Nurse-patient communication strategies: A proposal of an educational video for Nursing students

Objective: to create, validate and evaluate an educational video on nurse-patient communication strategies for undergraduate Nursing students. Method: this is a methodological study with a longitudinal design and quantitative analysis. The following stages were conducted: pre-production, production, post-production and evaluation of the video by the target population. Results: five female nurses evaluated the video storyboard and indicated understanding of the subject matter, the topics addressed and the language used as adequate and pertinent to the theme. Another five female nurses considered the following as present and desirable elements: quality of the audiovisual technique employed, simulated environment, characterization of the characters, and development of the nurse-patient communication strategies The final version of the video was evaluated by nine Nursing students that presented a level of item understanding of at least 96%. The video presents the following strategies: General communication strategies, Intercultural Communication, NURSE, Tell me more, Ask-Tell-Ask, Therapeutic Communication and Communicating Bad News. Conclusion: this study portrays the creation of a video, its validation by experts and its evaluation by the target population, which indicated it as a relevant educational resource for the teaching-learning process regarding communication strategies. Both the evaluators and the target population considered that the video is a valid instrument to teach content about the nurse-patient communication strategies.

When the barriers are related to the interlocutors, they can present themselves as physical conditions that involve difficulties expressing, receiving or understanding messages, level of hierarchy, forms of approaches or social treatments, use of technical language and cultural differences. Those related to the environment emerge as interferences related to the noise of equipment alarms, precarious lighting, parallel conversation in the environment and privacy; whereas those related to the situation have to do with the relevance given to the subject matter, in terms of communication. In addition, the barriers related to the professionals' skills and expertise and to empathy are related to the rules and sequences inherent to a conversation (4,(9)(10) .
These interferences can lead to lack of information sharing among team professionals, inconsistencies in medical records, losses in the identification and monitoring of the patient's clinical signs, and compromise in achieving good results (10) . In addition to that, the professionals' and patients' safety can also be affected, as failures in communication are pointed out as one of the main causes of adverse events in the Nursing area (11) .
The National Curriculum Guidelines for the Nursing course determine the content to be taught and emphasize that communicative skills are competences to be acquired during Nursing training (12) . However, some studies point out that communication is insufficiently addressed during undergraduate Nursing studies and that, when it takes place, it is not always able to develop skills that allow the students to deal with the patients' emotions (13)(14)(15)(16) .
Thus, given the need to propose forms of innovative strategies and effective methodologies in the teaching of communication, the development, for the time being, of an educational video on communicative strategies in Nursing is justified. It is estimated that using the video in a later study may be able to measure its impact on knowledge acquisition in the area.
For such purpose, the objective of this study was to create, validate and evaluate an educational video on nurse-patient communication strategies for undergraduate Nursing students.

Method Study design, locus and period
This is a methodological study with a longitudinal design and quantitative analysis (17) . It was conducted at a public Higher Education Institution in the city of Rio de Janeiro (RJ, Brazil). The process to create the video, validate it with experts and evaluate it with the target population lasted 24 months, encompassing the period from January 2020 to December 2021.

Participants
According to the literature, there is still no consensus on the number of evaluators required for content evaluation. Some authors indicate that a minimum of five and a maximum of 10 evaluators should participate in the validation process; whereas others suggest from six to 20 participants, with a minimum of three in each group of professionals selected (18)(19) . A minimum of five evaluators was selected in this paper.
In order to select the participants for validation of the storyboard, the inclusion criteria were the following: experience in the area of nurse-patient communication.
In turn, to select the evaluators for video validation, the professionals selected were those with experience in educational and audiovisual resources. The exclusion criterion corresponded to professionals that were not nurses. The following individuals participated in this Pereira JF, Silva NCM, Sampaio RS, Ribeiro VC, Carvalho EC study: ten nurses, five with experience in the area of communication in Nursing and five with experience in educational resources in health; as well as nine students attending the Nursing course (target population), regularly enrolled in the educational institution where the study took place.
The participants were invited by means of a letter sent to the professionals' email addresses. All the participants invited accepted to take part in the research.
In relation to the invitation for the target population, the following inclusion criteria were considered: students enrolled in an undergraduate Nursing course from the fourth period onwards and aged more than 18 years old.
A total of 25 participants were invited, although only 9 accepted to take part in the research.

Data collection
Data collection, as well as the instruments used, During pre-production, the video script and storyboard were prepared (20) . In order to write the script, a scoping review on the nurse-patient communication strategies was conducted, with its protocol registered in the Open Science Framework (OSF) under DOI: 10.17605/ OSF.IO/26QMX, based on the methodology proposed by the Joanna Briggs Institute (JBI) (21) .
Scoping reviews seek to map fundamental concepts of a given area, indicating the main available evidence.
It consists of the following stages: identification of the research question, identification of relevant studies, selection of studies and mapping of the findings (22) ; and presents its protocol based on the PCC strategy (Population, Concept and Context/Scenario) (23)  Thus, after extracting the information and based on the experience of the researchers involved, the findings were compiled and categorized to write the script.
The video storyboard was prepared with the purpose of guiding and clarifying the process to create the following stages. It was developed as a chart, with a description of each audiovisual resource to be used, such as the following: scenes, animations, voiceover and background sounds (20) .
Once finished, the storyboard was forwarded to be analyzed by five female nurses with experience in the area of communication in Nursing. The instrument for its evaluation was elaborated according to the criteria suggested in a previous study (24) , which presented the Communicating Bad News).
rehearsing with the actors and making the necessary adjustments to the scenes, the video was recorded in a simulation laboratory at the educational institution, which had similar conditions to the Nursing practice scenario and favorable acoustic conditions. Subsequently, images and animations were selected, in addition to a presenter for the video.
For the development of images and animations, the legislation referring to the copyright regarding use and reproduction of resources was respected (25) . In this way, they were selected from a search in the Google Images tool, provided that they were licensed under the

Data analysis
The records made by the participants, both nurses and students, were stored in a spreadsheet in Microsoft Office Excel ® , online version, for descriptive statistical analysis (absolute frequency, relative frequency, mean and standard deviation).

Ethical aspects
This proposal is part of the research entitled In order to reduce the risks inherent to collection carried out in a virtual format, the records were deleted from the virtual platforms and shared environments, and the data were stored on a local electronic device, thus ensuring secrecy and confidentiality. It is also added that the activities developed by the authors and presenter of the video were conducted voluntarily.

Results
The process for the creation, validation, and evaluation by the target population of the educational video on nurse-patient communication strategies is presented in Figure 1. Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) guide (26) shown in

Validation of the educational video
Five nurses with experience in health education resources agreed on the quality of the audiovisual technique, the simulated environment, characterization of the characters and development of the nurse-patient communication strategies.

Final version of the video:13min52s
Evaluation of the educational video by the target -Understanding level of at least 96%; -For most of the participants (n = 6), it would be necessary to watch the video one or two times to obtain information; -For everyone, the material is of high quality.
Writing of the script: based on the scoping review and on the researchers' clinical experience (inclusion of three text books and a Master's dissertation). . Tell-Ask (28) , Therapeutic Communication (29) and
Consequently, a category referring to the general aspects of communication was created, being the one most cited across the studies (n = 7). Among other aspects, it addresses actions and recommendations to develop good quality communication (28,(32)(33)(34)(35)(36)(37) . It is noted that, in one study, specific techniques related to surgical procedures were pointed out, which have the purpose of relieving anxiety, fear and anguish, inherent to the pre-, intra-and post-operative periods (37) .
With regard to Intercultural Communication, this was mentioned in only one study, defined as the interaction between health professionals and patients from different cultural backgrounds and characterized in three stages: intercultural awareness, intercultural sensitivity and intercultural efficacy (27) .
The Communicating Bad News category was cited in two studies and consists in the transmission of unpleasant information related to the patient; information that, in most cases, involves drastic changes in the perception of the future or health prognosis (3,(30)(31) .
On the other hand, Therapeutic Communication is a strategy defined as the professional's ability to identify the patient's needs, stimulating their coping and helping them solve their problems, autonomously, as identified by the authors in a study (29) .
One of the 11 articles included indicated the NURSE, Tell me more and Ask-Tell-Ask (28) strategies, although not presenting any definition of this concepts; it only describes its functionality and presents examples.
The main information related to the nurse-patient communication strategies identified in the review is arranged in Figure 3.

Nurse-patient communication strategies
General communication aspects ( Tell me more (28) : -Learning about another person's perspectives.
Ask-Tell-Ask (28) : -Obtain due permission to present information; -Present information clearly; -Verify understanding or agreement.
Therapeutic Communication (29) : -Help the patient discover and solve their problems and conflicts, recognize own limitations, adapt to what cannot be changed and face the challenges.
Communicating Bad News (3,(30)(31) : -Provision of emotional support; -Paying attention to the environment where the receiver is; -Knowing when not to speak, knowing how to listen, resorting to an affectionate touch, establishing visual contact and expressing feelings; -Bad news should be transmitted clearly, gradually and in a detailed manner, with truth and objectivity, without punishments or omissions and without resorting to technical terms, jargons or ambiguities; -Use of protocols such as SPIKES † ; -Stimulating hope based on reality; *NURSE = Acronym for Naming, Understanding, Respecting, Supporting and Exploring; † SPIKES = Acronym for Setting up, Perception, Invitation, Knowledge, The video script was prepared based on the review findings, shown in Figure 3, and on the experience of the researchers involved, adding three textbooks (4,(38)(39) and a master's dissertation (40) that addressed the theme analyzed.

Emotions and Strategy and Summary
The storyboard was prepared from the script. In the storyboard evaluation, there was total agreement among all the nurses, who pointed out that the content allowed understanding the topic and that the language used was easy to assimilate, being adequate to the target audience. In addition, all of them revealed that the topics addressed were pertinent to the theme; however, one indicated that the video did not follow a logical sequence. Thus, the researchers met and, in consensus,

Audiovisual technique
Initial identification of the content that is intended to be shown 5 5 Lighting required to adequately watch the scenes 5 5 Sound required to hear the narrator's voice 5 5 When desired, it allows going back to any part of the scenes 5 5

Environment
The scenario reflects the Nursing care practice routine 5 5 The audiovisual material contemplates all the resources required to develop what was presented 5 5 Simplification of the images, animations and scenes does not interfere in the fidelity of what it is intended to be shown 5 5

Characters
The language used corresponds to the one employed in the Nursing practice 5 5 The presenter's voice is clear 5 5 The tone of the presenter's voice is adequate 5 5 (continues on the next page...) Rev. Latino-Am. Enfermagem 2023;31:e3858.

Nurse-patient communication strategies
The concept of communication 5 5 Applicability of communication in Nursing 5 5 Importance of communication in Nursing care 5 5 General aspects of the nurse-patient communication 5 5

Nurse-patient communication strategies
Intercultural Communication 5 5 NURSE * 5 5 Tell me more 5 5 Ask-Tell-Ask 5 5 Therapeutic Communication: Expression 5 5 Therapeutic Communication: Clarification    (14) . In this sense, a study carried out with Nursing professors shows that the development of oral expression, non-verbal communication and listening in Nursing students is favored by active teaching methodologies, such as problem-based learning, problematization and simulation experiences in healthcare settings (41,44) .
That said, using videos as a teaching-learning strategy is considered promising for the development of knowledge involving professional training (45) . Therefore, the proposal to create, validate and evaluate an educational video focused on nurse-patient communication strategies can favor the development of skills of nurses in training.
One study showed that students had greater knowledge acquisition in the area of peripheral venipuncture after using a validated educational video on the theme (30) . In addition to that, using educational videos in student training can help fix technical knowledge and enable greater preparation and increased confidence in the performance of procedures (46) .  (4,16,49) .
The Tell me more Strategy allows the professional to understand the patient's emotions; there is a stimulus for verbalization (16) . For the professional to be able to employ it, it becomes necessary to recognize that communication will be based on three levels: understanding the information, understanding how the patient deals emotionally with the content conveyed, and understanding the meaning of the information for the patient (4) .
Similarly, the Ask-Tell-Ask Strategy is divided into three stages and aims at strengthening the nursepatient bond (16) . In the first stage, Ask, the professional evaluates the patient's doubts and questions; in the second, Tell, the nurse clearly answers the information that needs to be transmitted and; in the third and last step, Ask, the patient's understanding of the information received is verified (4,16,49) .

Regarding the Therapeutic Communication
Strategies: Expression, Clarification and Validation, the focus is on helping the patient to deal with their problems, recognize own limits, adapt to the new reality and face the challenges. This strategy is divided into three groups: Expression, Clarification and Validation.
In Expression, the professional encourages the patient to verbally express their thoughts and feelings, being more employed in the initial communication stage; in Clarification, the nurse tries to understand the message sent by the patient, with the possibility of requesting comparisons and descriptions in a logical sequence and; Rev. Latino-Am. Enfermagem 2023;31:e3858.
lastly, Validation seeks to ensure that the messages transmitted have been understood, and repetition of what was informed may be requested (4,16) .
The Communicating Bad News Strategy is understood as the transmission of unpleasant information, such as negative prognoses, which lead to drastic changes in the patient's lifestyle (3) . In this case, the focus needs to be on clarity, objectivity, honesty, detail and absence of omissions, having emotional support as a sustaining element (3,31) . In order to support transmission of this information, there are guides and protocols such as SPIKES, acronym for Setting up (preparing for the meeting), Perception (perceiving the patient), Invitation (inviting for dialogue), Knowledge (transmitting the information), Emotions (expressing emotions) and Strategy and Summary (summarizing and organizing strategies) (16,50) . This has the following objectives: understanding how the patient and their family members understood the message sent, providing information according to what the patient wants/bears receiving at the moment, welcoming the reactions to the content conveyed, and establishing a care plan (51) .
In relation to the video length, the final version lasted 13 minutes and 52 seconds, within the maximum limit recommended in studies involving the development of educational resources, which would be 15 minutes.
Exceeding this time can make the experience of watching the video tiring and cause dispersion in the viewers (46,52) .
The steps used to create and validate videos proved to be adequate to obtain a final product that is accurate, reinforcing their use in research instruments on this theme. An example is using video as a trigger for a situation that involves the teaching-learning process, with regard to nurse-patient communication for undergraduate Nursing teaching (53) .
The contributions of the video produced from this study to the advancement of scientific knowledge for Nursing are linked to the provision of a reliable educational resource that can favor the teaching-learning process.
This can be considered a tool for the development of communicative skills in Nursing students, thus contributing to improving the care provided.
As limitations of the current research, the small number of evaluators in each stage of the study can be considered, even if there was a high rate of satisfactory answers regarding evaluation of the storyboard, the video and its applicability.

Conclusion
This study covered the creation process corresponding to an educational video on nurse-patient communication However, it is recommended to conduct studies that assess changes, which can be attributed to the educational video, in the students' knowledge acquisition in terms of nurse-patient communication strategies.