Abstract
Despite longstanding recognition of their value, soft skills have been historically undervalued in nursing education compared to technical clinical competencies. The COVID-19 pandemic created a unique shift in nursing education, requiring periods of online instructional delivery that highlighted student needs for soft skills development. This article explores how an undergraduate community nursing simulation course adapted to a remote, discussion-based format during the pandemic, providing an unexpected but powerful space to cultivate essential soft skills. We use reflective observations to identify challenges in areas such as person-centered care, emotional sensitivity, accessible communication, and receiving feedback. The experience highlighted the need to rebalance curricula to more deliberately integrate soft skills development alongside technical training. Recommendations include suggestions for structuring simulations, utilizing standardized patients, and tailoring feedback to foster a resilient, communicative, and well-rounded nursing workforce.
Keywords
Implications for Practice, Education, Research, or Policy
Soft skills are core competencies that must be integrated across the nursing curriculum to ensure graduates meet requirements for safe, ethical practice. Simulation-based learning has been overlooked as a setting in which to include soft skill development. Formal evaluation of soft skills, particularly within a Competency-Based Education (CBE) model, ensures students develop the abilities required for comprehensive, patient-centered care.
Can you identify with the following experience? You received health-care services from a well-regarded medical provider who conducted a thorough evaluation, yet you felt uneasy when leaving the office. The provider rushed through the visit and looked at the computer the whole time. You felt scolded for your habits and your concerns were brushed side. The jargon-filled explanation of your condition left you confused and anxious. Though you received treatment, the encounter felt sterile and lacking in human connection. You wonder, are clinicians taught how to interact with people, or do they only learn the technical side of health care?
The American Association of Colleges of Nursing, a major accreditor of nursing programs, published the The Essentials: Core Competencies for Professional Nursing Education in 2021. The release of the Essentials signaled a fundamental shift in nursing education by moving from a content-based model to a competency-based framework centered around 10 distinct domains of professional nursing practice (American Association of Colleges of Nursing, 2021). This revision elevates the importance of soft skills by embedding competencies like communication, empathy, and social determinants of health directly within domains such as Person-Centered Care and Professionalism, underscoring that relational abilities are now foundational, not supplementary.
Although the Essentials recommend including skills like communication and compassionate care as core concepts in nursing education curricula (American Association of Colleges of Nursing, 2021) accreditors have required no minimum number of hours or required evaluations for these topics (Gutiérrez-Puertas et al., 2020). From a clinical as well as a simulation perspective, communication and empathy are often aims of practice but can take a back seat to technical skills, especially when time is a factor.
Suddenly, due to COVID protocols for distancing established in March 2020, hands-on technical skill practice became temporarily impossible for many institutions. During this shift to remote teaching, an undergraduate community nursing course used synchronous video conferences for discussion-based simulations, replacing hands-on scenarios with simulated interviews, collaborative planning for interventions, and patient education. From this experience, we learned what we had long suspected: students need more opportunities to learn abstract emotional and intellectual skills. We also realized that we, as faculty, have much to learn about teaching these skills.
Purpose
The purpose of this article is to describe our experiences understanding students’ needs for development of emotional and intellectual skills like communication (effective and empathetic), information seeking, knowledge appraisal, critical thinking, and intervention planning, also known as soft skills (Sancho-Cantus et al., 2023). These experiences happened during our time instructing a discussion-based community nursing simulation course in an urban university in the United States. This course moved to online during the pandemic. Along with describing our experiences, we will advocate for thoughtful integration of soft skills and their development in nursing curricula.
Why Soft Skills?
The way we label skills can have unintended consequences. Referring to technical competencies as hard skills implies that these skills are dominant, and perpetuates preferential emphasis on this skill set. While soft skills are less visible and often less valued, they are no less important (Goldman & Wong, 2020). Soft skills are not just an enhancement to care; they are essential to nursing practice. A nurse with excellent technical skills knows how to administer a medication, but a nurse who also has strong soft skills knows how to communicate the purpose of the medication to the patient, listen to their concerns, and recognize non-verbal cues that might indicate an adverse reaction. This human element is what allows nurses to build a trusting relationship with clients. Individual interpersonal skills impact our therapeutic communication skills, which include active listening, asking open-ended questions, clarification, validation, use of silence, and non-verbal communication. Genuine human connection and empathy are vital to understanding patients’ experiences, building trust, and conducting effective intervention planning.
Other soft skills such as critical thinking, adaptability, and lifelong learning are also essential for highly effective nursing practice (Bajjaly & Saunders, 2021). Critical thinking, however, is often miscategorized as a solely hard skill. While it involves the technical ability to analyze a patient's situation, synthesize information from various sources, and make sound clinical judgments, it is truly a comprehensive skill set that emerges from the fusion of both technical and interpersonal competencies. These soft skills are essential because they allow nurses to gather crucial subjective data—listening to a patient's story and observing non-verbal cues, which in turn informs and refines clinical judgments.
We recognize that using the term soft skills can undermine their critical importance in both personal and professional success. Soft skills are, in fact, core competencies crucial for success in communication, teamwork, problem-solving, and leadership—and thus foundational to a resilient workforce (Widad & Abdellah, 2022). Even so, this article will continue to use the potentially inaccurate term soft skills because of its general recognizability.
Using Simulation-Based Learning to Teach Soft Skills in Nursing
Simulation is an excellent opportunity for students to use realistic, yet controlled, recreations of clinical experiences to practice a wide range of clinical skills (Bajjaly & Saunders, 2021). In this section, we provide a brief description of common simulation practices. Scenarios typically consist of three phases: pre-brief, active scenario, and debrief (see Table 1).
Simulation Stages.
During the pre-brief, faculty provides students with scenario details including the patient's history, the clinical setting, and expectations for the simulation exercise. In the active scenario, students perform nursing care while faculty guide the narrative based on the students’ actions. The value of this phase is in observing how students navigate the human element of patient care, from using therapeutic communication techniques to demonstrating empathy. After the scenario, the faculty-guided debrief provides a structured opportunity for students to reflect on their communication choices, and receive targeted feedback. This reflective practice helps solidify the link between theoretical knowledge and the practical application of soft skills.
Proper performance of technical skills dominates most clinical courses and draws the majority of student and faculty attention. In our experience, evaluation of students’ hands-on skill performance takes priority and soft skills are only addressed if time allows. Though clinical course objectives refer to therapeutic communication and establishing rapport, students (and some faculty) struggle to understand what these objectives mean or how they look in practice. Unsurprisingly, students often need significant improvement in these areas. In our suddenly online community nursing simulation course, the increased time for soft skills practice was an exciting opportunity.
Experiences in an Online Discussion-Based Simulation
The scenarios we led in this online course were a mix of simulated telehealth visit via video conference and situation-based cases (e.g., discharge planning and creating a care plan for a child in a school setting). As we ran these scenarios scores of times starting in 2020, we noticed common needs, or themes, in soft skill development that encompassed several dimensions of soft skills. In the following sections, we describe situations and examples that illustrate these opportunities for soft skill development. These themes address dimensions of person-centered care (including empathy and emotional cues), adapting care based on needs, and using accessible language. We also describe themes of decision-making, and accepting and utilizing feedback.
Person-Centered Care
Empathy and Emotional Cues
Students often prioritized action-based intervention and correction of patient behavior over using empathy and perceiving patient distress. Our simulated patients often display deviation from recommended health promotion habits due to difficulty accepting or managing chronic conditions. Students often struggled to educate patients empathetically about medication adherence and lifestyle changes, frequently allowing judgmental reactions to overshadow opportunities for supportive communication.
Students also displayed discomfort while identifying and addressing potentially sensitive topics (e.g., mental and behavioral health, sexual health) or avoided these topics altogether. In one scenario, students conducted a telehealth home visit with a young adult client after a new ileostomy placement. The client was in psychological distress and struggled with the changes to their body. We found that many students, instead of addressing the client's psychosocial needs, pivoted to evaluating the client's knowledge of stoma care, a skill in which the students had more confidence. Addressing the client's psychosocial concerns related to their new diagnosis and body image were one of the learning objectives (see Table 2), yet many students avoided these issues. Whether students were unable to perceive the patient's emotional state or chose to avoid their findings, we noted opportunities to strengthen delivery of emotionally sensitive care.
Description of Ostomy Care Simulation.
Adapting Care Based on Needs
Person-centered care involves understanding and addressing the unique needs of each patient and requires a combination of communication, empathy, and critical thinking skills. The concept is woven throughout the nursing curriculum and though students describe understanding this concept in theory, there can be a disconnect between theoretical knowledge and application. Interviews within discussion-based scenarios allow students to learn about their patient and be flexible within an evolving situation. These situations call for creativity, resource-seeking behaviors, critical thinking, and empathy. We saw opportunities to improve students’ use of these problem-solving skills, evidenced in the extensive support we found students requiring while anticipating patients’ individual needs and searching for appropriate resources.
Using Accessible Language
Students frequently struggled to provide clear and concise patient education, often overwhelming clients with excessive information or medical jargon. Medication information was particularly difficult for most; they demonstrated difficulty connecting pharmacokinetics to disease processes, struggling to explain medication actions in simple terms. Students nearing graduation are expected to possess these skills in order to provide education to patients managing multiple comorbidities. Over the span of the course, some students adapted their language with prompting, but others did not. We also noted frequent gaps in students’ critical thinking about the purpose of specific medications in managing patient conditions.
Decision Making
During simulations, students are expected to collect and analyze data to make decisions and perform critical thinking to plan their next interventions. Uncertainty during in-person scenarios can lead students to inappropriately prioritize hands-on skills over critical decision-making because the hands-on skill is more familiar. We noted that purely discussion-based virtual simulations can foster autonomy by forcing students to practice analysis and decision-making. However, in these scenarios, students often hesitated to make any decisions at all, resulting in stalling or silence. Students were particularly uncertain about how much initiative they were expected or allowed to take, leading to missed opportunities for assessments and intervention planning.
Accepting and Utilizing Feedback
Students’ reactions to constructive feedback from both faculty and standardized patients during debriefing were mixed. Standardized patients provided valuable insights into the emotional impact of interactions and pointed out when students were successful or missed an opportunity to make them feel seen and heard. While some students used feedback for improvement, others became defensive and disengaged from the experience. Some students argued that effort alone should suffice, insinuating that receiving feedback violates the terms of psychological safety important for a simulation environment. We found this perspective particularly challenging because we aim for students to understand that while effort is important, the goal of simulation is to continuously refine skills. These ranges in response showed us the need for faculty adaptability; quickly tailoring feedback approaches to support all students effectively.
Discussion and Implications for Nursing Education
Nursing simulation experiences provide an excellent environment to develop essential soft skills (Widad & Abdellah, 2022).We recommend that students and faculty approach soft skills with the same rigor as technical skills. The following recommendations aim to provide practical strategies and insights for nurse educators to foster a learning environment that prioritizes and nurtures soft skills.
Simulation Preparation
In our experience, students often perceive pressure to individually accomplish all stated learning objectives during their short time in a scenario. We recommend scenarios to be written without excessive focus on the number of tasks completed, to support students’ experimentation with skills like effective communication and independent decision-making. Scenario content should align appropriately with time available and intentionally include room for soft skills practice. Simulation facilitators should emphasize quality of skill practice over number of skills performed.
Low levels of anxiety have been associated with more optimal performance among nursing students performing in a clinical simulation setting (Al-Ghareeb et al., 2019). In our experience, students appreciate structure during pre-briefing, because often they become anxious facing an unfamiliar scenario without the comfort of a familiar hands-on routine, and are more unlikely to experiment with soft skill development. By mitigating anxiety, faculty can create a space where students feel secure enough to experiment with their therapeutic communication style, ethical decision-making, and independent judgment (Rudolph et al., 2014). Thus, we recommend faculty provide purposeful transparency when presenting students with scenario objectives. We recommend that learning objectives be clearly defined, manageable, and based on both the learning environment and learner characteristics. Students should receive clear instructions about expectations for applying theoretical and abstract concepts. Faculty may even need to be explicit about the types of soft skills students might practice and emphasize the expected level of critical thinking applied to the scenario.
We recognize that effective pre-briefing requires a careful balance between structure and freedom; while structure can reduce student anxiety and build confidence, excessive structure can hinder development of soft skills like prioritization and critical thinking (McDermott, 2020). To provide an environment conducive to soft skill development, during pre-brief faculty should stress the integration of technical content with soft skill development, clearly outlining skills expected to be performed without directing students to specific outcomes. In our experience, excessively long pre-briefing periods can run into the time set aside for the scenario, sacrificing time for soft skill practice and debrief analysis. Faculty can reduce pre-brief time by stressing students’ accountability for independent preparation.
Incorporating Standardized Patients
We encourage use of standardized patients for soft skills development whenever possible. Standardized patients are professional actors carefully trained to accurately and consistently portray patients of varying demographics and diagnoses in simulation scenarios. They provide an invaluable resource for developing and evaluating soft skills, offering immediate, authentic feedback from a patient's emotional and relational perspective on the student's communication and empathy.
Standardized patients are invaluable for practicing communication skills involving human responses that we want our students to recognize and address (Knight & Prettyman, 2020). They provide realistic, high-fidelity experiences (McDermott, 2020) that allow faculty to observe and analyze student performance. To maximize the impact, students should understand the standardized patient role, their training, and the feedback process. Faculty and facilitators should check in with the standardized patient before the scenario to provide objectives and expectations. Professional standardized patients are wonderfully adept at customizing their approach as long as we inform them about our needs.
Students can receive valuable feedback from standardized patients that simulate the viewpoint of the patient (George et al., 2022). This feedback can initiate effective debrief discussions for developing effective relational, analytical, and planning skills. While faculty can comment on clinical accuracy and give their objective assessment of a student's communication skills, the standardized patient is better positioned to state authentically how they felt from the patient's perspective. For example, the standardized patient may state, “When you avoided eye contact, it made me feel like a task, not a person.” This feedback is invaluable for initiating a discussion about relational skills.
Feedback from standardized patients, as compared to feedback from faculty or peers, could potentially be a less threatening entry point for discussing sensitive topics like communication style and empathy, especially when students might react negatively to direct faculty feedback. Because we understand the vital role of constructive feedback in continuous learning, professional development, and confidence (Mrayyan et al., 2023), we welcome any additional strategies to initiate discussion about potentially sensitive topics like communication style, tone, perceived bias, and use (or lack) of empathy.
While we recommend the use of standardized patients whenever possible, we recognize the significant financial investment required for training, compensation, and maintenance of a reliable roster of these trained professionals. This highly effective teaching tool may not be widely accessible to all nursing programs due to the financial requirements.
Generational Considerations
We recommend that educators incorporate understanding of students’ diverse learning styles into their teaching methods. For example, many younger students value experiential and explorative activities (Riley & Nicewicz, 2022) like working with and receiving feedback from standardized patients in real time. These younger students may also struggle to utilize constructive feedback effectively due to prior experience in environments that emphasize positive reinforcement over critical feedback, making traditional critiques feel harsh and demotivating. Their social habits may have accustomed them to instant gratification and validation, making them more sensitive to criticism (Miller & Mills, 2019). To effectively support younger learners, educators must recognize that while feedback may still be straightforward and candid, it should also be actionable, with clear utility, so that students do not simply feel criticized.
Improvisational games are other strategies to tap into younger generations’ social nature and may be successful strategies to teach and practice soft skills in a safe environment (Riley & Nicewicz, 2022). For instance, the game “Yes, And…” in which one participant makes a statement and the next must affirm it, may be particularly effective. This simple structure engages students in practicing core communication skills like active listening, validation, and collaborative problem-solving in a low-stakes environment (Riley & Nicewicz, 2022). In our experience, these types of exercises are most effective in groups with high levels of participatory buy-in. We also want to acknowledge that while these generational trends provide a useful lens, it is crucial for educators to avoid overgeneralization and remain attuned to the diverse needs of individual students.
Evaluation
Historically, nursing educators have not consistently evaluated soft skills performance (Gutiérrez-Puertas et al., 2020). We recommend that soft skills be evaluated purposefully using a combination of approaches including student self-evaluation, faculty evaluation, and group reflection activities.
Building bridges between the didactic and clinical/simulation experiences is a strategy that is often underutilized in nursing programs (Fey & Morse, 2024). Simulation experiences as mechanisms to foster practice-based competency development are an appropriate approach, and educators anticipate an expansion of simulation-based learning across nursing education settings in response to the Essentials (American Association of Colleges of Nursing, 2021; Lewis et al., 2022). Competency-based education (CBE) puts students at the center of the learning experience. This student-focused approach involves building skills step-by-step through repeated practice and regular feedback in different settings, ensuring that students are competent at each stage of the curriculum. (Gonzalez & Kardong-Edgren, 2017; McGaghie et al., 2015).
Soft skills should be an integral part of nursing competencies. Evolutions in health care, which increasingly recognize the importance of concepts like trauma-informed care (Grossman et al., 2021) and influences of social determinants of health (Abiri et al., 2025), call for a more holistic approach than the traditional medical-surgical priorities. Instead of confining relational skills like therapeutic communication to behavioral health and other non-medical-surgical courses, they should be integrated into all courses. In our experiences, both students and faculty place heavy priority on courses that teach technical skills and prepare students to pass the national licensure examination, which are often medical-surgical or critical care courses. These courses are often overlooked as excellent settings to teach and reinforce soft skills. We should be clear that interpersonal, relational, and critical thinking skills are priorities in all settings because they work in tandem with all other necessary skills.
Multidimensional simulations that incorporate various technologies and integrate both technical and soft skills can support CBE by providing realistic practice environments where students can apply their knowledge and skills and receive immediate feedback. These simulations foster collaboration and expose students to diverse clinical scenarios, including rare and critical situations like end-of-life or palliative care, in which skills like empathy contribute significantly to positive outcomes (Sinclair et al., 2017). As an example, we routinely run a technically and emotionally complex end-of-life simulation in our center. In the scenario, we expect students to manage technical skills (e.g., pain assessment and management) while simultaneously using soft skills to build a genuine connection with the patient and family. Students have opportunities to practice offering comfort to the patient and family, hearing their concerns, and ensuring the patient's dignity. Unlike in a fast-paced emergency scenario that values speed, this scenario requires the nurse's compassionate presence and ability to recognize and respond to the patient's needs as a whole person. A major goal of this experience is to teach students that the simple act of being present and attentive to a patient's final needs is just as important as any technical skill.
Students should also be aware, for their own self-interest, that nursing employers value and seek to hire candidates with strong soft skills. Employers have noted challenges with new nurses bridging the gap between theoretical knowledge and practical application in the clinical setting (Bajjaly & Saunders, 2021). Effective nurses possess a comprehensive skill set that goes beyond technical proficiencies. While technical skills may help new graduates pass their exams and enter the workforce, they are not sufficient for the complexities of real-world nursing. Nursing education must evolve to emphasize the importance of these skills to ensure that new graduate nurses are well-rounded and prepared for the realities of patient care.
Conclusion
In the ever-changing landscape of health care and a world brimming with uncertainty, nurses must be adept at navigating challenging situations. Soft skills are not supplementary; they are foundational for nursing excellence and should be more wholeheartedly integrated into clinical education as core competencies. We believe that a committed approach to soft skills fosters an environment of open communication, curiosity, and willingness to learn. In such an environment, students and faculty are empowered to dive deep into learning and to engage and ask insightful questions that explore problems rather than simply seeking out the right answers. Simulation provides such a safe space to experiment and venture beyond one's comfort zone. We must remind learners that the journey of learning is as important as the destination. By championing the importance of soft skills and fostering an environment where these skills are actively practiced and valued, we can better prepare nurses to navigate the complexities of modern health care and deliver exceptional patient care.
Footnotes
CRediT Author Statement
PV contributed to conceptualization, writing—original draft, and writing—review and editing. AW contributed to conceptualization, writing—original draft, and writing—review and editing.
Author Contribution(s)
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical Considerations
This article does not contain any studies with human or animal participants.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
