Teaching and Learning in Nursing (2011) 6, 28

www.jtln.org

Therapeutic communication skills and student nurses in the clinical setting

Suzanne Rosenberg MS, RN, CCRN, Les Gallo-Silver MSW, LCSW-R
LaGuardia Community College, City University of New York, Long Island City, NY 11101, USA KEYWORDS:
Nursing student; Communication skills; Therapeutic communication Abstract Patients facing life-altering medical conditions with anxiety, depression, and anger present barriers to optimal care. This article suggests that the nursing student be facilitated through a process of connecting to patients using role playing, cognitive/behavioral techniques, and specific didactic information on how to interpret patient barriers to care. Teaching therapeutic communication using this model could help students respond to the distressed patient, depersonalizing negative messages, and formulating goaldriven relationships within their two-year clinicals. Published by Elsevier Inc. on behalf of National Organization for Associate Degree Nursing.

1. Introduction
The new nurse will enter a profession of seemingly insurmountable pressures: increased work hours, shortages in staff/services, emotional/physical strain, and intimate contact with suffering and at times terminal patients. Despite these familiar elements of being a new nurse, or perhaps because of them, nursing remains a calling as well as a career. Nurses have excelled in the Honesty and Ethics rankings of the Gallup Poll every year, except for one, since l999. Eighty-four percent of Americans polled rated nursing standards of honesty and ethics either high or very high (Gallop Poll, 2009). Preparing students to interact and create constructive communicative relationships with clients is essential to nursing practice. Elements of communication are systematically ingrained in nursing education. Professional dress code is required in the clinical setting and conveys respect for the patient. Students are monitored in their abilities to foster trust, through observation in communicating warmth and demonstrating consistency, reliability, and
* Corresponding author. E-mail address: srosenberg@lagcc.cuny.edu

competence. Advocacy for patients is emphasized in instruction and combined with the patient-centered philosophy that can be beneficial to persons concerned about losing control of their health management. Assertiveness is stressed, composed of respect for others and oneself through consistent communication. The nurse in the clinical area faces varied interpersonal experiences. Use of therapeutic communication provides a means to navigate through demanding challenges and remains highly regarded, as the Gallop Poll indicates. The ability to make personal sacrifices, absorb new information, and acquire new skills often cannot be sustained by a caring and committed new nurse. All nurses need to possess additional exceptional qualities that include the willingness and talent to create and sustain trusting relationships with patients. A trusting relationship promotes growth and healing in a patient's life and is a source of energy, gratification, and growth in the new nurse as well. The key to establishing a trusting relationship is the integration, usage, and mastery of therapeutic communication skills (Belcher & Jones, 2009). As the student nurse in clinical training soon learns, the most compassionate caregiver can be quickly exhausted by

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Therapeutic communication skills and student nurses in the clinical setting his or her patient's distress; the distress of patients' family/ caregivers; his or her own personal reactions to the patient's anguish; and the competing demands of supervisors, physicians, and institutions. If a nurse is to successfully meet these challenges, she or he must integrate the capacity to communicate emphatically, accurately, in a timely manner, and with attention paid to her or his own psychological and physical energies (Warelow, Edward, & Vinek, 2008). This article explores therapeutic communication (TC) as a professional technique founded on empathy, and boundary maintenance for the purposes of increasing understanding and stress reduction in both the cared-for and the caregiver. TC helps enhance the student nurse's experience of her or his clinical settings due to the flexible applications and information gathering benefits of the technique (O'Gara & Fairhurst, 2004). Accurate assessment of a patient is predicated on a working relationship with the student nurse that is as empathic as it is efficient (Kirk, 2007).

2. TC defined
It is important for the student nurse to imagine a newly admitted patient surrounded by strange technology, intimidated by the medical environment, and anxious and uncomfortable. Add to this patient's concerns is the mortification of being dressed in a hospital gown, which although provides easy access for the health care team, leaves many patients feeling exposed and more vulnerable. The other stresses include meetings with physicians that are unplanned and/or unscheduled that further erode the patient's sense of control and autonomy. This increases the stress on families who may be quizzing the patient on what a doctor has said or when the doctor will be available. Invasive tests increase the patient's feelings of vulnerability regardless of the results. As the student nurse puts these elements of a patient's experience together, she or he becomes aware that officious language, poor listening skills, and impatience could only increase a patient's distress. It is within this atmosphere of patient stress and distress that the student nurse must identify the root causes of the patient's discomfort, elicit personal information from the patient, and complete her or his history and physical of a patient who may be both frightened and passive. The student nurse's key goal is to gain the patient's cooperation and trust often in a limited amount of time. Relationship building is both an immediate and gradual process that requires an expenditure of the student nurse's emotional reserves. Caring and empathy are related nursing activities but are not the same. Caring is a physical act of taking care of a patient's physical needs, whereas empathy is caring put into words, nonverbal communication, and comportment. In their conversations with nonprofessional relationships in their lives, student nurses, as with most people, may speak casually using intuition as a guide to responding to,

requesting of, and advising family and friends. At times, a person can inadvertently interrupt, change subjects, insult, anger, or hurt a significant other or acquaintance. Intuition can fail, especially when we are stressed, preoccupied, anxious, sad, or fatigued (Marcus & Buffington-Vollum, 2005). Naturally, this can easily lead to negative reactions by the receivers of less-than-optimal communication. This can push others away from us and can create a barrier to the development of a trusting relationship. Given the concentrated short period that the student nurse must create a trusting relationship with the patient, problems in communication can present a considerable obstacle to obtaining descriptive and accurate answers. Direct questions to obtain information can lead the student nurse to barrage the patient with requests for information using a check-off system. Patients tend to experience this type of approach as blunt and uncaring (Neukurg, 2002). The uncaring factor comes from the student nurse's lack of responsiveness to the patient's answer as she or he goes immediately on to the next question. Closed questions that limit information by presenting an either-or comparison such as Do you feel hot or cold? not only sound officious but also lose opportunities to gather important information. Poor communication skills elicit neither reflection nor the detail necessary for the patient's health care assessment and treatment plan. The new relationship between student nurse and patient is in jeopardy of not meeting the needs of the cared-for and the caregiver. Open questions that promote and encourage patient expression are better able to enhance trust in a relationship as it conveys the student nurses' interest and investment in the patient (Neukurg, 2002). Open questions would be structured thusly: I would like to know how you are feeling in terms of temperature. This open question would elicit not only an answer that includes hot, cold, or warm but perhaps also other more descriptive answers such as burning, freezing, and others, as well as additional information about feelings and emotions such as scared, worried, upset, and other feeling descriptors. TC elicits information in an emotionally present way as the new nurse responds empathically to the information given to her or him before she or he goes on to the next topic or area of evaluation. Empathy communicates the shared humanity of the nurse patient relationship rather than any specific facts. An example of this would be when the student nurse is engaged in repositioning a patient in bed. In a natural way, the nurse asks for confirmation if the new position is comfortable and, if not, discusses ways to help the patient be more comfortable. The same questionresponse pattern is helpful in more complex and urgent situations as TC can assist patients in coping with these situations.

3. Introducing TC to students
TC is an integral part of the fundamentals of nursing curriculum (Potter and Perry, 2005). Students are introduced

4 to strategies that communicate empathy and those that result in distancing and defensiveness. Communication concepts are taught didactically in lecture/laboratory and experientially in the clinical setting. Many nursing students may describe patient interviews as the most frightening part of their training. During the transition from class to clinic, students may describe patients who won't let me wash them, won't eat, or won't talk with me, implying that the problem is with the patient. Claiming to legitimize the patient's rights of autonomy, the student nurse appears almost relieved to forego her or his clinical responsibilities. TC seeks approaches that recognize the underlying patient feelings that might be producing this rejection, giving patients' choices or input and eliciting their cooperation. TC helps students recognize that the patient is undergoing possibly life-altering issues, and refusal is an expression of the patient's personal concerns, having nothing to do with the student. The student has an opportunity to turn conflict into a bridge of communication by remaining confident, showing concern, and pursuing opportunities to develop trust with the patient. Remaining cheerful and interested in the patient helps the student focus on approaches of interaction rather than their own feelings of rejection. Specific problems and challenges from the student's current clinical setting undergo a peer problem-solving review in lecture/laboratory normalizing challenges and obstacles to TC. This process reveals common themes among student nurses such as managing an angry patient, recovering from patient rejection, responding to patient sadness/crying, and coping with sudden patient acknowledgement of their medical situation. In each of these themes, the student nurse could respond by personalizing the patient's communication, withdrawing from the patient in fear, developing anxiety about having done something that hurt or upset the patient, and believing that he or she is not suitable for a career in nursing. Student nurses may experience performance anxiety in the clinical setting that is not evident or demonstrated in a typical lecture/laboratory setting. In response to this, the student is taught to look at the feeling tone of the patient, acknowledge the emotion, and support the patient's self-esteem. Such responses as Mr. Jones, you seem angry today, I would like to help conveys respect, acknowledgment of, and interest in the patient. The previously difficult-to-manage displays of emotion can then be used as opportunities for building trust. Through standard role plays and discussion, students identify therapeutic and nontherapeutic responses and learn the rationale behind effective communication techniques. Role playing also helps to redefine the difficult patient as one who is suffering and is in distress rather than as one who is troublesome and problematic. By practicing the facilitators and blocks to TC, students learn the phrases that might be appropriate for patients and caregivers. Afterward, students discuss the scenarios and write descriptive analyses of the role players' communication skills, identifying blocks and

S. Rosenberg, L. Gallo-Silver facilitators to a productive nursepatient interaction, and emphasizing specific areas for improvement. Students then enact a more positive therapeutic versions using body language and other facilitators to engage, interview, and connect with the patient. Advanced role-play techniques are targeted to address the central themes as the students enact the role of the difficult patient and faculty enact the role of the student nurse. The purpose of this interaction is to provide the student with a method of productive ventilation of feelings through the enactment of the difficult patient. The goals of role play are to help the student nurse anticipate their worst fears and plan proactively to manage the situation and their personal feelings while remaining patient focused. Sample role-play scenarios are the following:
1. The angry patient in pain: Mr. A is a 90-year-old man admitted for fevers due to infected bedsores on his buttock and sacrum. He has congestive heart failure and is cared for at home by a home health aide 5 days a week, 3 hours a day, and his older sister who lives next door to him. The student nurse is responsible for taking the patient's history, evaluating the current home care, and documenting observations of the patient's decubiti. Mr. A answers the student nurse's questions with one-word answers or grunts. His eyes remain closed. The student nurse informs Mr. A that she needs to check his wounds. In response, he yells and curses at the student nurse. 2. The patient feeling the impact of the illness and treatment: Ms. B is a 28-year-old single woman admitted to the hospital for a complete hysterectomy due to metastatic ovarian cancer. Ms. B has just been transferred to a regular bed on the medicalsurgical floor from the surgical step down unit. The student nurse is responsible for orienting Ms. B to the floor and explains the bed and call bell operations. During the explanations, Ms. B begins to sob with a mixture of distress and despair. 3. The silent, mistrustful patient: Mr. C is a male child who appears to be between 12 and 16 years old with no known street address, guardians, or emergency contacts. He presented to the emergency room with pneumonia and a right pneumothorax. He also presented with syphilis and rectal bleeding. The child protective service was contacted, and Mr. C was now in protective custody. He has been in the hospital for 6 days. The student nurse is responsible for recording the fluid collection in the chest tube. Mr. C does not return the student nurse's greeting, does not answer any of her questions, and stares aggressively when he makes eye contact. 4. The tangential, avoidant patient: Ms. D is a 64-year-old woman admitted to the hospital due to a left-sided hip fracture after a fall. Ms. D fell in her bathroom and remained on the floor until her son returned from school 8 hours later. Ms. D has been transferred to a rehabilitation unit in the hospital. The student nurse is responsible for taking a history and orienting the patient to the new unit. Upon entering the room, Ms. D tells the student nurse about her son who is going to school to become a dentist. The student nurse begins to take a history but instead of answering the questions, Ms.

Therapeutic communication skills and student nurses in the clinical setting

D gives the student nurse a physical description of her son, shows a photograph of him, and extols his virtues as a devoted child. The student nurse tries again to take a history, and Ms. D begins to ask the student nurse personal questions.

projecting the distressing images on to it and then shutting off the projector or television (Fennel, 2007).

4. Guiding TC
Small clinical groups that allow the student to play the patient and the faculty to be the nurse can be reviewed using video recordings. This allows the student nurse to better identify with the patient's experience and to observe seasoned faculty modeling management of the situation. This level of preparation and rehearsal based on real-time issues for fellow students in the hospital provides a point of reference for all students when they experience a similar patient situation. Using cognitive concepts, in the form of relaxation techniques, students can be taught that anticipating catastrophe; however likely or unlikely can decrease their performance anxiety in difficult situations. For some student nurses, this performance anxiety can result in considerable negative self-talk that can prevent the student nurse from responding in the most empathic manner. Built into this approach is specifically addressing the student nurse's selfesteem as she or he identifies herself or himself as part of the nursing profession. This goal can be addressed by teaching student nurses coping statements that will enable them to comfort themselves when stressed as well as thought stopping to prevent negative images from intruding on the nursepatient relationship. Coping statements are positive self-talk used to counter negative thinking. We all converse with ourselves using our inner voice that gives words to our thoughts and feelings. The student nurse who is challenged by an angry patient may hear his or her inner voice say, Now look what you did. This is a mess. I can't do this. What do I do now? While having this conversation, the student nurse withdraws from the patient at the point that the patient needs more support and emotional presence. Coping statements can shorten or prevent this withdrawal from the patient by removing the student nurse from negative self-talk. The replacement statements could be My patient is communicating something about themselves, not me. I want to find out what my patient needs right now. This is all about the patient not me and other elements of positive self-talk germane to the situation (Demertzis & Craske, 2006; MacInnes, 2006). Thought stopping counters negative self-talk and the wish to withdraw that can arise from difficult interactions with patients. When the student nurse's inner voice uses negative self-talk, she or he can imagine a big red stop sign to disconnect from those thoughts and reconnect with the patient. At times, negative self-talk is accompanied by images of distressing situations in the past, imagining escalation of the patient's difficulties, some sort of disciplinary action for doing a poor job, and others. At times, distressing images occur during the negative self-talk. The student nurse can imagine a screen or television and Faculty can present opportunities for students to experience difficult patient encounters in the laboratory. An exercise requiring the students to be divided into groups of three, in which one student is the patient, another is the student, and the third is the observer. Several cue cards suggesting gestures and words can be given to the patient, allowing for expressions such as a patient who is using hostile language at the student. Another card can depict the language of a client who is withdrawn and refusing care. A third possibility can be the overly anxious patient who needs to dominate the dialogue and direction of care. The patient who is withdrawn and noncommunicative is another challenge for practice. The observer student can see if the student displays behaviors and verbal exchanges, which are directed toward developing a rapport and uses TC (Fig. 1). The observer can use a checklist and note specific responses of the student or, if resources allow, video record the incident for class experience. Practice can be identified as met or not met and would include the following: welcomes patient, shows empathy, provides encouragement, orients patient to environment, enhances patient's sense of control, responds to patient's cues, and initiates nurse patient partnership. Cue cards could require the patient to exhibit statements and behaviors that are challenging. The student needs to demonstrate the ability to remain collected and focused and help the client become a participant in the plan of care. The third student, faculty, or the entire classroom, if videoed, can evaluate the experience. Sample patient cues are the following:
1. 2. 3. 4. 5. Turn your head away from the nurse. Look up at the ceiling while the nurse is talking. Pretend to pick your nose and discover that it is bleeding. Pretend to have flatulence. Pretend to receive a telephone call and begin speaking to the caller, ignoring the nurse. 6. Ask the nurse a personal question that has no relationship to your interaction with him or her. 7. Complain about feeling itchy and pretend to expose yourself. 8. Pretend to gag and vomit.

5. Reflection
Reflection enables student nurses to practice selfevaluation of their nursing practice. This increases their awareness that effective nursing is the combination of their intellect and emotions. Student nurses can become more aware of how they feel about themselves, think, and act and

S. Rosenberg, L. Gallo-Silver

Fig. 1

Tool to measure student's therapeutic communication. *Information based on College of Nurses of Ontario (2009).

of the impact of all three on their patients. Reflection can also bolster confidence and self-esteem through appreciating what one has done well and maturely, accepting what one has to improve. Student nurses who are more comfortable with

themselves as people and as healers are able to be both authentic and natural with their patients while performing their responsibilities as professionals. (Berman, Snyder, Kozier, & Er, 2008).

Fig. 2

Prompts and processes in reflection.

Therapeutic communication skills and student nurses in the clinical setting

6. Reflection/self-study tool
Students are given a blank form with only prompt identified and completed the form for demonstration purposes (Fig. 2). After the role play, students can share their feelings and frustrations and get feedback from faculty and peers. To help the student to deepen the experience, through reflection, the faculty guides the student. Through these reflective experiences, students can better identify their weakness and, through practice in a safe environment, can better direct their thoughts and responses and not personalize patients' behaviors.

developing a rapport, he sensed I cared about him and was there to help him, he calmed down Using empathy, understanding, patience, I saw how TC enhanced my relationship with my patient. He trusted me more and more and shared with me his life before the surgery and told me how much I helped him to understand his condition and take care of himself after the discharge. I used the TC technique of listening. When I just listen to what my patient is saying, I am showing that I care about the patient's feelings and problems. I used assertive communication when I explained to Mrs. J. why I needed to take her pulse and respirations. I did this without violating her rights. A good listener can provide reassurance, lightening another person's burden

7. Applying TC
Application of therapeutic communication and student patient interaction is best observed in the clinical hospital setting. High achievers in the classroom may become robotic, tongue tied, and unable to apply their learning in the clinical setting. In this case, students need guidance in being more assertive in educating the patient to the benefits of care. The student must learn that treatment refused or postponed is nevertheless necessary. TC can liberate the student nurse from her or his own concerns and instead focuses the student nurse on understanding the patient and helping the patient understand them. Assertive communication is conveying directness and objectives, not anger or frustration. This is demonstrated by empathically setting limits and helping people follow rules for their own safety and well-being. Postconferencing at the end of each clinical day enables students to discuss the ways TC enhanced their caregiving. In postconference, students reported on their patients, often recounting their personal stories, struggles, and successes. Students reported positive practices of assertive communication that clarified misunderstanding, helped to gather necessary information, and provided reassurance. In postconference, students reported that using TC aided and supported their care. By demonstrating genuine interest and listening attentively, they opened up a dialogue and allowed them to better understand their patients.
Upon me entering his room, Mr. P was verbally abusive and yelling. When I introduced myself as a nursing student, he became even more verbally abusive. The patient stated, I need a nurse, get out of here. I don't need a student. I was taken aback and horrified with that initial experience. I didn't know how to react. I went out immediately and informed the nurse. Then I was thinking what I have to do. Itried to understand the reasoning behind his aggression. I did not take it personally and said to myself it is not about me but it is about the patient. I went back in a more relaxed manner and asked him if there is anything I could do. I developed a rapport with him and not concentrate on his colostomy or disease. I asked him what he liked doing. He mentioned he like cooking and we talked about his favorite dish. I just listened. After

My patient refused a.m. care. When I entered her room, I talked in a calm voice, asked why she refused to take a shower. Through TC, I gathered information needed for my plan of care. I learned she feels really cold, that's why she refuses to take a bath. My action was to teach the importance of hygienic care. TC means a lot to a patient. A simple gesture, a smile, or hello has a great importance.

8. Conclusion
Using TC effectively helps to create a nursepatient relationship that promotes choice and responsibility, gains patient input and cooperation, maximizes care outcomes, and thereby helps to avoid litigious confrontations. Integrating knowledge with compassion, the skill of therapeutic communication is the nurse's greatest asset in reducing stresses and establishing rapport. TC has been fully realized when the patient is able to partner in the management of his or her own health care. Nursing educators must empower students to reach their full potential as communicators and future professionals. We have the moral obligation to help students transfer the theory they have acquired in the classroom into the real world of work. Students will encounter tension, ambivalence, despair, and anguish. We must enable the individual nursing student to develop individual skills in therapeutic communication that will lead to the emergence of his or her own style of communication. By relieving both the tension and insecurities of the patient through TC, new nurses will better facilitate the delivery of health care and truly become healers.

References
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S. Rosenberg, L. Gallo-Silver
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