice should be improved by estab-
lishing ward-based communication skill training.
Currently, there are controversial opinions about the real require-
ment of nurses' educational level in good healthcare. Reports from
World Health Organization (WHO) demonstrated that some coun-
tries' education policy hold that the specialized middle school educa-
tion is enough for nursing students, while other countries insist that
the lowest request for nursing students who is ready to carry on clin-
ical practice should have at least university level education (2009).
For example, some studies demonstrated that nurses from different
educational levels have no distinctive disparities (Lin et al., 2008).
However, more studies indicated that the educational level of a
nurse is proportional to a better chance to save patients' life,
guarantee patients' security and improve nursing quality. The com-
munication ability of nurses who graduated from colleges or universi-
p Value ties is significantly better than those who received the lower
educational level (WHO, 2007). Indeed, our study showed that nurs-
b 0.05 ing students with high-school-education performed much better than
those with middle-school-education in communication behavior,
b 0.05 treatment communication ability and interpersonal ability. Further-
more, students who had registered for a 5-year nursing program
b 0.05
had better communication ability than those registered for a 4-year
nursing program (Table 3). Interestingly, we revealed that additional
communication skill training is still necessary regardless of educa-
tional levels.
Presently, there are no reports to investigate the influence of sib-
ling number and living circumstance on the students' communication
abilities. In this study we recruited participants from one-child fami-
lies. These children are often pampered since their childhood and
some of them are even self-centered. This dilemma might create a
communication barrier between nurse and patient. Indeed, our
study revealed that students from one-child families had significantly
lower treatment communication ability than students having siblings
(Table 4). In practical sessions, a majority of nursing students were
not able to comprehend completely patients' mood or understand
the needs of the patient by observing their body language and other
hints. Some students also failed to show appropriate respect for
their patients, alleviate patients' anxious mood and encourage
them to recover from disease. All these aspects cause patients to be
dissatisfied with nurses. In addition, the social structure is usually im-
balanced and divided into “wealthy city and impoverished country-
side”. Thus, the living conditions and cultural environments are very
different between urban and rural areas. Students living in rural
areas have a tendency to feel shy and often have lower communica-
tion ability due to their accents affecting their pronunciation. In this
study we found that students coming from rural areas not only
showed significantly lower interpersonal communication ability, but
also showed lower clinical communication behavior scores and treat-
ment communication ability (Table 4). In contrast, Lin et al.'s, (2008)
study demonstrated that nursing students from the urban area and
the rural areas have no obvious differences in communication ability.
The conflicting findings may reflect the sensitivity of different re-
search approaches.
Although this study was conducted with a bigger sample size,
there are several limitations. First, this study relied on self-report
measures. Self-report data have been criticized for their potential re-
sponse bias. However, in this study all of the questionnaires were
anonymously filled. This strategy may increase the accuracy of the
questionnaires and reduce the response bias. Second, this study was
conducted in only one teaching hospital, which limits the generaliza-
tion of the findings. However, the subjects come from 22 different
colleges and universities, which minimized the sampling bias. It is
better to re-verify the current findings with a study including multi-
ple medical centers or hospitals. Third, this study was only for stu-
dents who just entered hospital. The follow up study to see whether
these students' communication skills were improved after the clinical
practice session are desirable. Fourth, the questionnaire only served
for subjective investigation. In future research, some corrections or
modifications must be made to improve the questionnaires. Despite
these limitations, the present research provides an estimate of the
scope of the lack of communication skills among nursing students.
Conclusion
Our study addressed the requirement for nursing students to
improve their communication abilities in clinical communication be-
haviors, treatment communication skills and interpersonal communi-
cation skills and the importance of communication skill training prior
to the clinical practical session. We identified that educational level,
 J. Xie et al. / Nurse Education Today 33 (2013) 823–827 827

living circumstance, and sibling number are negative factors on nurs- Leonard, M., Graham, S., Bonacum, D., 2005. The human factor, the critical importance
of effective teamwork and communication in providing safe care. Quality & Safety
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to establish a communication skill course in current nursing programs Lin, F., Luo, Q., Cui, Y., 2008. Investigation of communication skills in nursing students.
or clinical communication skill training program for nursing students. Chinese Medical Education 2, 7–8.
Liu, J.E., Mok, E., Wong, T., Xue, L., Xu, B., 2007. Evaluation of an integrated communi-
cation skills training program for nurses in cancer care in Beijing, China. Nursing
Research 56, 202–209.
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