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Aim

To explore the effects of a humanistic care digital storytelling programme on the humanistic care ability, empathy, emotional intelligence and clinical communication ability.

Background

Humanistic qualities are vital for patient satisfaction and nursing quality. However, traditional nursing curricula may impede their development, especially in intensive care unit settings. Digital storytelling shows promise, but its effectiveness in enhancing humanistic qualities remains unclear.

Design

A quasi-experimental design with repeated measures, using a convergent parallel mixed-methods approach.

Methods

In a tertiary hospital in Changsha, China, 37 nursing students participated in the intervention group and 40 in the control group. The four-week intervention included educational sessions, reflective diaries and discussion groups. Humanistic qualities were assessed quantitatively at baseline, post-intervention and one-month follow-up using repeated measures ANOVA. Qualitative data from diaries and interviews were analyzed using reflective thematic analysis.

Results

The intervention group demonstrated significantly improved humanistic care ability and empathy scores compared with controls (p < 0.05). Interaction effects were significant for both humanistic care ability (p < 0.05) and emotional intelligence (p < 0.001). The intervention group also showed statistically significant improvements in humanistic care ability and emotional intelligence at both post-intervention and follow-up (p < 0.05). Qualitative analysis revealed four themes: Infectious fusion and Educational Significance, Balancing Enjoyment and Reflection, Complementary Relationship between the Teaching Curriculum and Clinical Practice and Recommendations for Improving the Teaching curriculum.

Conclusion

The digital storytelling programme effectively enhances humanistic qualities among intensive care unit nursing students, supporting its integration into nursing education for improved outcomes.

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1 Introduction

The Intensive Care Unit (ICU) is a high-pressure environment characterized by continuous monitoring of patients' vital signs and intensive medical interventions. ICU patients endure extensive treatments, prolonged bed rest, frequent alarm sounds and severe health conditions, leading to significant psychological strain and adverse feelings ( Hasandoost et al., 2023). Furthermore, being isolated from their families and normal routines heightens their emotional and psychological needs ( Zhang et al., 2024). In this demanding setting, nursing students in ICUs are tasked with the critical role of delivering compassionate and high-quality care. By developing humanistic qualities, healthcare providers can effectively assess and address the complex needs of their patients, gaining the necessary insights and empathy to create a supportive environment for those under immense stress ( Liu et al., 2022).

Nursing institutions emphasize that apart from imparting nursing students foundational knowledge and technical skills, the nurturing of humanistic qualities is quite essential to patient-centered care. These qualities primarily include providing humanistic care, demonstrating empathy, excelling in interpersonal communication and engaging in moral reasoning ( Ha et al., 2017; Qian et al., 2018). Existing evidence indicates that nursing students in ICUs may be insufficiently prepared for providing humanistic care ( Ferri et al., 2017; Jian et al., 2022; Wang et al., 2022). They also frequently exhibit lower levels of empathy ( Korkmaz Doğdu et al., 2022; Wang et al., 2024) and this issue seems to exacerbate as their clinical training advances ( Ferri et al., 2017). Additionally, ICU nursing students often experience heightened levels of compassion fatigue ( Storm and Chen, 2021) and struggle with effective emotional communication with patients and their families ( Cheng et al., 2024).

Various factors contribute to the differences in humanistic qualities among nursing students in ICUs such as gender, educational background, social dynamics, professional demeanor, the clinical environment and formal training in humanistic care ( Fr et al., 2022; Shalaby et al., 2018). Training methods aimed at cultivating these qualities include experiential training ( Hill, 2017), implicit education ( Raso et al., 2019), balint group discussions ( McManus et al., 2020) and narrative medicine education ( Xue et al., 2023). However, these methods encounter challenges in spreading due to limits in format and content. A recent study highlighted that purely theoretical instruction and a lack of engagement in the classroom environment were identified by nursing students as key areas requiring improvement in their training program ( Zhang and Tian, 2024). To address these issues, educators are exploring innovative alternatives like Digital Storytelling. This approach, based on narrative medicine education, uses visual storytelling through photographs, videos, drawings and related brief reflective annotations other than traditional text-based methods to convey experiences and emotions ( Rieger et al., 2018). Digital storytelling effectively preserves narratives over time and provides a more engaging and resource-efficient way to teach ( Moreau et al., 2018). Studies have shown that Digital storytelling can significantly enhance student interest, motivation, reflective thinking and empathy ( Leyva-Moral et al., 2021; Rodríguez-Almagro et al., 2021). Moreover, it has received positive feedback from students and demonstrates potential for broader integration into nurse education ( Rodríguez-Almagro et al., 2021). However, most studies on digital storytelling have focused more on exploring narrative experiences and developing materials rather than assessing its direct educational impact ( Mojtahedzadeh et al., 2021).

Our team has developed a humanistic care digital storytelling programme for nursing students in ICUs. Initial feasibility studies have validated the intervention, showing high participant satisfaction with the curriculum and significant emotional engagement with the digital stories ( Deng et al., 2024). Despite the promising results achieved by our team, the specific impact and mechanisms of the programme on the humanistic qualities of ICU nursing students remain unclear. Given the insufficient preparation of ICU nursing students in critical areas such as humanistic care, empathy, emotional intelligence and clinical communication, it is essential to assess and clarify these impacts. Therefore, this study aims to thoroughly examine these effects by evaluating participants' experiences, reflections and feedback throughout their educational journey. It seeks to evaluate the effectiveness of the humanistic care digital storytelling programme as an educational approach in nurse education, offering valuable insights into strengthening ICU nursing students' humanistic qualities and enhancing overall quality of nurse education.

2 Methods
2.1 Study design and setting

This study used a quasi-experimental repeated measures design combined with a convergent triangulation approach ( Creswell and Clark, 2017) to assess the effect of humanistic care digital storytelling on nursing students in ICUs. Both quantitative and qualitative data were given equal weight, ensuring a comprehensive evaluation of the intervention’s effects. The study followed the GRAMS (Good Reporting of A Mixed-Methods Study) guidelines for reporting mixed-methods research ( O’cathain et al., 2008) (Appendix A) and employed the TREND checklist for non-randomized trials ( Des Jarlais et al., 2004) (Appendix B). The study was conducted from August to October 2022 at a tertiary hospital in Changsha, Hunan Province, China.

2.2 Sample and population

We used G Power Version 3.1.9.2 to determine the sample size for our study, which involves repeated measurements on two sets of samples. With an assumed effect size of 0.25, a bilateral significance level set at 0.05 and a desired test power of 90 %, we determined that a total of 70 participants would be needed. To account for a potential 10 % attrition rate, the minimum required sample size was adjusted to 77 participants.

Participants were recruited using a convenience sampling method. The inclusion criteria were: 1) age 18 or older; 2) full-time nursing students pursuing a college or undergraduate degree; 3) in their final year of study and completing a minimum 6-month hospital internship; 4) preparing for at least one month in the ICUs; and 5) consenting to participate in the study. The exclusion criteria were: 1) current participation in another exercise programme; 2) documented mental disorders or recent significant psychological trauma; and 3) a leave of absence exceeding 3 months. Eligibility was verified through interviews and review of personal information records maintained by the Clinical Nursing Teaching and Research Office. Data from participants who were absent for personal reasons, arrived more than 20 minutes late, or left more than 20 minutes early from intervention sessions were excluded from analysis.

Due to the staggered scheduling of clinical internships across several nursing colleges, there was uneven participation among students during the same period. To enhance the feasibility of the intervention, nursing students from one batch undergoing ICU internships were selected as the control group, while students from another batch served as the intervention group. Practical constrains limited the groups to 37 participants in the intervention group and 40 in the control group. Quantitative data were collected before the intervention (T0), immediately after the intervention (T1) and one month after the intervention (T2). During the intervention and data collection phases, six participants were excluded due to withdrawal from the study or lack of follow-up. The final analysis included data from 71 participants: 36 in the control group and 35 in the intervention group ( Fig. 1).

2.3 Intervention
2.3.1 Control group

Participants in the control group followed their standard ICU internship training plan. This training encompassed a range of clinical skills, including sputum aspiration, electrocardiogram (ECG) monitoring, use of micro infusion pumps, gas cutting nursing, central venous pressure (CVP) monitoring, arterial blood pressure (ABP) monitoring, ventilator connection, basic parameter adjustment, deep vein catheterization nursing, tracheal intubation oral care, as well as participation in small lectures, symposiums and two-way feedback sessions, among other activities.

2.3.2 Intervention group

In addition to the standard internship training, participants in the intervention group participated in the humanistic care digital storytelling programme ( Deng et al., 2024). This programme incorporated humanistic care principles into the education of nursing students in ICUs, using the SHARE care framework ( Hsu et al., 2013) and emphasizing five main themes: perception of patient needs, assisting patients through challenges, empathizing with patient emotions, proactive communication and explanation and respecting patient privacy. Clinical stories relevant to these themes were collected during the initial stages of the study and digital stories were produced. Discussions focused on the framework were conducted throughout the intervention phase ( Deng et al., 2024).

The implementation plan was carried out by the first authors (X.D. and J.G). Spanning four weeks, the intervention included four educational sessions, and two discussions centered on reflection diaries. This approach followed three essential steps of narrative education: detailed reading, introspection and reaction ( Milota et al., 2019). Educational sessions were conducted weekly, during which ICU nursing students viewed four digital stories. Classroom discussions focused on the videos' content and its alignment with the humanistic care framework. Students were tasked with writing reflection diaries starting from the initial intervention, writing 2 diaries per week. These diaries were intended to integrate their clinical experiences with their understanding of the SHARE care framework. Discussing of these reflective diaries were held after every two classroom sessions. For an illustration of the intervention steps, see Appendix C.

2.4 Measures and data collection

Two trained research assistants (J.Z. and S.G.) who were blind to group allocation, administered the Humanistic Care Ability, Empathy, Emotional Intelligence and Clinical Communication Ability Scales at T0, T1 and T2. Rigorous real-time checks were conducted to ensure the completeness, validity and authenticity of the questionnaires during both distribution and collection. Qualitative data were collected within one month after the intervention using reflective diaries and semi-structured interviews. Participants' self-reflection abilities were assessed based on the reflective diaries they maintained during the intervention, which provided insights into their thought processes and clinical experiences. Additionally, semi-structured interviews conducted after the intervention offered further understanding of each participants' experiences.

2.4.1 Quantitative evaluation measures

We used a self-designed questionnaire to collect demographic data, covering age, gender, school, residence, education level, sibling status, clinical internship duration, department rotation time and educational background. In addition, participants completed four established scales measuring humanistic care ability, empathy, clinical communication ability and emotional intelligence. Table 1 provides a detailed summary of these four scales, including their dimensions, number of items, scoring ranges, total score ranges, reliability (including Cronbach's α) and other details regarding validity or reliability.

2.4.2 Qualitative evaluation measures
2.4.2.1 Reflective diaries

Intervention group nursing students wrote two weekly reflective diaries in Chinese, totaling eight diaries, each at least 300 words long. The recommended writing steps were as follows: 1) described and analyzed the clinical event; 2) outlined the measures and resources provided by themselves or others; 3) reflected on their thought process; 4) assessed whether the humanistic care framework was helpful in managing the situation; 5) discussed their strengths and areas for improvement; and 6) considered alternative actions they would take if faced with a similar situation in the future. The diaries were reviewed by 24:00 each Sunday to ensure timely completion.

2.4.2.2 Semi-structured qualitative interview

We used purposive sampling to recruit nursing students from the intervention group for semi-structured face-to-face interviews. Interested participants were invited and required to sign a written informed consent form before their inclusion. Appointments were scheduled at each participant's convenience. The interview outline is shown in Appendix D. Within one month of the program's conclusion, two trained research assistants (X.L. & L.H.), who had no knowledge of the quantitative results, carried out interviews. These interviews, which lasted between 30 and 40 minutes each, were conducted in a peaceful, private room at the hospital. Both interviewers were nursing graduate students with hospital experience, chosen to ensure a comfortable environment for the students to freely express themselves without concerns about their internship outcomes.

2.5 Data analysis

Quantitative data were analyzed using SPSS 26.0. Descriptive statistics summarized participants' demographic characteristics and scale scores：frequency and percentage for categorical data, while mean and standard deviation for continuous data. Chi-square tests compared categorical data between the two nursing student groups, while analysis of variance (ANOVA) was used for continuous data. Normality and variance homogeneity were checked using Kolmogorov-Smirnov, Shapiro-Wilk, Levene's test of equality of error variances and Box's test of equality of covariance matrices. Data from 6 participants (2 from the intervention group and 4 from the control group) with missing exit data were excluded. A two-way repeated measures ANOVA was used to analyze the changes (between-group intervention effect, within-group time effect and interaction effect) in humanistic care ability, empathy, clinical communication ability and emotional intelligence across three time points (T0-T2) between the intervention and control groups.When the interaction effect was significant, simple effects analysis was conducted using the Bonferroni method for post-hoc testing of intervention and time sub-effects. When the interaction effect was not significant, between-group comparisons were performed using independent samples t-tests and within-group time differences were examined by one-way repeated measures ANOVA with Bonferroni post-hoc tests. Primary analyses were based on the per-protocol (PP) sample, which included participants who completed all six interventions and successfully provided data at three data collection points (T0-T2).

Regarding qualitative data, the semi-structured qualitative interviews were transcribed verbatim and checked for accuracy. These Chinese transcripts and the reflective diaries were imported into Nvivo 11.0 for simultaneous analysis, which was conducted by J.G. and X.D. using inductive reflexive thematic analysis. This method was chosen for its flexibility in uncovering shared meanings in the data ( Riegel et al., 2023). The analysis followed a 6-phase process: familiarization with the raw data, generating initial codes, identifying themes, reviewing potential themes, defining and naming themes and writing reports. Theme redundancy was achieved in the 19th interview and additional interviews were conducted with two participants to confirm the data saturation. Regular meetings with the research team facilitated discussions on the analysis. To enhance the reliability of the analysis, we employed “investigator triangulation” ( Carduff et al., 2014). Ten percent of the transcripts were randomly selected and analyzed independently by a different researcher who was not part of the data collection process. Any discrepancies were resolved through consensus, which may have included the introduction of new codes or modifications to existing ones. Finally, the specific participant quotes of qualitative research reports selected for inclusion in the manuscript were translated into English by JG, verified by JZ and then reviewed and revised by a bilingual nursing professor.

After separately analyzing the quantitative and qualitative data, the two databases were integrated for comparison through merging. The joint display approach was used to interpret and report the integrated results ( Fetters et al., 2013). Through merge data, the results from quantitative and qualitative research are mutually explained, enhancing our understanding of the effectiveness of the digital storytelling intervention programme.

2.6 Ethical considerations

The study received ethical approval from the College Ethics Review Committee of Xiangya Nursing School of Central South University (Approval Number: E2022126). Authorization was obtained from the authors of all assessment tools used. Each participant signed a written informed consent form before participating. Reflective diaries and semi-structured interviews were anonymized for confidentiality, with each diary or interview assigned a unique identifier for organizational purposes.

3 Results
3.1 Quantitative data
3.1.1 Demographic characteristics

The average age of the 71 nursing students included was 19.79 ± 0.844 years, with 11 males (15.49 %) and 60 females (84.51 %). Nearly half chose nursing as their major out of personal interest (45.07 %). Most participants had taken courses related to humanistic qualities (80.28 %) and reported a good or excellent humanistic care environment at their schools (98.59 %). There was no statistically significant difference in demographic characteristics between the two groups (P > 0.05) ( Table 2).

3.1.2 Effectiveness of the humanistic care digital storytelling programme on humanistic care ability, empathy, emotional intelligence and clinical communication ability

Participants' outcome variables at T0, T1 and T2 are presented in Table 3. Mean scores (and standard deviations) of humanistic care ability, empathy, emotional intelligence and clinical communication ability scale over time are portrayed in Fig. 2. At T0 (Appendix E), there was no significant difference between the intervention and control groups in humanistic care ability (t = 0.398, p = 0.692), empathy (t = 1.164, p = 0.248), emotional intelligence (t = -0.812, p = 0.42) and clinical communication ability (t = 0.834, p = 0.407). Mauchly's test indicated sphericity for humanistic care ability, empathy and clinical communication ability (P > 0.05). However, for emotional intelligence, Mauchly's test showed a violation of sphericity (P < 0.05), thus Greenhouse-Geisser correction was applied.

3.1.2.1 Effectiveness of the intervention on humanistic care ability

There was a significant between-group intervention effect, within-group time effect and interaction effect on humanistic care ability (p < 0.05). Between-group comparisons from the simple effects analysis revealed the intervention group scored significantly higher in humanistic care ability than the control group at both T1 (F = 7.391, p = 0.008), and T2 (F = 10.026, p = 0.002). Within-group comparisons from the simple effects analysis showed significant difference on humanistic care ability in the intervention group across the three time points (p < 0.001). Pairwise comparisons indicated statistically significant differences on humanistic care ability for the intervention group between T0 and T1 (MD = −11.2), as well as between T0 and T2 (MD = −18.057).

3.1.2.2 Effectiveness of the intervention on empathy

There was a significant between-group intervention effect (F = 4.460, p = 0.038), but no significant within-group time effect, nor interaction effect on empathy (p > 0.05). Independent samples t-tests showed that the empathy scores in intervention group were significantly higher than the control group at T1 (t = 2.332, p = 0.023) and T2 (t = 2.017, p = 0.048).

3.1.2.3 Effectiveness of the intervention on emotional intelligence

There was a significant interaction effect and between-group intervention effect on emotional intelligence (p < 0.05), but no within-group time effect (P > 0.05). Between-group comparisons from simple effects analysis indicated no significant difference in the emotional intelligence between the two groups at T1 (P＞0.05), but the intervention group scored significantly higher than the control group at T2 (F = 16.004, p = 0.000). Within-group comparisons from the simple effects analysis showed significant difference on emotional intelligence in the intervention group across the three time points (p < 0.001). Pairwise comparisons revealed significant differences on emotional intelligence for the intervention group between T0 and T1 (MD = −7.257), as well as between T0 and T2 (MD = −7.257) (p < 0.05).

3.1.2.4 Effectiveness of the intervention on clinical communication ability

For clinical communication ability, there was no significant between-group intervention effect, interaction effect, nor within-group time effect (p > 0.05).

3.2 Qualitative data

After the intervention, 215 reflective diaries were received from 35 students in the intervention group. All members of this group submitted reflective diaries, with varying levels of adherence to the submission requirements: 5 students (14 %) strictly submitted 8 reflective diaries as required, 1 student submitted 7 diaries, 28 students (80 %) completed 6 diaries each and only 1 student submitted 2 diaries. 21 nursing students who participated in the digital storytelling intervention programme completed qualitative interviews. Among them, 5 were male (23.8 %) and 16 were female (76.2 %), with an average age of 19.64 ± 0.69 years.

The qualitative analysis of interviews and reflection diaries resulted in four themes: Infectious fusion and educational significance, Balancing Enjoyment and Reflection, Complementary Relationship between the Teaching Curriculum and Clinical Practice and Recommendations for Improving the Teaching Curriculum. Each theme has supported sub-themes and quotes ( Table 4).

3.3 Integration of quantitative and qualitative findings

After integrating both quantitative and qualitative results, three types of data integration fit were identified: Confirmation (where the results from both data types support and validate each other’s findings), Discordance (where the results from the two data types are inconsistent) and Expansion (occurs when findings from different data sources address various aspects of a single phenomenon, offering a more comprehensive understanding of the research subject). The “fit” of data integration is defined as the coherence between quantitative and qualitative findings ( Fetters et al., 2013) ( Table 5).

Both quantitative and qualitative data confirmed the effectiveness of the digital storytelling programme in enhancing humanistic care ability, empathy and emotional intelligence, indicating consistent conclusions from both sources. By understanding participants' genuine feelings and learning experiences, the qualitative results provided a more detailed explanation and served a supplementary role to the quantitative findings. In terms of clinical communication ability, there was a discrepancy emerged: quantitative data indicated no significant impact of the intervention, while qualitative data revealed that some participants recognized potential benefits through an improved understanding of nurse-patient communication and actively listening and explaining to patients. Furthermore, qualitative data uncovered further insights from participants, including the inspirational impact of the intervention and the balance between enjoyment and reflection. It also revealed effects beyond the primary objectives, such as the enhancement of professional identity. Additionally, the data emphasized the importance of role models in teaching effectiveness and offered recommendations for improving the teaching curriculum.

4 Discussion

This study aimed to implement a humanistic care digital storytelling programme for nursing students in ICUs during their clinical practicum. The effectiveness of the educational intervention was evaluated using mixed-methods research approach.

Quantitative results demonstrated that ICU nursing students' humanistic care ability were significantly higher in intervention group than in the control group at both T1 and T2. This indicated that the digital storytelling method effectively enhanced the ability, with its impact sustained for at least one month. Qualitative data corroborated these findings: students used the frameworks to analyze digital stories in their reflective diaries, thereby enhancing their reflection skills and understanding of humanistic care. Moreover, semi-structured interviews revealed that students consciously applied and guided their own practices during subsequent clinical placements. This may be attributed to the intervention's foundation on the “SHARE Care Framework” ( Hsu et al., 2013), where each digital story is expert-reviewed and comprehensively covers the five key aspects of the framework: perception of patient needs, assisting patients through challenges, empathizing with patient emotions, proactive communication and explanation and respecting patient privacy. Each instructional activity immersed students in contexts rich with humanistic care implications, prompting them to derive insights into humanistic care through vivid digital stories ( Hsu et al., 2015). Similar to previous studies, both verbal exchanges and collaborative discussions in class, alongside introspective reflection and critical review through diary writing, further deepened students' understanding and application of humanistic care principles ( Li et al., 2022). Furthermore, in our study, reflective diaries proved essential as some students found it challenging to express their thoughts verbally in class, thus relying on reflective diaries to articulate their ideas and enhance their grasp of humanistic care.

The nursing profession necessitates nurses to actively participate in empathetic therapeutic relationships to deliver compassionate care ( Isobel and Thomas, 2022). However, educational programmes aimed at enhancing empathy among ICU nursing students are limited. Consistent with prior research on the effectiveness of digital storytelling in health science education ( Leyva-Moral et al., 2022), our study contributed additional evidence supporting the effectiveness of this teaching approach in fostering empathy in nurse education. Digital storytelling created immersive experiences by setting detailed scenes, allowing students to empathize deeply with the protagonists. Quantitative results indicated that the intervention group scored higher in empathy than control group at both T1 and T2, suggesting the intervention's effect lasts at least one month. Similarly, qualitative data showed that participants focused more on understanding patients' inner worlds during clinical placements, achieving perspective-taking and empathy through their observations and insights. However, this study did not reveal significant changes in empathy levels over time among the ICU nursing students in intervention group. This may be due to empathy being a cognitive attribute that involves comprehending patients' inner feelings and conveying that understanding ( Daryazadeh et al., 2020). Previous studies had reported a decline in empathy levels among ICU nursing students as they progress through their academic years, often linked to the pressures of clinical practice, lack of support and emotional fatigue ( Ferri et al., 2017; Hogan et al., 2018). In this study, the control group also showed a trend of declining empathy levels over time, although it was not statistically significant. This suggested a need for future nurse educators to remain attentive to potential declines in empathy among ICU nursing students during clinical placements, advocating for long-term longitudinal monitoring and the development of structured educational interventions.

Interpersonal relationships and emotions are indispensable components of nursing that significantly enhance the quality of patient care ( Dugué et al., 2021). Emotional intelligence, defined as the capacity to recognize, process and effectively use emotional information, is a crucial trait that can be cultivated through targeted interventions ( Christianson, 2020). Our study found that the digital storytelling intervention improved the emotional intelligence of ICU nursing students. By T2, a significant difference in emotional intelligence scores emerged between the intervention and control groups. This difference can be attributed to a marked increase in the emotional intelligence scores of the intervention group post-intervention, which remained stable from T1 to T2. In contrast, the control group experienced a notable decline in scores from baseline to T2. These findings indicate that the intervention effectively countered the decline in emotional intelligence among the nursing students. The reflective diaries and interviews results provided a deeper insight into how students developed emotional intelligence through immersive experiences, perceiving emotions of patients and nurses in stories and practicing self-regulation and empathy in clinical settings. Despite these findings, research in this area remains limited. Further research is necessary to confirm these findings and clarify the underlying mechanisms. Future studies could investigate the integration of the tripartite model into nurse education to better prepare students for the emotional challenges inherent in the profession ( Dugué et al., 2021). Additionally, as noted in previous research ( Shanta and Gargiulo, 2014), the decline in emotional intelligence among nursing students is concerning. Future research should identify the factors contributing to this decline to refine educational strategies.

While the quantitative results did not demonstrate significant difference on clinical communication ability between the two groups, the qualitative results revealed the potential effectiveness of the intervention. Participants reported that the digital stories enhanced their understanding of the importance of patient communication and demonstrated a gradual internalization of this knowledge in their clinical practice, including a willingness to actively listen to patients and provide clear explanations. The observed differences between the quantitative and qualitative results could stem from the participants' already high baseline levels of clinical communication ability. Consequently, the quantitative tools may have been unable to capture in terms of subtle differences in intervention effects, aligning with findings from a previous study ( Zhu et al., 2019). Furthermore, the focus of the programme did not include a standalone module specifically targeting nurse-patient communication. Therefore, further targeted training is crucial for ICU nursing students with weaker clinical communication ability, even though the digital storytelling intervention can enhance overall understanding and willingness to engage in effective nurse-patient communication.

Furthermore, the reflection diaries and semi-structured interviews provided insights into ICU nursing students' perspectives on the intervention of digital storytelling in terms of teaching formats, education experience and recommendations, thus expanding the quantitative findings. Participants believed that learning about humanistic qualities through digital storytelling made the course more enjoyable, addressing the perceived rigidity of traditional methods. Additionally, participants highlighted that diverse teaching formats such as digital stories viewing, classroom discussions, reflective diary writing and the reflection diary discussion significantly enhanced their self-reflection on personal behaviors ( Contreras et al., 2020). It is noteworthy that both digital stories and exemplary clinical practices in real-life scenarios play crucial roles in education. A professional and caring teaching image positively influenced students' cognition and behavior ( Doja et al., 2021). Regarding the educational experience, our study used digital storytelling materials based on real ICUs cases. Participants reported a more immersive experience compared with cinematic depictions, emphasizing the authenticity of clinical environments. Moreover, qualitative results seem to provide outcomes exceeding the primary objectives of the intervention. Participants reported that they gained a sense of accomplishment from witnessing patients improve following diligent care from nurses. By engaging with digital stories, students enhanced their understanding of the nursing profession and solidified their professional identity, a perspective seldom investigated in prior research.

Finally, we gathered some valuable teaching suggestions from the nursing students. During periods of heavy practical training, conflicts arose between the scheduling of nursing students and the arrangement of their coursework, potentially adding extra stress to participants ( Yi et al., 2024). Additionally, for some, the requirement of writing two reflective diaries per week proved overly burdensome. Therefore, nurse educators should personalize course scheduling more effectively and adjust the number of reflective diary entries reasonably to alleviate the potential burden on students during intensive clinical training and preparation for their careers.

5 Limitations

This study has several limitations. Firstly, participants were recruited from only one hospital, which may restrict the generalizability of the research findings. Secondly, the follow-up period in this study was relatively short, which limited our ability to evaluate the long-term effects of the intervention. Lastly, participants may have been inclined to report socially desirable responses. Future research is recommended to include long-term follow-ups of digital storytelling interventions to observe sustained effects on certain variables and to conduct larger-scale multicenter studies.

6 Conclusions

The digital storytelling intervention effectively enhances ICU nursing students' abilities in humanistic care, empathy, emotional intelligence and potential in clinical communication. This programme engages ICU nursing students through dynamic and effective teaching methods, making it a promising and innovative tool for nurse educators and administrators. It has the potential to effectively promote nursing students' understanding and practice of humanistic qualities in nurse education.

Ethical considerations

The study was approved by the ethics review committee of Xiangya Nursing School of Central South University,China (approval number:E2022126).

Funding sources

This study was supported by Clinical Nursing Research Foundation of the Second Xiangya Hospital of Central South University ( 2020-HLKY-04) and Education Research Project on Education and Teaching Reform of Central South University ( 2023jy092).

CRediT authorship contribution statement

Ye Man: Writing – review & editing, Resources, Methodology, Funding acquisition, Conceptualization. Huang Lihua: Writing – review & editing, Investigation. Li Xuting: Writing – review & editing, Investigation. Gao Shurui: Writing – review & editing, Investigation. Zhu Jie: Writing – review & editing, Investigation. Deng Xianjiao: Writing – review & editing, Writing – original draft, Methodology, Formal analysis, Data curation, Conceptualization. Guo Jiayi: Writing – review & editing, Writing – original draft, Visualization, Methodology, Formal analysis, Data curation.

Declaration of Competing Interest

None.

Acknowledgement

We sincerely thank all the nursing students who participated in this study.

Appendix A Supporting information

Supplementary data associated with this article can be found in the online version at doi:10.1016/j.nepr.2025.104348.

Appendix A Supplementary material

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Supplementary material Supplementary material


Scale Name Dimensions Items Scoring Scale Total Score Range Cronbach's α Validity/Reliability Details
Humanistic Care Ability Scale developed by Huang (2008) The scale consists of 8 dimensions, including instilling beliefs and hopes, health education, humanity, altruistic values, scientifically solving health problems, assisting in meeting basic needs, providing a good environment, promoting emotional communication and helping alleviate difficulties 45 Likert 5-point 45–225 0.904 ( Huang, 2008) Content validity coefficient = 0.960; Split Half Reliability = 0.925; Retest Reliability = 0.824 ( Huang, 2008)
The Jefferson Medical Staff Empathy Scale developed by Hojat et al. (2001) and sinicized by Ma (2009) The scale consists of 3 dimensions, including viewpoint selection, emotional care, and empathy 20 Likert 7-point 20–140 0.797 ( Ma, 2009) Split Half Reliability = 0.788 ( Ma, 2009)
Clinical Communication Ability Scale for Nursing Students developed by Yang et al. (2010) The scale consists of 6 dimensions, including keen listening, establishing harmonious relationships, confirming patient issues, participating together, conveying effective information, and verifying patient feelings 28 Likert 4-point 28–112 0.840 ( Yang et al., 2010) Dimensional Reliability ranges from 0.670 to 0.800 ( Yang et al., 2010)
Emotional Intelligence Scale for Clinical Junior Nurses developed by Schutte et al. (1998) and sinicized by Wang (2002) The scale consists of 4 dimensions, including emotional self-perception, emotional expression, emotional assessment of others, and emotional utilization 33 Likert 5-point 33–165 0.832 ( Wang, 2002) Dimensional Reliability ranges from 0.605 to 0.775; Retest Reliability = 0.913 ( Wang, 2002)
Table 1

Validated questionnaire instruments employed.


Variable Category Intervention
（N = 35）		 Control（N = 36） F/χ2 P
Age mean (standard deviation) 19.64 ± 0.69 19.94 ± 0.96 0.004 0.115
Gender male 8 3 1.857 0.173
female 27 33
Permanent Residence rural area 27 30 0.128 0.721
city 8 6
Only child Yes 10 7 0.388 0.533
No 25 29
Academic performance during school Moderate 16 13 0.338 0.561
Good 19 23
Have received a scholarship Yes 21 20 0.019 0.89
No 14 16
Have ever served as a student cadre Yes 9 14 0.869 0.351
No 16 22
The humanistic care atmosphere of the school Modnerate 0 1 1.507 0.471
Good 17 14
Very Good 18 21
Number of Humanities Education Hours Learned < 9 7 8 2.007 0.571
9—16 4 19
17—24 10 7
> 24 4 2
passion for the nursing profession dislike 3 0 5.702 0.127
Modnerate 7 3
like 14 18
Very like 11 15
Reasons for choosing a nursing major Personal interests 18 14 1.486 0.476
Opinions from family, friends, and teachers 10 15
obtain employment 7 7
Have you participated in any courses related to humanistic qualities Yes 30 27 0.699 0.403
No 5 8
Table 2

Participants’ socio-demographic and humanities-related characteristics.


Variables Group(n) T0 (Mean±SD) T1 (Mean±SD) T2 (Mean±SD) Between groups F(p) Within group F(p) Interaction effect F(p)
ANOVA
Analysis a		 Humanistic Care Ability Intervention (35) 133.8 ± 18.42 145 ± 14.57 151.86 ± 17.67 6.254 (0.015) 13.932 (0.000) 4.01 (0.020)
Control (36) 131.89 ± 21.87 134 ± 19.14 137.61 ± 20.13
Empathy Intervention (35) 107.54 ± 13.51 108.66 ± 13.19 108.34 ± 16.13 4.460 (0.038) 0.368 (0.688) 1.205 (0.302)
Control (36) 103.56 ± 15.26 100.53 ± 16 100.22 ± 17.73
Emotional Intelligence Intervention (35) 132.37 ± 14.87 139.63 ± 12.78 139.63 ± 10.76 3.393 (0.07) 2.137 (0.126) 8.738 (0.000)
Control (36) 135.11 ± 13.54 133.67 ± 17.10 128.75 ± 12.09
Clinical Communication Ability Intervention (35) 89.83 ± 10.90 91.94 ± 9.89 92.34 ± 10.08 2.498 (0.119) 2.828 (0.063) 1.757 (0.176)
Control (36) 87.81 ± 9.51 86.19 ± 11.29 90.14 ± 10.64
Variables Group(n) T0 (F/t, p) T1 (F/t, p) T2 (F/t, p)
Comparison between Groups b Humanistic Care Ability Intervention (35) F = 0.158,
p = 0.692		 F = 7.391,
p = 0.008		 F = 10.026,
p = 0.002
Control (36)
Empathy Intervention (35) t = 1.164,
p = 0.248		 t = 2.332,
p = 0.023		 t = 2.017,
p = 0.048
Control (36)
Emotional Intelligence Intervention (35) F = 0.660,
p = 0.420		 F = 2.757,
p = 0.101		 F = 16.004,
p = 0.000
Control (36)
Clinical Communication Ability Intervention (35) t = 0.834,
p = 0.407		 / /
Control (36)
Variables Group(n) T0 - T1 (MD) T0 - T2 (MD) T1 - T2 (MD) F(p)
Comparison within Groups c Humanistic Care Ability Intervention (35) −11.2 * −18.057 * −6.857 12.587 (<0.001)
Control (36) −2.111 −5.722 −3.611 1.313 (0.276)
Empathy Intervention (35) −1.114 −0.800 0.314 0.131 (0.869)
Control (36) 3.028 3.333 0.306 1.526 (0.226)
Emotional Intelligence Intervention (35) −7.257 * −7.257 * 0.00 7.784 (0.001)
Control (36) 1.444 6.361 * 4.917 3.023 (0.055)
Clinical Communication Ability Intervention (35) / / / /
Control (36) / / / /
Table 3

Comparison of outcome variables of nursing students between intervention and control groups at different time points.


Theme Sub-theme Quotes
Infectious Fusion and Educational Significance: The humanistic care digital storytelling programme had an inspirational impact on participants by immersing them in realistic scenarios of nurse-patient interactions. This exposure helped participants develop a more empathetic view of ICU care and highlighted nursing as a profession grounded in compassion. The interview and reflective diaries indicated that participants used narrative framework analysis to enhance their reflective practices and articulate their insights, deepening their understanding of humanistic qualities in nursing. Additionally, the programme reinforced participants' professional identity. By witnessing the dedication portrayed in the digital stories, participants experienced an increased sense of accomplishment and a stronger connection to their future profession. Furthermore, the digital stories emphasized the critical role of effective nurse-patient communication, allowing participants to gain a deeper appreciation for how communication impacts treatment outcomes in real clinical settings beyond theoretical knowledge. Inspirational Impact “My first experience with humanities courses like this has left a deep impression on me. In just a short ten-minute video, I saw the protagonist, Little Gratitude, transform from a wrinkled ‘old man’ into a chubby little child, which really moved me. Even though I've never raised children myself, it felt like I genuinely experienced the process of nurturing and caring for them.” (Reflection Diary 57)
“It's very touching! When something happens around you, it can really touch your heart and make you understand the patients' pain and the emotions of the teacher (the nurse in the video).” (N14)
Deepening Understanding of Humanistic Care “In the video, the SHARE care framework was applied as follows:S: (Perception of patient and family needs): 1. Emotional needs (During Xiaoxin's illness, after implementing some measures, the nurse teacher patiently comforted Xiaoxin's parents). 2. Social needs (Xiaoxin was preparing for the civil service exam when she suddenly fell ill. We carried out a series of treatments and restored her to health)……” (Reflection Diary 42)
“It's a warm course where you see a lot of love being conveyed. The nurse teachers are incredibly patient with the patients, genuinely caring about their health and considering how to ensure both physical and psychological recovery. The exchange of love is filled with humanistic care.” (N6)
Enhancing Professional Identity “Xuehua's story has changed my perception of nurses. I now truly admire this profession, realizing their dedication is no less than doctors'. Our goals are the same: to serve patients wholeheartedly, prioritizing their well-being. Every discharged patient gives me a sense of accomplishment. Each compliment and encouragement fuels my determination to continue.” (Reflection Diary 43)
“Nursing profession might seem ordinary, but it’s incredibly important and essential.” (Reflection Diary 75)
Understanding the Significance of Nurse-Patient Communication “Through the video, we learned about the importance of communication. The nurse communicated based on the patient's condition and achieved a good encouraging effect.” (Reflection Diary 72)
“My teachers always stressed the importance of communicating with patients and their families, but I didn't grasp it until I struggled with it during my internship. Seeing Xuehua's story made me realize its significance. Without the nurse manager's insistence on communication, Xuehua might have missed the best treatment opportunity.” (N8)
Balancing Enjoyment and Reflection: The digital storytelling program greatly captivated ICU nursing students, who highly appreciated its departure from traditional classroom settings and its ability to enhance the excitement of learning. This programme emphasized humanistic qualities through storytelling, creating a more relaxed and enjoyable learning environment that facilitated better understanding of concepts. The participants reported that the diverse teaching methods, including digital stories, reflective diaries and theses discussions significantly enhanced their self-reflection. By sharing and discussing reflections with peers, participants gained valuable insights into various practices of humanistic qualities and their practical applications. Engaging Non-traditional Courses “Interesting, isn't it? You get to hear others' stories and see how they care for patients in those videos. It's like watching a little story yourself, very intriguing, and you can empathize with it. In classes, teachers usually stick to textbooks, not telling us through stories like this. Through these little stories, we can better understand the content—it's not rigid.” (N15)
Various Forms Facilitating Thought and Reflection “This class is very diverse, presented in many different forms, offering a wide range of insights. Because everyone is different, our discussions often lead to collisions of ideas. It's fascinating to see how different people perceive the same thing. For example, I might approach it one way, but others might have better or different approaches. It makes me think, 'Oh, I didn't realize it could be done like that.' Next time, I can try using their approach.” (N9)
Complementary Relationship between the Teaching Curriculum and Clinical Practice: In clinical practice, participants applied the "SHARE Care Framework" they learned during the programme, integrating it with their experiences. This combination of theoretical knowledge and practical application, supported by the reflective diary, improved their focus on patient-centered care. Qualitative data revealed that observational skills became a crucial aspect of their practice, as participants carefully noted patients' expressions and environments, which improved their understanding of patient needs. Participants also became more attuned to patients' emotional struggles, fostering compassionate connections with both patients and their families. Moreover, participants demonstrated a dedication to active listening and effective communication, employing various techniques to connect with patients and establish trust. They found inspiration from digital stories that showcased skilled ICU nurses as role models. Furthermore, the importance of exceptional clinical mentors and courses was recognized by the participants, who emphasized how leading by example significantly impacted their approach to patient care. Practicing Care Frameworks “After attending several classes, I've noticed changes in myself. Now, I proactively pay attention to patients' psychological aspects and integrate the stories from videos with actual cases.” (N2)
“Before writing our reflections, we need to do some things to have something to write about. This process also motivates me to learn more about patients in daily routines and engage in more caring actions.” (N10)
Keen Observation and Patient Needs Perception “Before, I didn't pay much attention to patients right after surgery, like covering them with blankets. The nurse in the video talked about how post-op patients often don't feel cold themselves and need constant care, just like family. I just realized that we need to actively perceive the needs of patients, but this may not be learned suddenly。” (N18)
“I often see that some patients just need a look or a gesture, and the nurses know what they need. I think it’s the result of their daily care and developed understanding. Gradually, I feel like I’m starting to develop that kind of intuition too.” (Reflection Diary 36)
Caring for Patients' Inner Worlds “One time when I was suctioning mucus, I stood beside him and held his hand to keep him from moving. Suddenly, he grabbed my hand, and it touched my heart deeply. He was so young, staying in the ICUs for such a long time, and due to the pandemic, his parents couldn't visit, leaving him feeling insecure and longing for them.” (Reflection Diary 61)
“Do you feel pity when you see a few-month-old baby in the ICU? Do you think about how hard it must be for their mothers when the baby is just days old and already facing surgery? But this is their chance to stay in this world.” (N8)
Active Listening and Explanation “We must be the eyes, ears, and nose for doctors, and the voice for patients in the ICUs. We need to listen to patient’s feelings and conveying their thoughts.” (Reflection Diary 35)
“I remember it was past 2 AM, and I thought we could rest. Then, grandpa kept tapping the bed. My teacher and I rushed over to ask him what was wrong. He made mouth movements but couldn’t speak. We brought paper and pen, and I patiently tried to understand, but my patience wore thin as he repeatedly wrote '1, 2, 3′. The teacher suggested he use nods and shakes for yes and no, but grandpa didn’t respond. After an hour, I thought about the human-centered care videos and stayed patient. Finally, grandpa wrote down a name. When I asked if it was his daughter’s name, he nodded. I realized he missed his daughter.” (Reflection Diary 37)
The Power of Role Models “It's their (the nurses in the video) conscientious and careful attitude that helps these patients recover faster and overcome illness. In my upcoming internship, I am determined to learn from these teachers and approach tasks with thoroughness and care.” (Reflection Diary 29)
“I admire my preceptor a lot. She has never been impatient with me. When we encounter difficulties in turning theoretical knowledge into practice, she remains patient and supportive.” （N15)
Recommendations for Improving the Teaching Curriculum: To improve the teaching curriculum, addressing the scheduling of classes and the burden of reflective diaries is crucial. Participants have expressed concerns about class schedules sometimes conflicting with their days off or requiring attendance immediately after night shifts, which can lead to negative emotions and reduced enthusiasm. Adjusting course schedules to better align with participants' shift rotations could enhance their engagement. Additionally, while reflective diaries is valuable for self-reflection and understanding humanistic qualities, the current requirement of two diaries per week can be overwhelming. Participants suggested that reducing the frequency of feedback or providing more flexibility could alleviate their burden and enhance the work quality. Optimal Course Scheduling within Shift Rotation System “I actually find those videos quite moving, but I'm not keen on attending classes because they always seem to fall on my days off, which makes me feel uncomfortable and unhappy. Every time I'm off, I end up rushing over for class, and it really affects my experience. Some people might be lucky enough to attend during their work hours, and I envy that.” (N8)
“I think students with different shifts could have separate classes. That way, those who are off that day wouldn't feel so bothered.” (N13)
The Burden of Reflective Diary “Given our limited clinical experience, writing a three to four hundred-word diary entry is tough. Even if we manage it, the content often feels shallow. I propose writing just three or four pieces like this, capturing insights when they arise, rather than weekly. This should boost overall quality.” （N13)
“I think it might be a bit stressful to write two reflective diaries per class. One diary would suffice, there's no need to write two.” (N8)
Table 4

Themes, sub-themes and quotes of qualitative data.


Main categories Quantitative findings Qualitative findings Data integration fit
Humanistic Care Ability The intervention group scored significantly higher than the control group at both T1 (F = 7.391, p = 0.008),and T2 (F = 10.026, p = 0.002). Additionally, there were significant differences in humanistic care ability scores between the intervention group at T0 and T1 (MD = −11.2), as well as between T0 and T2 (MD = −18.057). Deepening Understanding of Humanistic Care Practicing Care Frameworks Confirmation
Empathy The empathy scores in intervention group were significantly higher than the control group at T1 (t = 2.332, p = 0.023) and T2 (t = 2.017, p = 0.048). Caring for Patients' Inner Worlds Confirmation
Emotional Intelligence There was no significant difference between the two groups at T1 (P＞0.05). At T2, the intervention group achieved significantly higher emotional intelligence scores than the control group (F = 16.004, p = 0.000). Additionally, significant differences in emotional intelligence scores were observed within the intervention group between T0 and T1 (MD = −7.257), and between T0 and T2 (MD = −7.257) (p < 0.05). Keen Observation and Patient Needs Perception Confirmation
Clinical Communication Ability No significant differences were observed. Understanding the Significance of Nurse-Patient Communication Active Listening and Explanation Discordance
/ Expanded categories: Inspirational Impact Enhancing Professional Identity Balancing Enjoyment and Reflection The Power of Role Models Recommendations for Improving Teaching Curriculum Expansion
Table 5

Comparison Between the Quantitative and Qualitative Findings.

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