Factors affecting the communication competence in Iranian nursing students: a qualitative study.

BACKGROUND: Communication competence in nursing students is one of the nursing education requirements, especially during the internship period, the final stage of the bachelor nursing education in Iran. Several factors can influence this competence and identifying them could help provide safe care by nursing students in the future.
OBJECTIVES: This study aimed to investigate factors that influence nursing students' communication competence. PATIENTS AND METHODS: A purposeful sampling technique was used to select 18 nursing students who had completed their internship. Semi-structured interviews were conducted and data were analyzed by the conventional qualitative content analysis method.
RESULTS: After data analysis, three main categories were achieved: organizational factors, humanistic factors and socio-cultural factors. The main and latent theme that affected the students' communication competence was not being accepted as a caregiver in the clinical environment.
CONCLUSIONS: With regards to students not being accepted in health care environments, it is recommended to plan special programs for empowering students to acquire better social state and acceptance by the health care team.

1. Background

Competency as the outcome of an educational system is a complex concept, encompassing different areas of learning (1). Nursing competency covers a wide range of knowledge, performance and ability in various fields (2). Nursing care environments need a nurse who is able to work independently at a competent level; however, administrators are concerned about the performance of newly graduated nurses. Therefore, the competency of students is approved by the education system when they are about to graduate (3). This is the internship period in Iran, which is during the fourth year of bachelor of nursing. During this period, students pass all clinical courses again and then they can enter clinical environments as newly graduated nurses. Complete achievement of professional competencies is the outcome of a good education system yet unfortunately according to conducted researches, the achievement of professional competencies by students is not enough (1, 4). One of the basic components of clinical competency is how to communicate with co-workers, managers and patients (3, 5). Nurses should have sufficient communication power (6, 7), which affects the patients' experiences during their hospital stay and is associated with patients' satisfaction, anxiety reduction and their recovery (8, 9). Acquiring communication skills and interpersonal relationships is fundamental for beginners, (10) and is associated with students’ professional growth and development (11); therefore newly registered nurses should have effective, multidisciplinary and therapeutic interaction with patients, families, caregivers and other medical team members (12, 13). Preparing students to create constructive communicative relationships is essential to nursing practice (14), because it enables students to respect (15) and provide safe nursing care for patients. However some studies show that nursing students do not have the necessary knowledge and skills to communicate with patients (16) and one of the problems of newly graduated nurses is the lack of readiness to communicate with patients and families, that is recognized as a disturbing factor for nurses' clinical performance (17). A review on the topics of the nursing curriculum in Iran showed that communication skills are not considered as a unique syllabus and in some courses only a few hours are dedicated to it. Therefore, it can be claimed that the Iranian nursing students are not able to communicate effectively after graduation and require both educational and clinical support for acquisition of this competence (18). Apart from the lack of theoretical education of this competency in nursing faculties of Iran, other factors can also influence acquisition of communication competence by students, especially during the internship period as the final part of education. Considering the unique properties of the internship period in Iran and that the required competencies vary from one place to another (19), it could be accepted that factors affecting Iranian students' communication competence, can also be different. Therefore, in the current study we tried to obtain basic information from different Iranian institutions.

2. Objectives

This research aimed to assess factors that affect the communication competence of nursing students in Iran during the period between 2012 and 2014.

3. Patients and Methods

This study was a qualitative content analysis. Semi-structured interviews were used to collect data. The researchers organized the large amounts of data, made inferences in the data on the basis of the context, provided new insights, and conceptualized realities presented in the text.

3.1. Participants

The participants in this study were selected by the purposive sampling method, which is an appropriate method of sampling in qualitative studies (20). In order to create maximum variety in samples and perceive broader dimensions of the subject (maximum variation sampling) the participants from different universities and hospitals were involved in this research. We selected the cases that had excellent experience during their Internship period and had the ability to express their opinions (21). The inclusion criteria for students was having passed the internship period, and for educators was having experience in internship training, and for nurses was working in educational units in which internship students were trained. Lack of tendency to cooperate, not passing the internship period (for students) and revoking conscious satisfaction, were considered as the exclusion criteria. However nobody refused to participate in this study.

3.2. Data Collection

All the interviews were performed by the first author, and recorded on a digital voice recorder. The interviewer was a nursing PhD student and faculty member of the university with sufficient experience in the field of internship, with some studies and publications on this subject. The participants were interviewed face-to-face by the interviewer visiting their hospital or their university, and were coded in chronological order (Table 1). In-depth semi-structured interviews (30-90 minutes) were held for questions requiring open-ended and interpretative answers (20, 21). The key question for the students was: "during the internship period, what factors have had the most influence on your communication skills, positively or negatively?" and the instructors' and personnel's question was: "According to your experience, what factors can affect students' communication competence acquisition?" Follow-up questions continued based on the participants' responses. The sampling was continued until there were no new findings and similar matters were becoming repetitive. In other words, interviews were continued to obtain data saturation. Finally, by the 18th interview, we reached data saturation.

Table 1.

Demographic Characteristics of the Participants [a]

Participant’s Code	Educational/Work Level	Work or Education City	Gender	Age, y	Work Experience, y	Work Experience during the Internship Period, y
N1	Head nurse (Bachelor)	Isfahan	Female	37	13	13
N2	Registered nurse (Bachelor)	Isfahan	Female	32	9	8
N3	Registered nurse (Bachelor)	Shahrekord	Female	35	11	10
CA1	Master in nursing (Administrator)	Najafabad	Female	38	13	12
I1	Instructor (master degree)	Ahvaz	Male	33	8	8
I2	Instructor (bachelor degree)	Najafabad	Female	35	5	2
I3	Instructor (master degree)	Babol	Female	37	12	8
I4	Instructor (master degree)	Booshehr	Male	40	13	13
I5	Instructor (master degree)	Tehran	Female	36	11	9
S1	Bachelor of nursing student	Isfahan	Female	22
S2	Bachelor of nursing student	Najafabad	Female	23
S3	Master of nursing student	Laar	Male	24
S4	Master of nursing student	Babol	Female	23
S5	Bachelor of nursing student	Isfahan	Male	23
S6	Bachelor of nursing student	Najafabad	Female	22
S7	Bachelor of nursing student	Isfahan	Female	23
S8	Master of nursing student	Tehran	Female	23
S9	Master of nursing student	Tehran	Female	24

a Abbreviations: N, Nurse; CA, Clinical Administrator; I, Instructor; S, Student.

3.3. Data Analysis

Data collection and analysis were done simultaneously during 16 months in 2013 and 2014. The maxqda10 software was employed for transcription and classification of codes. Conventional content analysis was used to identify categories and themes by means of the Zhang approach (Table 2) (22). Transcribed interviews were studied several times to produce an overall impression of the data, and then, important sentences were highlighted and codified into the smallest meaningful units. Meaningful units were labeled with codes and comparative analysis was performed in order to extract primary codes. During the next stage, the primary codes were classified based on differences and similarities in abstract categories and a coding scheme was shaped. The coding scheme was tested on a sample of text and then all the text was codified. All of the researchers participated in the data coding process. Continuous analysis of data began from the beginning of codification, and continued until the end of data collection. Conclusions from codified data are presented in Tables 3 and 4, and are reported in this article.

Table 2.

The Summary of Steps of Analysis Based on the Zhang Method

Steps	Action
Step 1	Preparation of the Data
Step 2	Definition of the Unit of Analysis
Step 3	Development of Categories and a Coding Scheme
Step 4	Testing of the Coding Scheme on a Sample of Text
Step 5	Coding All the Text
Step 6	Assessment of Coding Consistency
Step 7	Drawing Conclusions from the Coded Data
Step 8	Reporting Methods and Findings

Table 3.

Main Categories and Subordinate Themes Obtained by Data Analysis

Categories	Subcategories
Organizational factors
	The lack of student's organizational position
	Physician autocracy
Humanistic factors
	Student characteristics
	Patient behavior
	Clinical nurses
	Instructors
Socio-cultural factors
	Social and cultural status of students
	Cultural differences of patients and students

Table 4.

Descriptions and Participants Excerpts Corresponding to the Socio-Cultural Factors Category and its Subcategories

Integrative Codes	Initial Codes	Meaning Units
Social and cultural status of students
Patients not accepting students as a caregiver
	Not communicating with students	"At the beginning, I did not introduce myself; when we introduced ourselves as a student, they did not communicate with us or behaved in a way that we did not dare to go to their room."
	No admission of students	"When they (patients) understand that you are a student, they think they are regarded as a laboratory mouse and we want to do operations on them."
Trust and rely on students
	Use of unethical methods to gain the confidence of the patients	"I was afraid that they would not communicate with me. There would be better communication, if I told them that I was one of the personnel." and "Some students put the instructors' label on their pockets to attract the patients' attention and trust. Because as soon as they realized that we were a student, they would pay no attention to us."
	Trusting students	"Only a burn patient came and communicated with us. She was self-immolated. She told us about her family problems. Nevertheless, she did not say anything to the staff about herself. She had trusted us, perhaps because we were students. We were there for a short time, wouldn’t tell others what she had told us."
Family and cultural education of student	Family of student	"I had a student that was trained by me for a semester, he said hello to me during that semester but did not greet me during the next semester because he had no classes with me. I believe that is related to his family upbringing and what they have taught him"
Cultural differences of patients and students
Problems in cultural perception	Cultural framework of patient	"In some cultures, asking about the patient's sexual function results no clear and correct answer; but if someone identified the culture of his patient and ask him the questions according to his cultural framework, the patient would trust and answer clearly."
	Difficulty in language perception	"I had a patient who spoke the Arabic language… an Arabic student can communicate with him very well. But I couldn’t "
	Differences in language, gender and age	"During injections and giving care, in some cultures, male patients like to receive care from a male nurse or vice versa. In some cultures, this is not important but in some other cultures it is very important"

3.4. Rigor

To ensure trustworthiness, credibility, dependability and transferability (23), some methods were used to exactitude this research. Choosing participants from different places and various experiences increased the credibility of the research. Sample codes were given to three participants who confirmed the harmony of the codes with their statements. In addition, some sections of the transcriptions and extracted codes were sent to three experts to consider the analysis process and determine its accuracy. Finally, categories and subcategories of different interviews were combined and a complete description of factors that influence students’ communication competency was obtained. For increasing the dependability of this study, prolonged sampling (16 months in duration), selection of the most suitable meaning unit, simultaneous analysis and emerging of data were conducted. The research team members discussed about the content of the study, by an open dialogue, until consensus was reached. To facilitate transferability, a clear description of the characteristics of the internship period in Iran, methods of selection and characteristics of participants, process of data collection, analysis and findings with appropriate quotations are explained in this article (20).

3.5. Ethical Considerations

All of the participants were informed of the study aims and methods, and were assured that participation was anonymous and voluntary. The places of interview were determined based on agreement between the hospital or university and the interviewer. Written informed consent was obtained from all participants prior to recording of their voice, and the interviewer explained the study aims. The participants were assured that all of their information and sound files would remain confidential. The interviews were carried out only in the presence of the researcher and the interviewee and no one else. All participants signed the form of conscious satisfaction designed by the interviewer on the basis of ethical codes regarding work with human cases, and the study was approved by the Ethics Committee of the Faculty of Medical Sciences of Tarbiat Modares University (registered under 52112234 dated 22/1/2012).This study was carried out after receiving permission from all involved universities and hospitals.

4. Results

After analysis and codification, three main categories were extracted: organizational factors, humanistic factors and socio-cultural factors (Tables 3 and 4). The latent and major theme of this research was" patients not accepting the students", which was obvious throughout the research and in all categories. Nursing students are not accepted in clinical settings and this causes a reduction in their communication competence (Figure 1).

Figure 1.

Factors Influencing Communicative Competence of Iranian Nursing Students

4.1. Organizational Factors

This research identified that organizational factors such as position of nursing students in the clinical environment and physician autocracy affected their communication competency.

4.1.1. The Lack of Student's Organizational Position

Lack of an adequate organizational position of nursing students in clinical environments was one of the organizational factors that the participants complained about. Duties and responsibilities of a nursing student are not clearly determined; and each member of the health care team expresses their personal opinion and this factor ruins the relationship of students with others: "Supervisors obligate us to do all work because we do not have an instructor or we are from Azad University; they think we are their servant"(S7).

4.1.2. Physician Autocracy

Physician autocracy was another negative organizational factor in Iranian hospitals: "I remember that there was a patient that neither doctors nor nurses were aware of...we were talking to him and he was speaking about his disease... meanwhile, during our conversation, the physicians came and shouted at us, asking why we were talking there? He told us to leave the room. Our fault was talking with the patient"(S3).

Even instructors are affected by the physician autocracy’s atmosphere and don’t play their educational role: "Our managers stay away from the physicians… they never communicate with the physicians, they asked us to stay during their medical round while they go out. This also makes us stay away from physicians little by little" (S7).

4.2. Humanistic Factors

Humanistic factors that can affect students’ communication competence include options by other students, patients, clinical nurses and instructor characteristics. The participants believed that the existence of some features in the students’ personality enables or stops them to reach communication competency: "I know communicating with the patient, depends on my character... I could not communicate with my patients"(S5).

Social communication ability of students such as flexibility and having appropriate behaviors with different people can affect their communication competence: "The students were different, some had trouble with others, while some, although upset, they would adopt themselves with the condition. Some would get angry and quarreled" (S6).

Introspection and fear of communicating with patients is one of the characteristics of student that affect their ability of social communication: "I was always afraid to communicate with the patients because of my disability to do so"(S2).

4.2.1. Patient's Behavior

Type and severity of the patient's disease can affect the tendency of the patient to communicate with the student: "Burned patients with bad body image, had weak communication. During the week that we were at the burn hospital, we did not have any relationship with any of the patients"(S4).

Anxious and nervous behavior of critically ill patients with nursing students was another complaint of students: "I wanted to visit a patient with liver cirrhosis; I entered the room, he behaved badly. He said, "Go out, why you ask me these questions? I’m tired of you, I want to die" (S3).

4.2.2. Clinical Nurses

The participants believed that clinical nurses had an effective role on students’ communication competency. Most participants talked about the lack of acceptance by clinical nurses: "They would not pay any attention to us. The personnel would ignore us." (S6); "In most wards, the nurses deal with students very badly. They do not pay attention to them" (I2); "She did not teach us how to behave when dealing with patients. She just screamed at the patient and his companion"(S1).

4.2.3. Instructor

Many participants emphasized on the key role of the instructors as a communicative model for internship students: "At the beginning, some masters would introduce students very well and this made the staff to become familiar with students. Nevertheless, other masters would not introduce students to personnel and would not identify which patient is for which student…, therefore the students thought that they were far from the ward personnel"(N2).

Some of the instructors would not pay any attention to students' acquisition of communication competency: "When a student came to the ward, instructors just wanted them to measure blood pressure and they would not encourage them to communicate with the patients"(H1).

4.3. Socio-Cultural Factors

4.3.1. Social and Cultural Status of Students

According to the participants’ experiences, the public viewpoint about nursing students is not positive. When the students are in the ward, the patients feel that they are undergoing different clinical tests and treatments for the students to learn new things and students do not care for the patients like personnel. Therefore, they do not accept students as caregivers: "When a student had come to visit a patient; she asked if he was a student? And then told him to go and tell your instructor to do the work herself"(I1).

Family features and cultural background of students is one of the factors that affect students' communication competency achievement: "There are some students that cannot communicate with others well, why? Because it depends on their family background; their families have not taught them how to communicate with others" (I3).

4.3.2. Cultural Differences of Patients and Students

Because of cultural gaps between students and patients and lack of cross-cultural understanding, they cannot communicate with each other. In many situations, ethical and religion principles are one of the disturbing factors: "Communicating with the patients is very hard, especially when their cultures are different, especially their language. In many situations besides gender differences, we cannot communicate with an old man at all"(S6).

5. Discussion

The findings revealed that "patients do not accept students" because of organizational factors, while individual, social and cultural attributes of students, instructors, clinical nurses and patients, are the most important factors that affect the acquisition of communication competence during internship. During the internship program, because of direct contact with the higher organizational people, acceptance of the organizational position of the students by officials and nursing directors leads to less communicative problems. In the study by Beitz and Wieland (24), one of the main factors, that affected the students' view of the clinical learning environment, was the students' communication with nurses and nursing managers. Communications with physicians may be more difficult if there is a physician autocracy atmosphere (5). Physician autocracy had a negative effect on student-patient relationships in this study; and this means that, in accordance with the studies of Hanifi et al. (5) and Ardahan et al. (25), physicians still look at nurses as individuals who should implement the physicians order before meeting the needs of patients. Nursing students have deficiencies in their communication competence such as nurse-patient communication during medication administration (26). The students are concerned about rejection by patients and their families just because of being a student (27). A number of the students participating in the current research stated that they were afraid of communicating with patients. Fear of dealing with the patient, lack of confidence and emotional distress are the main known causes that make the students become distant from the patients (28), conversely, knowing the student’s personality with potentials and limitations is essential for a facilitative relationship (11) and providing care for patients without prejudice toward different patients is one of the most important items of professional values (29). Clinical nurses, as future coworkers, have a vital role in training nursing students (30). In many educational hospitals of Iran, the instructor doesn’t have a stable presence during the internship period, so the student works directly with clinical nurses. Therefore, some nurses who are interested in training will teach the students informally, while they are also the students' coworkers or supervisors. Students believe that clinical nurses are a procedure model; a qualified, powerful and attractive model (30). Nursing students are concerned about mistakes made due to insufficient knowledge and skills (31). Thus, positive relationships between students and experts, and interested and kind ward staff, can reduce the stress of students in the clinical environments (32) and are critical for them because the student’s need for support, respect and acceptance from more experienced colleagues is of major importance to them (33) and this sense of belonging can influence their communication competency acquisition. The results of this research, similar to the study of Atack et al. (34) showed that even simple suggestions such as offering to sit or invitation to the break room, create a sense of admiring and belonging for the nursing student. Many participating students claimed that in many situations they were ignored or met with indifference. These findings confirmed the results of studies about the fact that students are not admitted as legal members of the team; thus they are neglected, isolated or abandoned. These researchers have emphasized on the importance of the sense of belonging for nursing students as part of the health care team (28, 35). In the nursing education system of Iran, clinical instructors are the main people responsible for training nursing students during their internship. One of the most important criteria for effective clinical instructors is their ability to establish an interpersonal communication competence (36). If the instructor does not establish a good relationship with the members of the clinical team, she/he cannot cooperate with them (37). The personal attributes of the instructor not only directly affect training, nursing or interpersonal relationships, but indirectly influences all of them (38), thus having a friendly and supportive behavior is very important for the clinical educator (31). Nursing instructors could have a good relationship with their students when they respect them, have realistic expectations, are honest and truthful, encourage them, and help them in clinical environments (28). According to the research participants, instructors who have these features had a positive effect on the students' communication competency acquisition. Unfortunately, the nursing profession in Iran does not have a positive reputation amongst the pubic (5, 39), and this negative view could affect the nursing students. The relationship between students and patients seems to be largely determined by their preconceptions and stereotypes about one another and personal qualities of both of them (11). In most cases included in this study, the lack of students' acceptance by patients and their families was mentioned and consistent with some previous study results; patients did not take the opportunity to contribute to student learning (11). Finally, based on the results of our research, it seems that the main factor that affects the students' communication competence is the lack of students' acceptance as a caregiver by health care providers, instructors, patients and their families in clinical settings (Figure 1). By considering the purpose of the internship period and the fact that effective teaching of communication skills is critical for preparing future nurses and delivering safe care (40), it is recommended for authorities to design a comprehensive system for training nursing instructors with appropriate communication skills, and to improve the organizational and social position of the nursing students. We suggest that in order to develop this competency, firstly, health authorities must prepare the environment for accepting students and defining their clinical situation as care providers in hospitals. Because of the sampling strategy of this study and focus on an Iranian population, when generalizing the study findings, cultural differences must be considered. Although heterogeneous samples have yielded wide findings, the present results can be considered to have a wider relevance to similar clinical contexts. The focus of this study was to determine the effect of individuals, who are present in clinical settings, on the acquisition of communication competency in students.