Visualized Standardized Narrative Communication Training for Empathy and Reflective Practice Among Outpatient Nurses: A Nonrandomized Controlled Study

Summary

This nonrandomized controlled study evaluated a visualized, standardized narrative nursing communication training (SNNCT) program for outpatient nurses. SNNCT was associated with improvements in empathy, reflective practice, communication fidelity, and patient communication experience. The findings support the potential of structured visual communication pathways to strengthen humanistic care in high-volume outpatient settings.

Abstract

Outpatient nurses frequently work under substantial time constraints and high emotional demands, making consistent empathic and reflective communication difficult. This nonrandomized controlled pre–post study evaluated whether a visualized, standardized narrative nursing communication technique (SNNCT) was associated with improvements in empathy, reflective practice, communication performance, and patient communication experience among outpatient nurses. Sixty-eight outpatient nurses at a tertiary hospital in Nanchong, Sichuan, China, were assigned nonrandomly to the intervention group (n = 38) or the control group (n = 30). The intervention combined standardized narrative communication training with visual workflow tools, including flowcharts, and structured reflective debriefing. Outcomes included nurse-reported empathy, reflective practice, communication self-efficacy, patient-centered values, patient-reported communication experience, implementation fidelity, and observer-rated communication quality. Mixed-effects models and mediation analyses evaluated intervention effects. Compared with the control group, nurses receiving SNNCT showed greater improvements in empathy, reflective practice, communication self-efficacy, reflective competence, implementation fidelity, observer-rated communication quality, and patient-reported communication experience. Mediation analyses indicated that improvements in empathy and reflective practice partially explained improvements in patient communication experience. These findings suggest that visualized, standardized narrative communication training may strengthen humanistic communication and support high-quality outpatient nursing care in busy clinical settings.

Introduction

Outpatient nursing is one of the most frequently encountered components of healthcare services and directly influences patient experience^1,2. With the widespread adoption of patient-centered care models, the objectives of nursing communication have expanded beyond information transmission to fostering understanding and trust, supporting shared decision-making, enhancing compliance behaviors, and alleviating emotional distress^3,4,5. In recent years, mainstream improvement approaches in clinical and nursing education ha....

Protocol

This study was conducted in accordance with the institutional guidelines governing research involving human participants. It was approved by the Medical Ethics Committee of Beijing Anzhen Nanchong Hospital of Capital Medical University & Nanchong Central Hospital (Approval No. 2026 Ethics Review No. 159). Written informed consent was obtained from all nurse and patient participants before data collection.

Study design

This study was conducted in the outpatient department of a tertiary hospital in Sichuan Province using a nonrandomized, parallel-group controlled training design to evaluate the effec....

Results

Baseline

A total of 68 outpatient nurses were enrolled, including 38 in the SNNCT group and 30 in the control group. All 68 allocated nurses were retained in the group-based mixed-model analyses using available repeated observations, whereas intervention process data were complete for 36 of the 38 nurses in the intervention group. The groups were similar in demographic and occupational characteristics, including age, sex, body mass index (BMI), marital status, education level,.......

Discussion

This study proposed a SNNCT that integrates standardized narrative communication modules with visual implementation tools to support outpatient nurses during routine clinical practice. The findings demonstrated improvements in nurses’ empathy, reflective practice, communication self-efficacy, patient-centered professional values, and patient-reported communication experiences following implementation of the intervention. These observations are consistent with previous studies suggesting that narrative communication.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Audio/video Recording Equipment	Research site (institutional audio/video recording equipment)	Not applicable; no specific make or model identified in the manuscript	Used to record nurse–patient communication encounters at T0, T1, and T2 for masked independent behavioral assessment.
Communication Self-Efficacy Scale	Department of Nursing, Beijing Anzhen Nanchong Hospital of Capital Medical University & Nanchong Central Hospital	Study-specific, content-reviewed and cognitively pilot-tested version; 0–100 scoring	Locally developed nurse-reported outcome measuring communication self-efficacy. Higher scores indicate greater self-efficacy; no external validation is claimed.
Empathy Script Library	Department of Nursing, Beijing Anzhen Nanchong Hospital of Capital Medical University & Nanchong Central Hospital	Custom-developed	Standardized phrase bank supporting emotional cue recognition, empathic validation, reflective listening, and summarization during outpatient encounters.
Jefferson Scale of Empathy–Health Professionals (JSE-HP)	Thomas Jefferson University; validated Chinese Healthcare Providers version described by Cheng et al. (2011)	Validated Chinese JSE-HP Healthcare Providers version; 20 items; 7-point responses	Measures nurse empathy. Total scores range from 20 to 140, with higher scores indicating greater empathy. No alternative or abbreviated JSE form was used.
Microlecture Training Modules	Department of Nursing, Beijing Anzhen Nanchong Hospital of Capital Medical University & Nanchong Central Hospital	Version 1.0	Instructional modules used during the 3.5-week SNNCT program together with demonstrations, simulation, role play, drills, and OSCE practice.
Narrative Communication Coding Protocol	Department of Nursing, Beijing Anzhen Nanchong Hospital of Capital Medical University & Nanchong Central Hospital	Custom-developed; seven modules scored 0–10 each (total score: 0–70)	Used by two trained independent raters to assess de-identified recordings presented in random order; raters were masked to group allocation and time point.
Patient-Centered Care Values Inventory	Department of Nursing, Beijing Anzhen Nanchong Hospital of Capital Medical University & Nanchong Central Hospital	Study-specific, content-reviewed and cognitively pilot-tested version; 1–5 item-mean scoring	Assesses patient-centered professional values. Scores were reported as a 1–5 item mean and linearly transformed to a 0–100 scale for graphical presentation; no external validation is claimed.
Patient Communication Experience Questionnaire	Department of Nursing, Beijing Anzhen Nanchong Hospital of Capital Medical University & Nanchong Central Hospital	Study-specific, cognitively pilot-tested 8-item version; four domains; 5-point responses	Assesses feeling heard, emotional support, information clarity, and shared decision-making. Domain scores were calculated as (mean item score − 1)/4 × 100; the overall score is the mean of the four domain scores. No external validation is claimed.
Pocket Cards (Quick-reference Guides)	Department of Nursing, Beijing Anzhen Nanchong Hospital of Capital Medical University & Nanchong Central Hospital	Version 1.0	Quick-reference visual guides supporting use of the seven-step SNNCT pathway during routine outpatient communication.
Reflective Practice Questionnaire (RPQ)	Priddis and Rogers (2018); doi:10.1080/14623943.2017.1379384	Original 40-item, 6-point version; Chinese study translation prepared by forward translation, reconciliation, and back-translation	Measures reflective practice. Mean scores range from 1 to 6, with higher scores indicating greater reflective capacity. The Chinese study translation underwent clinical review before pilot testing.
R Statistical Software	R Foundation for Statistical Computing, Vienna, Austria	R version 4.6.0; lme4, lmerTest, emmeans, lavaan, boot, and performance packages	Used for descriptive analyses, linear and generalized linear mixed-effects models, serial mediation with 5,000 bootstrap resamples, and robustness analyses.
Situational Simulation Scenarios	Department of Nursing, Beijing Anzhen Nanchong Hospital of Capital Medical University & Nanchong Central Hospital	Version 1.0	Role-play and OSCE scenarios used for practice, calibration, feedback, and transfer of SNNCT behaviors to outpatient encounters.
SNNCT Implementation Fidelity Checklist	Department of Nursing, Beijing Anzhen Nanchong Hospital of Capital Medical University & Nanchong Central Hospital	Custom-developed per-encounter checklist	Contains predefined criteria for each communication component. Key thresholds included visual-tool use in at least 80% of encounters and completion of at least six core components in at least 70% of encounters.
Structured Reflective Debriefing Templates	Department of Nursing, Beijing Anzhen Nanchong Hospital of Capital Medical University & Nanchong Central Hospital	Version 1.0	Templates supporting structured post-encounter reflection, feedback, reflective summaries, and weekly debriefing.
Teach-Back Checklists	Department of Nursing, Beijing Anzhen Nanchong Hospital of Capital Medical University & Nanchong Central Hospital	Version 1.0	Checklists used to document teach-back and verify patient understanding of treatment and follow-up information.
Visualized Standardized Narrative Nursing Communication Technique (SNNCT) Toolkit (Flowcharts and Decision Trees)	Department of Nursing, Beijing Anzhen Nanchong Hospital of Capital Medical University & Nanchong Central Hospital	Version 1.0	Core intervention package comprising workflow maps, decision trees, pocket cards, phrase banks, teach-back checklists, and structured debriefing templates.