Effect of early clinical exposure on communication, history-taking, and nursing diagnosis skills: A brief report

Abstract

BACKGROUND:

Clinical education is a key component of the nursing curriculum. Therefore, it is necessary to use new methods to learn basic clinical skills better. This study examines the effect of an early exposure educational program on first-year nursing students’ communication, history-taking, and nursing diagnostic skills.

MATERIALS AND METHODS:

Using a census method, this brief report included all first-year students of the Dezful University of Medical Sciences in two academic semesters in 2023. An early exposure program was implemented for one group of students. In the second semester, both groups’ communication skills, history-taking, and nursing diagnoses were measured in the clinical environment using a checklist. Pearson’s and Spearman’s correlation coefficients were used in this study. Data were analyzed using the IBM SPSS version 16 (IBM Corp., Armonk, NY, USA) with a 95% determination level.

RESULTS:

Communication skills (35.6 ± 4.87, 23.73 ± 2.28), patient history-taking (14.03 ± 1.158, 8.47 ± 1.59), and nursing diagnosis (8.03 ± 1.31, 3.26 ± 1.86) were significantly higher in the intervention group than in the control group. In the intervention group, there was a significant and positive correlation between communication and nursing diagnosis (r = 0.366), communication and history-taking (r = 0.433), and history-taking with nursing diagnosis (r = 0.523).

CONCLUSIONS:

Based on the positive results of this study, nursing managers should provide the possibility of implementing methods, such as early exposure, by creating a suitable platform.

Introduction

Clinical education is a main part of the nursing curriculum, and approximately 50% of the nursing education curriculum is dedicated to this topic. Without clinical education, the training of competent and efficient nurses is a distant goal, and any problem in clinical education can undermine their effectiveness. Studies conducted in Iran have shown a relatively deep gap between the nursing education process and clinical practice. Therefore, current clinical education fails to provide students with the necessary means to prove their abilities and clinical skills, resulting in a lack of desired efficacy.[1]

In this regard, various studies in non-Iranian studies also indicate that some basic skills of nursing students, such as nursing diagnosis, communication, and history-taking, are facing problems. Many nursing students and new nurses struggle to master and improve their skills in history-taking, with their performance often being unsatisfactory. Taking a patient’s health history into account is crucial for nurses to prioritize care and choose the best interventions for improving patient outcomes.[2] Although communication is crucial in healthcare and can enhance care quality, minimize errors, and support teamwork, nursing students often face communication challenges.[3] Research has indicated that nursing students face challenges when converting patients’ problems into nursing diagnoses, setting diagnostic goals, and prioritizing diagnoses.[4]

Historically, traditional teaching methods involving passive knowledge reception have faced challenges in meeting modern professional demands. Thus, nurse educators are now incorporating diverse teaching approaches like problem-based learning, patient simulation, case-based learning, and mentors to enhance clinical nursing education quality and efficiency. Despite the implementation of various teaching methods in clinical settings, debates continue regarding their impact.[5]

Changing teaching methods is necessary to enhance students’ clinical performance in nursing education. Current curricula are advancing, but teaching approaches must also evolve. It is important to adapt to new methods for better learning outcomes. Embracing various contemporary methods beyond traditional lectures is essential. Effective study strategies can help nursing students succeed academically and professionally.[6]

One of the latest teaching approaches that is being highly acknowledged nowadays is early exposure. Early clinical exposure (ECE) combines classroom and clinical learning during students’ academic years.[7] ECE offers a clinical context to basic science education and promotes early engagement in the healthcare field, which motivates and guides students towards professional growth.[8] Several research studies have demonstrated the positive impact of this teaching method on students, helping them acquire clinical skills like phlebotomy and basic life support[9] as well as understand fundamental subjects such as neuroanatomy[10] and nervous system physiology.[8]

The first year of nursing education is the cornerstone of preparing students to enter the clinical environment, so preparing them to acquire important skills such as patient communication skills, history-taking, and nursing diagnoses that facilitate providing an appropriate care plan for patients is important. On the other hand, no study has been conducted in the field of examining the effect of early exposure on nursing diagnosis skills, history-taking, and communication in Dezful nursing students, so this study was conducted in this direction.

Materials and Methods

Study design and participants

This was a brief report. Because Dezful University of Medical Sciences accepts nursing students twice in one academic year, using the census method, all entries from one academic year in 2023 were included in the study.

Study participants and sampling

Students who were studying at the university at the time of intervention and did not apply for transfer to universities in other cities to continue studying in the second semester were included in the study. Failure to attend more than two training sessions led to the removal of students from the intervention group.

Data collection tools and technique

Data collection tools included demographic information (age, gender, and place of residence) and three checklists to assess communication skills, nursing diagnosis, and patient history.

The checklist developed by Saboori et al. (2010)[11] was utilized to assess students’ communication and history-taking skills. The checklist consisted of 14 items related to communication skills (score range: 14–42) and 5 items related to patient history-taking (score range: 5–15). The scoring guidelines were as follows: Acceptable = fully demonstrated the behavior (score 3), partially acceptable = did not fully demonstrate the behavior (score 2), unacceptable = did not perform the behavior (score 1). Higher scores indicate better skills.

The reliability and validity of the instrument were 0.78 and 0.80, respectively.

Another checklist that was used to evaluate nursing diagnosis skills was related to Florin et al. (2005).[12] Scores were given as “yes” (score 1) or “no” (score 0), resulting in scores ranging from 0 to 14. Higher scores indicate better nursing diagnostic skills.

The reliability and validity of the instrument were 0.79 and 0.79, respectively.

The clinic attendance program was implemented for students entering the first half of the academic year, but no intervention was performed for the students entering the second half of the year.

The attendance schedule of the students in the clinic was compiled into five groups of four and one group of three students and sent to the instructors and students. Based on the class list, the students were grouped. However, students could opt out of the group if they did not want to be in a group. We attempted to include both boys and girls in the groups. Each group attended the specialized clinic twice a week, from 8:00 a.m. to 12:00 p.m., for 2 weeks according to the specified schedule. An orientation session for students and instructors was held before entering the clinical environment. In the presence of the students, the instructors communicated with the patient, collected the patient’s history, and presented the nursing diagnoses to real patients. Next, the students performed the steps performed by the instructor on the next similar patient. After completing these steps, the instructor provides feedback to the student and reminds him of the positive and negative points.

Since first-year nursing students do not have the subject of diseases in their curriculum, to facilitate the learning process, the instructors chose specific and limited cases such as patients with diabetes, asthma, and high blood pressure. Before entering the clinic, the students could read the mentioned items.

The Nanda Nursing Diagnosis Handbook in Persian[13] and the Iranian Nursing Diagnosis[14] book were made available to help students provide nursing diagnoses.

At the beginning of the second semester and at the same time as the students entered the internship, the trainers evaluated the communication skills, history-taking, and presentation of nursing diagnoses in the students of both groups. To prevent delay in teaching these skills to the students of the control group during the internship, the evaluations were tried to be done on the first and second days of the internship.

Statistical analysis

Descriptive statistics, such as mean, standard deviation, and frequency tables, were used to describe demographic variables, communication skills scores, history-taking, and nursing diagnoses. Pearson’s and Spearman’s correlations were used to assess the relationship between the variables. The data were analyzed using IBM SPSS version 16 (IBM Corp., Armonk, NY, USA) with a 95% determination level.

Ethical consideration

The authors confirm that all patient consent forms have been completed. The code of ethics was obtained from the Dezful University of Medical Sciences (IR.DUMS.REC.1402.010). Data collection was conducted in accordance with the Declaration of Helsinki.

Results

Most participants in the intervention (60.6%) and control (56.5%) groups were male. In both groups, most participants (51.5% and 78.3%) were dormitory residents, and the intervention (81.8%) and control groups (91.3%) constituted the largest age group in the age group of 18 to 23. Table 1 summarizes the results of the demographic variables.

Table 1.

Frequency and percentage of demographic variables in the intervention and control groups

Variable				Intervention Group				Control Group
				Frequency		Percentage		Frequency		Percentage
Sex		Male		20		60.6		13		56.5
		Female		13		39.4		10		43.5
Age		18–23		27		81.8		21		91.3
		24–29		4		12.1		2		8.7
		30–35		2		6.1
Residence		Dormitory		17		51.5		18		78.3
		Family		16		48.5		5		21.7

The mean communication skills, history-taking, and nursing diagnostic scores were higher in the intervention group than in the control group. The results are presented in Table 2.

Table 2.

Mean communication, history-taking, and nursing diagnosis skills scores in the intervention and control groups

Variable		Intervention Group		Control Group
		Mean±SD
Communication		35.66±4.87		23.73±2.28
History-Taking		14.03±1.158		8.47±1.59
Nursing Diagnosis		8.03±1.31		3.26±1.86

The results of the study showed a positive but weak relationship between communication scores, history-taking, and nursing diagnosis in the intervention group. However, in the control group, the results were not significant. Table 3 shows the results.

Table 3.

Correlations between communication, history-taking, and nursing diagnosis in the intervention and control groups

Intervention Group						Control Group
Communication and nursing diagnosis		Communication and history-taking		History-taking and nursing diagnosis		Communication and nursing diagnosis		Communication and history-taking		History-taking and nursing diagnosis
P=0.042		P=0.012		P=0.004		P=0.509		P=0.888		P=0.655
R=0.366**		R= +0.433*		R=0.523*		R=0.045		R=0.290**		R=0.134**

Spearman test*. **Pearson test

Discussion

This study aimed to determine the nursing diagnosis, history-taking, and communication skills of first-year nursing students after ECE.

The results of the study showed improvement in first-semester nursing students’ communication skills, history-taking, and nursing diagnoses after the implementation of the early exposure program. In this regard, the results of another study showed that the use of ECE can meet the desired goals in its implementation.[15] Another study demonstrated that when early exposure is provided in primary care centers, outpatient clinics, and hospital departments that closely resemble the clinical environment, students will gain a better understanding of various aspects of patient care.[16]

The results of the study showed that the nursing diagnostic skills of the students improved after early exposure compared with the control group, although this increase was not high. Most of the students who participated in one study stated that online education was not effective or productive and that they had difficulty diagnosing the disease. In addition, the nursing process course should be presented face-to-face.[17] Another study conducted with nursing students showed that web-based training is less effective than face-to-face training.[18]

This study highlights the importance of real communication with the patient to provide a proper nursing diagnosis. In one study, the early exposure method was found to enhance students’ patient communication skills.[19] Another study demonstrated that face-to-face training is more effective than virtual training for improving patient communication learning.[20] The reason for this improvement may be that the presence of a patient in teaching a student can contribute to real and deep learning. Learning communication skills can be strengthened by creating an opportunity to practice and feedback to students. The lack of significant improvement in students’ scores in this dimension may be related to the presence of the patient’s family members during communication. On the other hand, the presence of other patients in the patient’s room and the crowded room may have harmed the student’s focus on important points related to effective communication.

The results showed that history-taking skills improved following the early exposure program. In this regard, one study showed that an early exposure program for third-year medical students in the hospital before the internship period improved their knowledge of history-taking.[21] Students’ scores in this dimension did not increase much after early exposure, which can be related to a lack of experience. Eren and Turkmen (2021) reported that first-year students are stressed during patient interviews. Students are concerned that they will not be able to answer questions about patients’ diseases. These results may be related to a first-year nursing student’s limited clinical experience and knowledge.[22]

Another finding of this study was a weak but statistically significant positive correlation between communication, history-taking, and nursing diagnosis. Patient care needs are one of the first steps in the nursing care process, so effective communication increases patient trust and respect and collects reliable medical history data.[22] In addition, given that history-taking provides data that supports nursing diagnoses, nurses must thoroughly assess the patient because incompletely collected information can influence a list of incorrect and inadequate diagnoses of the patient’s condition, which motivates failure in other steps of the care process.[23] Therefore, it can be concluded that effective patient communication motivates correct information and appropriate nursing diagnosis. The low correlation score between the items mentioned in the present study is attributed to the weak ability of students to communicate with the collected information, prioritize the information, and have a comprehensive view of problems.

Limitations and recommendations

This study had some limitations. The coach’s skill and its potential impact on the results were not considered. In addition, because the evaluation of students was postponed to the next semester, the time gap created may have affected the results (due to poor recall of information and learning done during the early exposure program). Because the total number of nursing students admitted to the Dezful University of Medical Sciences was low, this small sample size could affect the generalizability of the results. Therefore, we suggest that the program be conducted in a larger community of students and with trainers who have been trained before the implementation of the program.

Conclusion

An ECE program can help nursing students improve their communication skills, history-taking, and nursing diagnosis.

One of the important tasks of the nursing education system is to provide appropriate education and training for students who can provide the necessary care for patients with top quality. Therefore, by involving more students in learning and trying to institutionalize basic care skills, changing from traditional teaching methods to new methods can be an effective step in this field. Therefore, nursing managers should be able to implement methods such as early exposure by creating a suitable platform.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Dezful University of Medical Sciences.