Attitudes towards communication and perceived self-efficacy in nursing students: a longitudinal observational study

Introduction

Person-centred care is a healthcare paradigm that prioritises the individuality, needs, preferences and expectations of patients and empowers them to take an active role in managing their health (Ryan, 2022). Research has shown that person-centred care is associated with shorter hospital stays, lower readmission rates, better quality of care and greater satisfaction with the care provided (Rosengren, Brannefors & Carlstrom, 2021).

To move from paradigm to clinical practice, healthcare professionals need to be skilled in effective clinical communication (Lee & Son, 2022), which involves not only clear communication of information, but also the ability to listen, understand and respond appropriately to a person’s emotional and physical needs. This approach aims to impart knowledge and influence specific perceptions and attitudes (Stehr et al., 2022). The importance of communication is reflected in the nursing theories and models underpinning professional practice. For example, Jean Watson’s Theory of Human Caring (Watson, 2018) highlights the vital role that communication with both patients and their families plays as part of the care process.

By the late 2010s, a clear picture began to emerge in the literature: the communication training provided to nurses was insufficient to meet the demands of modern healthcare. While communication was widely recognized as a cornerstone of nursing practice, studies revealed that many nurses lacked essential skills in this area (Sánchez-Expósito et al., 2018; Shorey et al., 2018). Training programmes appeared heavily focused on clinical and technical competencies, with limited emphasis on developing interpersonal skills, teamwork, or effective communication strategies (Pires et al., 2017). This gap in training became increasingly concerning when its consequences were considered. Poor communication was linked to longer hospital stays, higher healthcare costs, and ultimately poorer health outcomes for patients (Agarwal, Sands & Schneider, 2010). However, despite the urgency to address this issue, there was little agreement on how communication training should be integrated into nursing curricula—questions remained about where and when such content should be included and how much time should be dedicated to it (Ruiz-Rojo et al., 2022).

These challenges were further exacerbated by the attitudes of nursing students themselves. As posterior evidence showed, limited emphasis on communication training often led to the development of negative attitudes towards its importance, contributing to a cycle of poor communication and suboptimal patient care outcomes (Sanchis-Giménez et al., 2023). Conversely, students who held positive attitudes towards communication were more engaged in their learning, invested more time in honing these skills, and applied them effectively in clinical practice (Givron & Desseilles, 2021). Given these findings, the need to not only enhance communication training but also address and shape nursing students’ attitudes towards communication became increasingly apparent (Chou, Tai & Chen, 2023).

It is worth noting that there is a paucity of research in the nursing field that has looked at this issue in any depth, with most existing studies being cross-sectional in nature. Recent studies by Giménez-Espert et al. (2021) and Sanchis-Giménez et al. (2023) examined attitudes towards communication in nursing education, revealing differences across student levels and relationships with factors like emotional intelligence and social skills. However, these cross-sectional studies fail to capture how attitudes evolve over time, particularly during clinical training. However, in the two longitudinal studies identified, there was a worrying trend of declining attitudes towards communication as students progressed through their training, particularly in the clinical setting (Givron & Desseilles, 2021; Rosenbaum, 2017). This observation suggests that there is an overriding need for longitudinal research to shed light on these changes over time.

There is also a need to tackle the lack of confidence students have in their ability to communicate with patients (Cannity et al., 2021). This is due to a number of barriers to effective communication, such as difficulty initiating or maintaining conversations (Lin et al., 2017). This study seeks to fill a gap in the literature by incorporating the dimension of perceived self-efficacy in therapeutic communication into the undergraduate nursing programme. Essentially, the aim is to explore students’ perceptions of their ability to successfully complete a task (Bandura, 1995; Doyle et al., 2011). Self-efficacy, grounded in social cognitive theory (Browne, 2023; Skoglund et al., 2018), plays a significant predictive role in students’ motivation, learning and performance (Escribano et al., 2022).

The purpose of this article is to provide a comprehensive analysis of how attitudes towards communication and perceived self-efficacy evolve in a cohort of nursing students over the course of their training. The lack of longitudinal research in this area adds weight to the importance and originality of this study, which provides valuable insights that may inform future teaching strategies and better equip students for patient-centred professional practice.

Methods

Results

A total of 131 subjects completed the baseline questionnaire. Of these, 85.5% were women (n = 112). The mean age was 20.44 years (SD =6.08, range = 18–51) and 90.8% (n = 119) were of Spanish nationality. Similar sociodemographic characteristics were observed at T2 (n = 120) and T3 (n = 106), with no significant changes in gender distribution, mean age, or nationality.

The baseline assessments revealed high scores for attitude (M = 50.04, SD = 3.87) and moderate scores for self-efficacy (M = 82.27, SD = 18.27). No statistically significant gender-based differences were observed for the variables attitude (Mann–Whitney U = 820; p = 0.11) and self-efficacy (Mann–Whitney U = 956.5; p = 0.48). However, a statistically significant association was found between age and attitude (Rho =0.25, p < 0.005) at baseline, whereas no significant association was found between age and self-efficacy (Rho 0.10, p = 0.25).

When the scores were compared (Fig. 1), repeated measures analysis revealed statistically significant differences between the scores obtained for the attitude variable (F = 33.25, df = 1.65, p < 0.001), indicating a large effect size (η² = 0.24). Post-hoc analyses using Bonferroni correction showed that the scores for attitudes towards communication were higher in the first year (M = 50.09, SD = 3.57) than at the beginning of the fourth year of the nursing degree (M = 47.87, SD =2.32) (Diff (1-2) = 2.22, p < 0.001). Scores were higher at the end of the training (M = 52.83, SD= 5.09) than at the two previous assessment points ((diff (2-3)= −4.96, p < 0.001); (diff (1-3) = −2.75, p < 0.001)).

When the scores were compared (Fig. 2), repeated measures analysis revealed statistically significant differences between the scores obtained for the self-efficacy variable (F = 35.59, df = 1.79, p < 0.001), with a large effect size (η² = 0.25). Post-hoc analyses using Bonferroni correction showed that scores for self-efficacy in communication in the first year (M = 82.43, SD = 17.83) remained stable at the beginning of the fourth academic year (M = 86.39, SD = 14.91), with no statistically significant differences (Diff (1-2) = −3.95, p = 0.06). At the end of the fourth academic year (M = 97.04, SD = 14.56), students perceived their self-efficacy to be higher than at the two previous points in time ((diff (2-3)= −10.65, p < 0.001); (diff (1-3) = −14.60, p < 0.001)) (Table 1).

Discussion

This study looked at the evolution of attitudes towards and self-efficacy in communication skills in a cohort of students enrolled in an undergraduate nursing degree programme.

Our findings indicate that attitudes towards communication evolve in a non-linear fashion over the course of the degree, with a decline in attitudes towards communication at the beginning of the fourth academic year, followed by an increase at its conclusion. This pattern aligns with prior research involving nursing students, both nationally (Giménez-Espert et al., 2021) and internationally (Kaplonyi et al., 2017; Smith et al., 2018), as well as studies in medical students (Givron & Desseilles, 2021; Ruiz-Moral et al., 2021). These studies observed declining attitudes towards communication as students progressed through their studies. This could be attributed to experiences of communication that are increasingly negative, challenging and demanding (Giménez-Espert et al., 2021; Ruiz-Moral et al., 2021), as well as clinical supervisors who lack the knowledge and skills to effectively teach students about communication in a healthcare context (Rosenbaum, 2017; Patidar et al., 2024). As we will discuss in more detail below, this negative perception is indicative of the ineffectiveness of the educational process (Škodová, Bánovèinová & Bánovèinová, 2018), whether due to features of the syllabus or clinical placements (Givron & Desseilles, 2021).

In the analysis of attitudes towards communication, a longitudinal pattern emerged: attitudes showed a significant decline at the beginning of the fourth academic year, followed by an improvement towards the end of the same year. According to our syllabus, this decline was associated with students’ challenging clinical experiences and a perceived lack of adequate preparation for these scenarios. During the initial years, students demonstrated more positive attitudes towards communication, which later shifted as they encountered clinical environments prioritizing technical care over patient-centred communication. An analysis of the syllabus revealed three important factors that may adversely affect students’ attitudes towards communication. Firstly, it is overwhelmingly biomedical in nature; secondly, there is an emphasis on the acquisition of technical skills, which thwarts the integration of and focus on the benefits of communication skills in everyday practice (Givron & Desseilles, 2021); and thirdly, as noted by Michael, Dror & Karnieli-Miller (2019), there is a curriculum gap during the nursing degree where students face complex communication situations during their clinical placements without the proper preparation and educational support (Giménez-Espert et al., 2021).

When we drill down into the challenges faced on clinical placements, four aspects emerge. Firstly, from an organisational perspective, the fact that clinical placements are undertaken in predominantly biomedical, technology-based and hospital-centric care settings, where the focus is on the reason for admission rather than the person, leads to the dehumanisation of care (Valenzuela-Anguita et al., 2019). Secondly, there is an inconsistency between the approaches taken in academic and clinical settings, which perpetuates the gulf between the two environments (Givron & Desseilles, 2021). Thirdly, the wide variation in the behaviour and attitudes of clinical supervisors (who serve as role models for students) is due to their lack of knowledge and skills in effectively teaching communication skills within the healthcare environment. This has a negative impact not only on the way supervisors model behaviour, but also on the quality of the patient-centred therapeutic relationship (Ammentorp et al., 2014; Lin et al., 2017; Rosenbaum, 2017). Finally, academic and clinical supervisors tend not to devote specific time or material to communication, despite it being an assessed component of clinical placements (Giménez-Espert et al., 2021).

In terms of self-efficacy in communication, our findings suggest that neither age nor the mere experience of having participated in clinical placements is sufficient to significantly improve self-efficacy. As can be seen, a significant increase in self-efficacy in communication skills is only observed after undergoing specific training in the final year. This observation is supported by Skoglund et al. (2018), who reported similar findings in second-year and final-semester students enrolled in a three-year degree programme, demonstrating that progression in knowledge and skills occurred independently of work experience or age. These findings are important because of the pivotal role self-efficacy plays in the academic and professional performance of healthcare professionals (Abusubhiah et al., 2023), mediating between theoretical and practical knowledge, behaviour and clinical experience (Abusubhiah et al., 2023). Self-efficacy also influences the acquisition, development and retention of competences (Bandura, 1995), making it a decisive factor in coping with challenges. Consequently, students with high levels of self-efficacy set higher goals and display greater tenacity in the pursuit of these goals (Michael, Dror & Karnieli-Miller, 2019). However, there is a need for further research into whether higher levels of self-efficacy lead to better overall performance (Bulfone et al., 2022).

The implications of our study are evident due to the use of a longitudinal approach. This clearly shows that attitudes towards communication and self-efficacy do not intrinsically improve with age, course progression or clinical experience. However, after receiving targeted person-centred training in their final year, students perceive their ability to be high in what they now consider to be a very important healthcare competence. When communication is treated as a cross-cutting competence in clinical placements, without specific training sessions, students perceive their communication skills to be moderate and view communication as a clinical competence of limited relevance in healthcare. This finding highlights disparities in the perception of communication as a core competence, which can be linked to the curriculum’s gaps, students’ exposure to complex communication scenarios without proper preparation, and biomedically-oriented syllabuses. However, it is important to note that the phrase “clinical competence of limited relevance” is not meant to suggest that communication is inherently irrelevant. Instead, it reflects the perception of students prior to specific training in communication, influenced by their experiences during placements and the structure of the academic curriculum. This clarion call for reform translates into a pressing need for systemic change at macro, meso and micro levels (Ryan, 2022). This entails legislative change at the macro level, institutional and organisational transformation at the meso level, and targeted attention to the individual competences and practices of future healthcare professionals at the micro level (Ryan, 2022). Understanding how attitudes towards communication and self-efficacy evolve over time provides a sound basis for curricular design in nursing education. This will help to equip students with effective communication skills that will have a positive impact on their future behaviour (Ajzen, 2011).

For this reason, and to promote practical and proactive change, we recommend that a number of elements be considered in the design of the undergraduate nursing syllabus: (1) align curriculum with the person-centred care paradigm (Ryan, 2022); (2) systematically introduce multimodal interventions with increasing levels of fidelity and difficulty (Molina-Rodríguez et al., 2023), starting with basic skills and progressing to simulation-based learning (Lo & Hsieh, 2020), to improve self-efficacy in communication skills; and (3) provide training and support to clinical supervisors on how to deal with communication skills in the healthcare setting (Rosenbaum, 2017).

Limitations

One potential limitation of this study is the involvement of students in sending reminders during the data collection process. Although measures were taken to mitigate ethical concerns, such as providing training on ethical research practices and ensuring that reminders were framed neutrally, unintended bias or perceived coercion remains. For instance, the relationship between the sender and recipient could have influenced response rates or the quality of responses (Resnik, 2018). Future research could explore alternative methods for sending reminders, such as employing automated systems or third-party personnel, to minimise these risks further and enhance data collection procedures’ robustness.

The response rate of 19.08% represents a limitation of this study despite implementing a standardised data collection procedure to encourage retention (Teague et al., 2018). Participation rate can be partially attributed to the well-documented 10% dropout rate of students between the 1st and 4th academic years in our faculty, commonly caused by factors such as relocation, changes in field of study, or academic underperformance. Moreover, during the final academic year, mobility scholarships could play a significant role in altering the composition of the student cohort, resulting in an influx of international students and the departure of some of our participants, who were consequently excluded from the study. Also, it is essential to note that T3 coincided with the students’ practicum, introducing a challenge to response rates, as students were immersed in their clinical duties and geographically dispersed. Despite our efforts, the response rate was likely affected by the demanding schedules and varying accessibility to online resources during this period.

Other limitation is the simulation was conducted as an integral part of one subject during the final year of the nursing degree, as this is a methodology which is in use and approved in the current syllabus. This precludes the use of an alternative approach, such as an experimental design, with the potential for analysis of its effectiveness in a control group, thereby increasing the internal validity of the study. Experimental designs in the form of clinical trials should therefore be used in the future.

Future research should also evaluate the communication skills acquired and their application in clinical practice, i.e., whether learners can incorporate these new behaviours in the applied context over an extended period of time (Lo & Hsieh, 2020). In addition, insight into skills retention will help in the planning of future programmes with a view to reinforcing skills through the nurses’ working lives (Cannity et al., 2021). These findings are critical for educators involved in the development of communication skills during undergraduate and postgraduate nursing training.

Conclusion

Attitudes towards communication and perceived self-efficacy do not intrinsically improve with age, course progression or clinical experience. In the absence of dedicated training sessions, students perceive their communication skills as moderate and regard communication as a clinical competence of limited relevance. However, after undergoing specific person-centred training in their final year, students perceive themselves as highly capable in a competence that is in fact highly relevant in the healthcare context.

These disparities are attributed to gaps in the curriculum, students being exposed to complex communication scenarios without the proper preparation, and biomedically-oriented syllabuses. Clinical placements pose additional challenges, including a lack of sessions focusing on communication, dehumanising environments with a focus on biomedical issues, and variations in the behaviour and attitudes of clinical supervisors.

We propose such practical measures as aligning the curriculum with the person-centred care paradigm, systematically integrating multimodal interventions with increasing levels of fidelity and difficulty, as well as providing clinical supervisors with training and support to deal with communication skills in the healthcare setting. A holistic and adaptive approach is needed in order to foster positive attitudes and effective communication skills in future healthcare professionals.

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