Teaching and Learning in Nursing (2011) 6, 2–8

www.jtln.org

Therapeutic communication skills and student nurses in theclinical 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

* Corresponding author.E-mail address: srosenberg@lagcc.cu

1557-3087/$ – see front matter. Publishdoi:10.1016/j.teln.2010.05.003

AbstractPatients facing life-altering medical conditions with anxiety, depression, and anger present barriers tooptimal care. This article suggests that the nursing student be facilitated through a process of connectingto patients using role playing, cognitive/behavioral techniques, and specific didactic information on howto interpret patient barriers to care. Teaching therapeutic communication using this model could helpstudents respond to the distressed patient, depersonalizing negative messages, and formulating goal-driven relationships within their two-year clinicals.Published by Elsevier Inc. on behalf of National Organization for Associate Degree Nursing.

KEYWORDS:Nursing student;Communication skills;Therapeuticcommunication

1. Introduction

The new nurse will enter a profession of seeminglyinsurmountable pressures: increased work hours, shortagesin staff/services, emotional/physical strain, and intimatecontact with suffering and at times terminal patients. Despitethese familiar elements of being a new nurse, or perhapsbecause of them, nursing remains a calling as well as acareer. Nurses have excelled in the “Honesty and Ethics”rankings of the Gallup Poll every year, except for one, sincel999. Eighty-four percent of Americans polled rated nursingstandards of honesty and ethics either “high or “very high”(Gallop Poll, 2009). Preparing students to interact and createconstructive communicative relationships with clients isessential to nursing practice. Elements of communication aresystematically ingrained in nursing education. Professionaldress code is required in the clinical setting and conveysrespect for the patient. Students are monitored in theirabilities to foster trust, through observation in communicat-ing warmth and demonstrating consistency, reliability, and

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competence. Advocacy for patients is emphasized ininstruction and combined with the “patient-centered”philosophy that can be beneficial to persons concernedabout losing control of their health management. Assertive-ness is stressed, composed of respect for others and oneselfthrough consistent communication. The nurse in the clinicalarea faces varied interpersonal experiences. Use of thera-peutic communication provides a means to navigate throughdemanding challenges and remains highly regarded, as theGallop Poll indicates.

The ability to make personal sacrifices, absorb newinformation, and acquire new skills often cannot be sustainedby a caring and committed new nurse. All nurses need topossess additional exceptional qualities that include thewillingness and talent to create and sustain trusting relation-ships with patients. A trusting relationship promotes growthand healing in a patient's life and is a source of energy,gratification, and growth in the new nurse as well. The key toestablishing 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, themost compassionate caregiver can be quickly exhausted by

l Organization for Associate Degree Nursing.

3Therapeutic 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'sanguish; and the competing demands of supervisors,physicians, and institutions. If a nurse is to successfullymeet these challenges, she or he must integrate the capacityto communicate emphatically, accurately, in a timelymanner, and with attention paid to her or his ownpsychological and physical energies (Warelow, Edward, &Vinek, 2008).

This article explores therapeutic communication (TC) as aprofessional technique founded on empathy, and boundarymaintenance for the purposes of increasing understandingand stress reduction in both the cared-for and the caregiver.TC helps enhance the student nurse's experience of her or hisclinical settings due to the flexible applications andinformation gathering benefits of the technique (O'Gara &Fairhurst, 2004). Accurate assessment of a patient ispredicated on a working relationship with the student nursethat is as empathic as it is efficient (Kirk, 2007).

2. TC defined

It is important for the student nurse to imagine a newlyadmitted patient surrounded by strange technology, intimi-dated by the medical environment, and anxious anduncomfortable. Add to this patient's concerns is themortification of being dressed in a hospital gown, whichalthough provides easy access for the health care team,leaves many patients feeling exposed and more vulnerable.The other stresses include meetings with physicians that areunplanned and/or unscheduled that further erode thepatient's sense of control and autonomy. This increases thestress on families who may be quizzing the patient on what adoctor has said or when the doctor will be available. Invasivetests increase the patient's feelings of vulnerability regardlessof the results. As the student nurse puts these elements of apatient's experience together, she or he becomes aware thatofficious language, poor listening skills, and impatiencecould only increase a patient's distress.

It is within this atmosphere of patient stress and distressthat the student nurse must identify the root causes of thepatient's discomfort, elicit personal information from thepatient, and complete her or his history and physical of apatient who may be both frightened and passive. The studentnurse's key goal is to gain the patient's cooperation and trustoften in a limited amount of time. Relationship building isboth an immediate and gradual process that requires anexpenditure of the student nurse's emotional reserves. Caringand empathy are related nursing activities but are not thesame. Caring is a physical act of taking care of a patient'sphysical needs, whereas empathy is caring put into words,nonverbal communication, and comportment.

In their conversations with nonprofessional relationshipsin their lives, student nurses, as with most people, may speakcasually using intuition as a guide to responding to,

requesting of, and advising family and friends. At times, aperson can inadvertently interrupt, change subjects, insult,anger, or hurt a significant other or acquaintance. Intuitioncan fail, especially when we are stressed, preoccupied,anxious, sad, or fatigued (Marcus & Buffington-Vollum,2005). Naturally, this can easily lead to negative reactions bythe receivers of less-than-optimal communication. This canpush others away from us and can create a barrier to thedevelopment of a trusting relationship.

Given the concentrated short period that the student nursemust create a trusting relationship with the patient, problemsin communication can present a considerable obstacle toobtaining descriptive and accurate answers. Direct questionsto obtain information can lead the student nurse to barrage thepatient with requests for information using a check-offsystem. Patients tend to experience this type of approach asblunt and uncaring (Neukurg, 2002). The uncaring factorcomes from the student nurse's lack of responsiveness to thepatient's answer as she or he goes immediately on to the nextquestion. Closed questions that limit information by present-ing an “either-or” comparison such as “Do you feel hot orcold?” not only sound officious but also lose opportunities togather important information. Poor communication skillselicit neither reflection nor the detail necessary for thepatient's health care assessment and treatment plan. The newrelationship between student nurse and patient is in jeopardyof not meeting the needs of the cared-for and the caregiver.

Open questions that promote and encourage patientexpression are better able to enhance trust in a relationshipas it conveys the student nurses' interest and investment inthe patient (Neukurg, 2002). Open questions would bestructured thusly: “I would like to know how you are feelingin terms of temperature.” This open question would elicit notonly an answer that includes hot, cold, or warm but perhapsalso other more descriptive answers such as burning,freezing, and others, as well as additional informationabout “feelings and emotions” such as scared, worried,upset, and other feeling descriptors. TC elicits information inan emotionally present way as the new nurse respondsempathically to the information given to her or him beforeshe 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. Anexample of this would be when the student nurse is engagedin repositioning a patient in bed. In a natural way, the nurseasks for confirmation if the new position is comfortable and,if not, discusses ways to help the patient be morecomfortable. The same question–response pattern is helpfulin more complex and urgent situations as TC can assistpatients in coping with these situations.

3. Introducing TC to students

TC is an integral part of the fundamentals of nursingcurriculum (Potter and Perry, 2005). Students are introduced

4 S. Rosenberg, L. Gallo-Silver

to strategies that communicate empathy and those that resultin distancing and defensiveness. Communication conceptsare taught didactically in lecture/laboratory and experien-tially in the clinical setting. Many nursing students maydescribe patient interviews as the most frightening part oftheir training.

During the transition from class to clinic, students maydescribe patients who “won't let me wash them,” “won'teat,” or “won't talk with me,” implying that the problem iswith the patient. Claiming to legitimize the patient's rights ofautonomy, the student nurse appears almost relieved toforego her or his clinical responsibilities. TC seeksapproaches that recognize the underlying patient feelingsthat might be producing this rejection, giving patients'choices or input and eliciting their cooperation. TC helpsstudents recognize that the patient is undergoing possiblylife-altering issues, and refusal is an expression of thepatient's personal concerns, having nothing to do with thestudent. The student has an opportunity to turn conflict into abridge of communication by remaining confident, showingconcern, and pursuing opportunities to develop trust with thepatient. Remaining cheerful and interested in the patienthelps the student focus on approaches of interaction ratherthan their own feelings of rejection.

Specific problems and challenges from the student'scurrent clinical setting undergo a peer problem-solvingreview in lecture/laboratory normalizing challenges andobstacles to TC. This process reveals common themesamong student nurses such as managing an angry patient,recovering from patient rejection, responding to patientsadness/crying, and coping with “sudden” patient acknowl-edgement of their medical situation. In each of these themes,the student nurse could respond by personalizing thepatient's communication, withdrawing from the patient infear, developing anxiety about having done something thathurt or upset the patient, and believing that he or she is notsuitable for a career in nursing. Student nurses mayexperience performance anxiety in the clinical setting thatis not evident or demonstrated in a typical lecture/laboratorysetting. In response to this, the student is taught to look at thefeeling tone of the patient, acknowledge the emotion, andsupport the patient's self-esteem. Such responses as “Mr.Jones, you seem angry today, I would like to help” conveysrespect, acknowledgment of, and interest in the patient. Thepreviously difficult-to-manage displays of emotion can thenbe used as opportunities for building trust.

Through standard role plays and discussion, studentsidentify therapeutic and nontherapeutic responses and learnthe rationale behind effective communication techniques.Role playing also helps to redefine the difficult patient as onewho is suffering and is in distress rather than as one who istroublesome and problematic. By practicing the facilitatorsand blocks to TC, students learn the phrases that might beappropriate for patients and caregivers. Afterward, studentsdiscuss the scenarios and write descriptive analyses of therole players' communication skills, identifying blocks and

facilitators to a productive nurse–patient interaction, andemphasizing specific areas for improvement. Students thenenact a more positive therapeutic versions using bodylanguage and other facilitators to engage, interview, andconnect with the patient. Advanced role-play techniques aretargeted to address the central themes as the students enactthe role of the difficult patient and faculty enact the role ofthe student nurse. The purpose of this interaction is toprovide the student with a method of productive ventilationof feelings through the enactment of the difficult patient. Thegoals of role play are to help the student nurse anticipate“their worst fears” and plan proactively to manage thesituation and their personal feelings while remaining patientfocused.

Sample role-play scenarios are the following:

1. The angry patient in pain: Mr. A is a 90-year-old manadmitted for fevers due to infected bedsores on his buttockand sacrum. He has congestive heart failure and is cared for athome by a home health aide 5 days a week, 3 hours a day, andhis older sister who lives next door to him. The student nurseis responsible for taking the patient's history, evaluating thecurrent home care, and documenting observations of thepatient's decubiti. Mr. A answers the student nurse'squestions with one-word answers or grunts. His eyes remainclosed. The student nurse informs Mr. A that she needs tocheck his wounds. In response, he yells and curses at thestudent nurse.

2. The patient feeling the impact of the illness and treatment:Ms. B is a 28-year-old single woman admitted to the hospitalfor a complete hysterectomy due to metastatic ovarian cancer.Ms. B has just been transferred to a regular bed on themedical–surgical floor from the surgical step down unit. Thestudent nurse is responsible for orienting Ms. B to the floorand explains the bed and call bell operations. During theexplanations, Ms. B begins to sob with a mixture of distressand despair.

3. The silent, mistrustful patient: Mr. C is a male child whoappears to be between 12 and 16 years old with no knownstreet address, guardians, or emergency contacts. Hepresented to the emergency room with pneumonia and aright pneumothorax. He also presented with syphilis andrectal bleeding. The child protective service was contacted,and Mr. C was now in protective custody. He has been in thehospital for 6 days. The student nurse is responsible forrecording the fluid collection in the chest tube. Mr. C doesnot return the student nurse's greeting, does not answer anyof her questions, and stares aggressively when he makes eyecontact.

4. The tangential, avoidant patient: Ms. D is a 64-year-oldwoman admitted to the hospital due to a left-sided hipfracture after a fall. Ms. D fell in her bathroom and remainedon the floor until her son returned from school 8 hours later.Ms. D has been transferred to a rehabilitation unit in thehospital. The student nurse is responsible for taking a historyand orienting the patient to the new unit. Upon entering theroom, Ms. D tells the student nurse about her son who isgoing to school to become a dentist. The student nurse beginsto take a history but instead of answering the questions, Ms.

5Therapeutic 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 adevoted child. The student nurse tries again to take a history,and Ms. D begins to ask the student nurse personal questions.

Small clinical groups that allow the student to play thepatient and the faculty to be the “nurse” can be reviewedusing video recordings. This allows the student nurse tobetter identify with the patient's experience and to observeseasoned faculty modeling management of the situation. Thislevel of preparation and rehearsal based on real-time issuesfor fellow students in the hospital provides a point ofreference for all students when they experience a similarpatient situation.

Using cognitive concepts, in the form of relaxationtechniques, students can be taught that anticipating catastro-phe; however likely or unlikely can decrease their perfor-mance anxiety in difficult situations. For some studentnurses, this performance anxiety can result in considerablenegative self-talk that can prevent the student nurse fromresponding in the most empathic manner. Built into thisapproach is specifically addressing the student nurse's self-esteem as she or he identifies herself or himself as part of thenursing profession. This goal can be addressed by teachingstudent nurses coping statements that will enable them tocomfort themselves when stressed as well as thoughtstopping to prevent negative images from intruding on thenurse–patient relationship.

Coping statements are positive self-talk used to counternegative thinking. We all converse with ourselves using ourinner voice that gives words to our thoughts and feelings.The student nurse who is challenged by an angry patient mayhear his or her inner voice say, “Now look what you did. Thisis a mess. I can't do this. What do I do now?” While havingthis “conversation,” the student nurse withdraws from thepatient at the point that the patient needs more support andemotional presence. Coping statements can shorten orprevent this withdrawal from the patient by removing thestudent nurse from negative self-talk. The replacementstatements could be “My patient is communicating some-thing about themselves, not me. I want to find out what mypatient needs right now. This is all about the patient not me”and other elements of positive self-talk germane to thesituation (Demertzis & Craske, 2006; MacInnes, 2006).

Thought stopping counters negative self-talk and the wishto withdraw that can arise from difficult interactions withpatients. When the student nurse's inner voice uses negativeself-talk, she or he can imagine a big red stop sign todisconnect from those thoughts and reconnect with thepatient. At times, negative self-talk is accompanied byimages of distressing situations in the past, imaginingescalation of the patient's difficulties, some sort ofdisciplinary action for doing a poor job, and others. Attimes, distressing images occur during the negative self-talk.The student nurse can imagine a screen or television and

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

4. Guiding TC

Faculty can present opportunities for students toexperience difficult patient encounters in the laboratory.An exercise requiring the students to be divided intogroups of three, in which one student is the “patient,”another is the student, and the third is the observer. Severalcue cards suggesting gestures and words can be given tothe “patient,” allowing for expressions such as a patientwho is using hostile language at the student. Another cardcan depict the language of a client who is withdrawn andrefusing care. A third possibility can be the overly anxiouspatient who needs to dominate the dialogue and directionof care. The patient who is withdrawn and noncommuni-cative is another challenge for practice. The observerstudent can see if the “student” displays behaviors andverbal exchanges, which are directed toward developing arapport and uses TC (Fig. 1).

The observer can use a checklist and note specificresponses of the “student” or, if resources allow, video recordthe 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 ofcontrol, responds to patient's cues, and initiates nurse–patient partnership.

Cue cards could require the patient to exhibit statementsand behaviors that are challenging. The student needs todemonstrate the ability to remain collected and focused andhelp the client become a participant in the plan of care.The third student, faculty, or the entire classroom, ifvideoed, can evaluate the experience.

Sample “patient” cues are the following:

1. Turn your head away from the nurse.2. Look up at the ceiling while the nurse is talking.3. Pretend to pick your nose and discover that it is bleeding.4. Pretend to have flatulence.5. 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 self-evaluation of their nursing practice. This increases theirawareness that effective nursing is the combination of theirintellect and emotions. Student nurses can become moreaware of how they feel about themselves, think, and act and

Fig. 1 Tool to measure student's therapeutic communication. *Information based on College of Nurses of Ontario (2009).

6 S. Rosenberg, L. Gallo-Silver

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

Fig. 2 Prompts and pro

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

cesses in reflection.

7Therapeutic communication skills and student nurses in the clinical setting

6. Reflection/self-study tool

Students are given a blank form with only promptidentified and completed the form for demonstrationpurposes (Fig. 2). After the role play, students can sharetheir feelings and frustrations and get feedback from facultyand peers. To help the student to deepen the experience,through reflection, the faculty guides the student. Throughthese reflective experiences, students can better identify theirweakness and, through practice in a safe environment, canbetter direct their thoughts and responses and not personalizepatients' behaviors.

7. Applying TC

Application of therapeutic communication and student–patient interaction is best observed in the clinical hospitalsetting. High achievers in the classroom may becomerobotic, tongue tied, and unable to apply their learning inthe clinical setting. In this case, students need guidance inbeing more assertive in educating the patient to thebenefits of care. The student must learn that treatmentrefused or postponed is nevertheless necessary. TC canliberate the student nurse from her or his own concernsand instead focuses the student nurse on understandingthe patient and helping the patient understand them.Assertive communication is conveying directness andobjectives, not anger or frustration. This is demonstratedby empathically setting limits and helping people followrules for their own safety and well-being.

Postconferencing at the end of each clinical day enablesstudents to discuss the ways TC enhanced their caregiving.In postconference, students reported on their patients, oftenrecounting their personal stories, struggles, and successes.Students reported positive practices of assertive communi-cation that clarified misunderstanding, helped to gathernecessary information, and provided reassurance.

In postconference, students reported that using TC aidedand supported their care. By demonstrating genuine interestand listening attentively, they opened up a dialogue andallowed them to better understand their patients.

Upon me entering his room, Mr. P was verbally abusiveand yelling. When I introduced myself as a nursingstudent, he became even more verbally abusive. Thepatient stated, “I need a nurse, get out of here. I don't needa student.” I was taken aback and horrified with that initialexperience. I didn't know how to react. I went outimmediately and informed the nurse. Then I was thinkingwhat I have to do. I…tried to understand the reasoningbehind his aggression. I did not take it personally and saidto myself it is not about me but it is about the patient. Iwent back in amore relaxedmanner and asked him if thereis anything I could do. I developed a rapport with him andnot concentrate on his colostomy or disease. I asked himwhat he liked doing. Hementioned he like cooking andwetalked about his favorite dish. I just listened. After

developing a rapport, he sensed I cared about him and wasthere to help him, he calmed down…”

…Using empathy, understanding, patience, I saw howTC enhanced my relationship with my patient. He trustedme more and more and shared with me his life before thesurgery and told me how much I helped him tounderstand his condition and take care of himself afterthe discharge.

…I used the TC technique of listening.When I just listen towhat my patient is saying, I am showing that I care aboutthe patient's feelings and problems. I used assertivecommunication when I explained to Mrs. J. why I neededto take her pulse and respirations…. I did this withoutviolating her rights. …A good listener can providereassurance, lightening another person's burden…

My patient refused a.m. care. When I entered her room, Italked in a calm voice, asked why she refused to take ashower. Through TC, I gathered information needed formy plan of care. I learned she feels really cold, that's whyshe refuses to take a bath. My action was to teach theimportance of hygienic care. TCmeans 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 nurse–patientrelationship that promotes choice and responsibility, gainspatient input and cooperation, maximizes care outcomes, andthereby helps to avoid litigious confrontations. Integratingknowledge with compassion, the skill of therapeuticcommunication is the nurse's greatest asset in reducingstresses and establishing rapport. TC has been fully realizedwhen the patient is able to partner in the management of hisor her own health care.

Nursing educators must empower students to reach theirfull potential as communicators and future professionals. Wehave the moral obligation to help students transfer the theorythey have acquired in the classroom into the real world ofwork. Students will encounter tension, ambivalence, despair,and anguish.Wemust enable the individual nursing student todevelop individual skills in therapeutic communication thatwill lead to the emergence of his or her own style ofcommunication. By relieving both the tension and insecuritiesof the patient through TC, new nurses will better facilitate thedelivery of health care and truly become “healers.”

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