Innovative Communication Learning: Combining TED Talks and Reflective Writing for Nursing Students

Abstract

Background

As educational programs compete with online and open courseware, TED (Technology, Entertainment, and Design) Talks provide meaningful complementary content that can be easily integrated into curricula.

Purpose

Evaluate an innovative approach to the standard lecture by combining media mixture with reflective writing.

Methods

Undergraduate nursing students were asked to view a TED Talk and write a brief narrative reflection as part of their preparation for a communication class.

Results

The video and reflective writing assignment were completed by 23/25 (92%) of students. Qualitative analysis of the reflective writing identified three primary themes: Communication as a Foundational Competency, Importance of Empathy, and Professional Role Development.

Conclusion

This illustrative talk and narrative exercise provided an interactive learning experience for novice nurses that served as a compelling means to critically reflect on effective health-care communication skills, prior to entry into practice.

Keywords

lecture qualitative research nursing students communication flipped classroom

According to Adult Learning Theory, adult learners are most interested in gaining knowledge with immediate relevance and value to their professional or personal lives (Illeris, 2018; Knowles, 1984). In higher education, learners are motivated to gain knowledge that has immediate relevance in their personal or professional lives. According to Experiential Learning Theory, learning is the process whereby knowledge is created through the transformation of experience; knowledge results from the combination of grasping experience and transforming it (Kolb & Kolb, 2009). This may be especially true for millennial learners. Although general cut-off points with age are not an exact science, according to the Pew Research Center (2020), people born between 1981 and 1996 (who are ages 24 and 39 in 2020) are considered Millenni-als. People born in 1997 or after are part of the post-Millennial era now recognized in pop culture and journalism as Generation Z (Pew Research Center, 2020). Millennials have developed as “digital natives” with exposure to information technology from a very young age. Over the course of their lifetimes, millen-nials have been subject to several modes of edutainment including the omnipresence of online technology and novel modes of communication, including cell phones, texting, e-mail, and many social media platforms (Roberts, Newman, & Schwartzstein, 2012). As digital natives have matured over the past decade, students ‘attentional capacities per se have not changed, but rather their acceptance of, and preference and tolerance for, traditional lectures and educational formats have changed (Prensky, 2010).

Across age groups, educators have developed innovative ways to “flip” or restructure the classroom to engage young learners (Bergmann & Sams, 2012). At the college level, professors who adopt the flipped classroom model assign lecture or instructional content as homework, thereby shifting from a teacher-centered approach to one that emphasizes student-centered discussion (Roehl, Reddy, & Shannon, 2013). The combination of engaging media mixture and experiential practices allow new knowledge to be brought to life in flipped classrooms (Friesen, 2011).

The standard lecture, often augmented with slides, is typically linear and non-interactive (Friesen, 2011). As a pedagogical form, lectures may be less appealing and effective for today's millennial learners.

The video encouraged students to trust in the expression and value of their own humanity, both verbally and non-verbally to connect with patients and fulfill that elusive yet vital goal of empathizing with patients.

In a recent retrospective study analyzing 1,735 slide presentations in nursing school curricula, classroom presentations often fell short of providing best educational practices that engaged students (Nowak, Speakman, & Sayers, 2016). Other educators question how to create a way to deliver all of our programs without physical facilities or buildings (Shushok, 2014). One option is for educators to integrate free online education program products into their courses such as Massive Open Online Courses (MOOC) and the Khan Academy (2011). Embracing the power of online platforms enables educators to supplement or replace didactic teaching by embedding more interactive content into courses.

An additional means to amplify interactive course content is to dedicate more time for learner reflection. Researchers have demonstrated that reflective writing leads to improvement of student empathy (Chen & Forbes, 2014). Including more reflective writing during the educational process promotes reflection for the purpose of “learning from practice, for practice” (Epp, 2008, p. 1379).

As educational practice relies less on rote memory and migrates away from outmoded chalk and talk lectures (Young, 2012), educators must find new ways to engage students to reflect and learn. In high-tech, high-touch health-care disciplines, educators are also expected to find compelling ways to foster communication skills and develop empathy within novice practitioners. TED (Technology, Entertainment, and Design) Talks enable speakers to present their most compelling innovative ideas, in 20 minutes or less, in a personal, conversational manner that most people can understand (Donovan, 2013). TED Talks are easily accessible online, free of charge, and viewed some 100 million times monthly (Anderson 2016, p. 242). The TED Talk format may offer health-care educators meaningful pathways to deliver contemporary interactive teaching options and to provide memorable, comprehensible learning experiences for healthcare students, especially because they are presented by skillful communicators who “reach your head and touch your heart” (Gallo, 2014, p. 8).

Health-care students are expected to graduate with competence in communication skills; however, for millennial learners, the current lecture format falls short in providing meaningful content and inspiring change. The aim of this study was to invigorate the traditional lecture on health-care communication skills by assigning students to view a video about the topic prior to class and write their reflections, then qualitatively analyze the themes from the reflections. In class, the reflections were collected, and a Facilitator's Guide was used to support class discussion about the importance of enhanced communication skills needed by health-care professionals. The TED Talk presenter (ECM) is a co-author of this article, but was neither known to the students nor directly involved in the students ‘learning activity.

Methods

Study participants were students born between 1982 and 2000, enrolled in a Bachelor of Science in Nursing program at a college in the northeastern United States. Institutional Review Board approval was granted from the college for the study. Written informed consent was obtained from the students, after their narratives were submitted.

Preparation

As preparation for a 3-hour innovative communication learning class, participants viewed a TED Talk titled On Being Present, Not Perfect (Meyer, 2014a) in their homes or dormitory rooms, and then immediately wrote a reflective narrative guided by two questions: What was the most meaningful part of the video? And What resonates with you personally and professionally? (The written reflections were not required or graded, but 92% of the students submitted them.)

Class Presentation

The video was then viewed collectively and discussed in class, supported by an accompanying Facilitator's Guide specifically designed for this TED Talk. The Facilitator's Guide served as a resource for faculty members, and functioned as a springboard for discussing general principles of health-care communication. Health-care communication skills, reflective listening, and empathic presence are emphasized throughout, thus making it an appropriate choice as “flipped classroom” preparation. On Being Present, Not Perfect incorporates personal and professional health-care experiences, and draws on a Wizard of Oz metaphor to highlight key ingredients of honest, effective health-care communication: courage, brains, and heart (Meyer, 2014b). The Facilitator's Guide introduces the talk this way:

The healthcare conversations that matter most are often the most challenging. From conveying serious diagnoses and disclosing medical errors, to ethical quandaries surrounding end-of-life care, these conversations are the bedrock of the patient-provider relationship. When conversations go well, patients ‘health outcomes, treatment adherence, trust, and satisfaction are enhanced. In this TED Talk, Dr. Elaine C. Meyer draws on her professional and personal experience to illustrate the profound gaps in healthcare communication and how to close them. She demonstrates the importance of reflective listening and empathic presence, providing memorable examples of communication and relationship building. (Meyer, 2014c)

Data Analysis

Content analysis of the narrative reflections was used to uncover key themes (Morse & Field, 1995; Weber, 1990). First, each individual transcript of student responses was read, and pertinent phrases and statements were highlighted as initial codes by a doctoral nursing student (MH), a doctorally-trained sociologist (DL), and a nurse/clinical psychologist (ECM). The researchers then met to collectively compare their coding, and to agree on an initial coding framework. The responses were then recoded according to this coding framework by one researcher (MH). The team met again to review the coding, to refine the final themes, and to provide a definition and label for each theme.

Results

Of the 25 third-year nursing students enrolled in the rotation, 23/25 (92%) completed the reflective writing assignment. Of those, 22 were female and 1 was male. Of the 23 who completed the assignment, 100% consented to participate and to have their de-identified reflections qualitatively analyzed. The reflective narratives ranged in length from 141 to 418 words. Three themes emerged from the data analysis:

The video draws on a Wizard of Oz metaphor to highlight key ingredients of honest, effective health-care communication: courage, brains, and heart.

Communication as a Foundational Competency, Importance of Empathy, and Professional Role Development.

Communication as a Foundational Competency

Respondents emphasized the importance of connecting and communicating with each patient and family to provide the best individualized plans of care. Students recognized the foundational nature of communication skills and that skill mastery requires more than a single learning experience:

“Communication is not a topic that will work best for just one class. It carries us through every aspect of our career and throughout our entire lives.”

During rigorous academic programs, nursing students are charged with mastering a different set of psychomotor skills with every course, while simultaneously maintaining a level of competency and comfort when communicating with patients and families. The TED Talk provided compelling reminders that, as students reported, “Small gestures really do count,” “Listening is key,” and to simply make time to “sit down and give it a chance.” Students may view silence as awkward, but learned that attentive listening and silence are essential:

“We easily forget that just being there to talk and listen to a patient or family member is so important. Five minutes can make a huge impression.”

In their written reflections, students highlighted the need to develop strong patient-provider relationships rooted in sound communication skills. Yet, as learners, they recognized their limitations, and gained a greater sense of developing competency:

“I get stressed when I try to think of the correct response. I don't want to say something that is incorrect or offensive. But I do want to give the patient an opportunity to say what's on their mind.”

Importance of Empathy

Student narratives described that for every meaningful nurse-patient relationship, empathic presence is at the core, including the ability to “walk in someone else's shoes,” be compassionate, and to have the courage to “go there.” As an inexperienced nurse, one student had underestimated her value and that her presence alone, accompanied with small acts of kindness, can be immensely valuable:

“I have had moments when patients are so upset and I have no idea how to respond. As a backup, I have held their hand.”

The simple act of hand-holding helped the student to realize that she was successful in demonstrating empathy by offering a measure of comfort to the patient. During their reflections, students expanded on the many advantages of engaging as empathic providers because, “In the end, it is how you make a patient feel.”

The video reassured and validated the students ‘attempts to empathize by drawing from their personal life experiences. In this way, students were encouraged to trust in the expression and value of their own humanity, both verbally and non-verbally, to connect with patients and fulfill that elusive yet vital goal of empathizing with patients.

“There is no textbook out there to perfectly formulate what to do, it comes from the natural tactfulness and the human nature to be compassionate.”

Professional Role Development

Students identified the talk as “timely” and “relatable” and one that held significant meaning on their journey to becoming nurses. Through reflection, students recognized their communicative hesitations and described an evolution in their thinking. For example, one student described an understanding that comforting a patient “in the moment” is critically important and need not wait until perfection is attained.

“As students, we need to remember that you do not always need to be thinking of the perfect things to say, but you do need to be there.”

The learners connected with memorable stories that could inform their future as health-care providers. They described a renewed level of commitment, as they refined their vision and mission in transitioning into their new role.

“Put the patient first in patient-centered care.”

The students reflected on how this assignment created a shared drive and purpose in relation to honest, effective health-care communication. The video inspired and empowered them as they embraced the opportunity to seek out new learning experiences to support patient-centered care:

“This semester, I hope to find opportunities where I can just sit down and be an open ear.”

“As nurses we need to have a heart to listen and be passionate about our profes-sion…we cannot underestimate our power and courage. We have a lot of power as nurses. We can provide strength to those who need it the most.”

The reflections built a case for health-care practitioners to become change agents. Participants described their motivation and commitment by transferring the learning into action:

“There is that emotional standard of care piece that sometimes we as health-care providers forget…being there for the patient is something that could be worked on continually.”

“I see the communication gaps and believe nurses can fix it.”

Writing brief narratives after viewing the video represented an opportunity to identify and fine-tune their interpersonal approaches to patient care, set their own intentions about how they might better communicate and engage empathically, and manifest their presence in everyday patient encounters.

Discussion

This work evaluated the integration of an illustrative TED Talk with a reflective writing assignment as a way to transform a standard undergraduate class about health-care communication. What emerged was a shift in how to convey knowledge and inspire and motivate students by creating a shared vision for communication skills. On Being Present, Not Perfect was chosen because it offers sound, realistic communication and relationship-building skills through emotionally charged stories that promote retention (Gallo, 2014), and climaxes with an audience-centric call to action (Donovan, 2013). Analysis of student reflections suggests that the video revealed an appreciation of the inherent value of good health-care communication, as well as the importance of empathy in patient-provider relationships. According to the Society of Pediatric Nursing, competency within the domain of communication in pre-licensure nursing programs is an expected learning outcome (Mott, et al., 2018). Given that transition into professional practice is a process, educators must provide cumulative learning opportunities that foster student growth and reflection throughout the educational process.

Our work supports previous research that TED Talks can humanize the classroom and revolutionize education through inviting and meeting learners where they are (Anderson, 2016). Multimedia offers educators a means to flip the classroom by first engaging students in independent experiential learning, and then, in collaborative discussion, thus promoting student engagement, learning, and reflection (Kahn, 2011). In contrast to a standard lecture, this method of content delivery is especially compelling because it appeals to diverse learners who rely on visual, auditory, and/or kinesthetic modes of information processing.

The importance of empathy was emphasized by the students in their reflections. TED Talk presenters can be compelling because “they get an audience's hearts to pound and their minds to explode with a sense of possibility” (Anderson, 2016, p 107). In this particular talk, the presenter shared a distressing personal health-care experience, but framed it as a missed opportunity for health-care providers to be present empathically As Gallo (2014) suggests in describing the successful components of TED Talks, On Being Present, Not Perfect captured the students ‘attention while also reaching their minds and touching their hearts. Further, writing brief narratives after viewing the video seemed for many to represent a unique opportunity to identify and fine-tune their interpersonal approach to patient care, set their own intentions about how they might better communicate and engage empathically, and manifest their presence in everyday patient encounters.

Professional role development was one of the major themes identified by the students, and many commented that developing an aspirational plan was inspirational to their growth as students.

Professional role development was one of the major themes identified by the students, and many commented that developing an aspirational plan was inspirational to their growth as students. The speaker's own story as a student nurse helped students to reflect on their own journeys to becoming nurses, and how to approach professional responsibilities. Faculty must continue to provide interactive teaching opportunities in order to facilitate a successful transition into nursing practice.

What makes our findings particularly interesting is that the reflections were not a required assignment, nor weighted as a test grade, but rather presented as standard preparation for a class. Students were asked to set aside 40 minutes, and 92% completed the assignment. As digital natives (Prensky, 2010), our millennial students may have been drawn to a video to deliver content rather than reading a text. The flipped classroom delivery of meaningful information was successfully utilized to support narrative reflections and a student-centered discussion on effective communication skills.

This study adds to the existing body of knowledge regarding approaches to enhance the quality of nurse–patient communication and relationships. Although the students ‘comments identified this video as a meaningful way to discuss communication challenges in health care, additional long-term data on the flipped classroom model are needed. Nursing faculty have also identified the need for ongoing evaluation of such innovative teaching approaches (Betihavas, Bridgman, Kornhaber, & Cross, 2016). Our innovative communication learning experience, combining a TED Talk, reflective writing, discussion, and accompanying Facilitator's Guide, offers promise as an interactive means to teach communication and relational skills to nursing students.

Limitations

This study has several limitations. Participants were drawn from one undergraduate program and our sample size was small. The study featured one specific TED Talk and the presenter was one of the authors of this article, though she was unknown to the students and did not have any direct contact with students. Participation was voluntary and responses may reflect a selection bias towards those who value class preparation or those who place inherent value in TED Talks. Our sample was largely female, and all were junior level nursing students. The data were self-reported and subject to the limitations of all such data.

Conclusion

We set out to provide an interactive way to augment the traditional lecture on communication skills for health-care students. What emerged through this study was a way to provide meaningful content and inspire change for millennial learners. Our findings contribute to the previous research on TED Talks and supports their usefulness as a pedagogical platform to meet millennial student learning needs to teach communication skills. The “flipping” function allowed content to be introduced outside of class, thus better utilizing time during class to enhance application of theoretical course content. The Facilitator's Guide helped to guide faculty in a class discussion by synthesizing video content with student comments. This particular video made an impact on learners and the narrative responses served to help educators better understand learners. Creative use of TED Talks can be part of a dynamic educational paradigm that motivates and amplifies learning. When coupled with narrative reflection, students may learn to appreciate the value and strategies of health-care communication and empathic presence, in the context of formative professional role development. Students described the innovative approach to health-care communication as a unique learning experience that engendered inspiration and commitment.

Implications for Practice

As undergraduate health-care programs compete with online and open courseware, TED talks offer worthwhile content free of charge (Anderson, 2016). Here, students identified with an inspirational teaching tool that emphasized the inherent value of empathic presence in patient-provider relationships. Possible next steps include study replication across disciplines such as medicine, child life, and the allied health sciences. The Facilitator Guide provided faculty with strategies to encourage nursing students to reflect critically on and value effective communication and relational skills, prior to entry into practice.

Footnotes

Acknowledgment

s. The authors would like to thank the nursing students in the School of Nursing at Curry College for their participation in this study.

Maureen Hillier, DNP, RN, (she/her/ hers), is an assistant professor at the Massachusetts General Hospital Institute of Health Professions and holds a staff position in the Medical Surgical Intensive Care Unit at Boston Children's Hospital.

Donna Luff, PhD, (she/her/hers), is the Director of Curriculum Design & Quality at Boston Children's Hospital Simulator Program (SIMPeds) and an assistant professor of Anesthesia at Harvard Medical School in Boston Massachusetts.

Elaine Meyer, PhD, RN, (she/her/hers), is a senior attending psychologist at Boston Children's Hospital and an associate professor of Psychology at Harvard Medical School in Boston, Massachusetts.

Editor's Note. The TED Talk presenter, Elaine C. Meyer, is a coauthor of this article. She was neither known to the students nor directly involved in the student's learning activities at the time of data collection.

Disclosure. The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

Funding. The author(s) received no specific grant or financial support for the research, authorship, and/or publication of this article.

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