- Email: [email protected]
Improving Therapeutic Communication in Nursing Through Simulation Exercise
Teaching and Learning in Nursing 14 (2019) 260–264
Contents lists available at ScienceDirect
Teaching and Learning in Nursing journal homepage: www.jtln.org
Improving therapeutic communication in nursing through simulation exercise Tim Blake, RN, MS a,⁎, Tayler Blake, PhD b a b
Ohio University-Zanesville, Ohio 43701, USA Department of Statistics, The Ohio State University, Columbus, Ohio 43201, USA
a r t i c l e
i n f o
Article history: Accepted 6 June 2019 Keywords: Therapeutic communication Nursing Simulation exercise
a b s t r a c t Becoming proficient in therapeutic communication requires adequate educational preparation, as well as ongoing practice and personal reflection about one’s ability to communicate. This article discusses a study that examines the effects of a nursing lab simulation used to increase the self- efficacy of 32 nursing students with their ability to utilize effective communication skills. We concluded that the lab simulation was helpful in improving student self-efficacy regarding their therapeutic communication skills. © 2019 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
Introduction Nursing is both an art and a science that involves numerous subspecialties. We often think of mental health nursing as an area that involves effective communication skills as a prerequisite for a nurse to be effective in providing patient care. However, communication skills are paramount in all fields of nursing in order for the nurse to be successful. Teaching therapeutic communication to nursing students assists them to become competent in communicating not only with patients but also with other health care professionals. Background Laffan (2011) defines therapeutic communication as a face-toface interaction that focuses on improving the emotional and physical welfare of the patient. Using therapeutic communication, nurses can provide emotional support and vital information to the patient. To accomplish these goals, a variety of techniques should be used when communicating with the patient. The ability to communicate effectively can foster healthy professional relationships with patients and health care professionals alike. Therapeutic communication can help establish and build relationships, prevent mistakes, and provide an improved level of patient care (Neese, 2015). According to James (2013), up to 440,000 people die annually because of preventable medical errors. This number represents a significant portion of the fourth leading cause of death, ⁎ Corresponding author. Tel.: +1 740 588 1470; +1 740 328 9075 (Cell). E-mail address: [email protected]. (T. Blake).
which is unintentional injuries (Heron, 2016). Furthermore, the Joint Commission estimates that 80% of serious medical errors involve miscommunication (Kulczycki, 2012). The Joint Commission's analysis of 2012, 2013, and first quarter data of 2014 revealed that communication was one of the top three leading causes of unanticipated events in a health care setting that results in death or serious physical or psychological injury (Neese, 2015; Jointcommision.org, 2012. Therapeutic communication is generally referred to as a dialog between the nurse and the patient with the purpose of improving the patient's health, safety, and comfort as well as building well-being and trust. It is necessary for the nurse to be able to effectively communicate with other health care professionals in order to achieve those same goals. Improvements in communication among nurses and allied health can decrease medical errors and increase positive patient outcomes. Starmer et al. (2014) concluded that medical error rates in nine children's hospitals decreased 23% after the implementation of a handoff program designed to enhance and standardize communication. Growing evidence reveals that improving communication between nurses and patients, and involving patients more closely in their care, results in greater adherence to the care plan, fewer hospital readmissions, and better patient health (Stimpfel, Sloane, McHugh, & Aiken, 2016). In order to be successful communicators, nurses must study communication skills and the dynamics of interpersonal communication as part of their education process (Kourkouta & Papathanasiou, 2014). It is important to emphasize the communication between patient and nurse as well as the communication between the nurse and other members of the health care team. Therapeutic communication
https://doi.org/10.1016/j.teln.2019.06.003 1557-3087/© 2019 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
T. Blake, T. Blake / Teaching and Learning in Nursing 14 (2019) 260–264
between the nurse and the patient requires the use of empathy, which is distinctly different from sympathy. Empathetic communication denotes an understanding of the patient's perception (Jarvis, 2016; Varcarolis, 2013). Another facet of therapeutic communication is the use of active listening. (Jarvis, 2016; Varcarolis, 2013). Active listening requires nurses to pay full attention to the patient's message, while blocking out other concerns and disturbances that may detract from the interchange. Active listening requires nurses to interpret the patient's messages and provides clarification when necessary (Jarvis, 2016; Varcarolis, 2013). By using personal reflection, nurses can come to understand their own feelings and values, thus making the communication process more effective. Self-awareness of one's own values is necessary when working with patients who may have a different value system. Nurses must also be able to demonstrate genuineness and honesty in order to facilitate therapeutic communication. Knowing how one communicates allows nurses to make improvements in their communication skills.
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Simulation Objectives • Students will participate in a simulation exercise utilizing previously learned communication skills. • Students will explore their communication strengths and areas for improvement in a postsimulation setting. • Students will explore their own self-efficacy related to their ability to communicate therapeutically. Participants The subjects for this study consisted a convenience sample of 35 nursing students in their capstone course of a nursing program located in the midwest of the United States. The simulation received exempted status from Institutional Review Board because no identification was used when collecting data. Description of Instruments
Teaching Therapeutic Communication to Nursing Students Using Standardized Patients Many nursing students consider communication skills a challenge, and many students express their concerns about therapeutic communication, particularly with psychiatric patients. This concern often begins before clinical rotations in psychiatric/mental health nursing. Even after mental health nursing, students continue to feel a lack of confidence regarding their communication skills. Students often feel anxious about communicating with psychiatric patients prior to entering mental health clinical (Cowen, Hubbard, & Hancock, 2016). Students voice concern that they will say the wrong thing to their patients or are uncertain how to respond to patients in certain situations, resulting in patients harming themselves (Halter, 2014). Henceforth, clinical skills may be adversely affected by high levels of anxiety, leaving students unable to safely administer care to patients (Ross, Bruderle, Meakim, Willens, & Holmwood, 2016). The importance of teaching therapeutic communication cannot be overstated. However, nursing students may feel there is a gap between classroom experiences and experiences in the clinical setting (Flood & Robinia, 2014). In other words, students must become proficient in utilizing open-ended and closed-ended questions, as well as being able to use clarifying, exploring, validating, and paraphrasing. These are all critical verbal skills to learn. It is also imperative to develop a skill in interpreting nonverbal communication. The classroom is one place utilized for teaching communication skills as well as laboratories, where simulations may be utilized. Classroom activities may include theory related to therapeutic communication, as well as examples of therapeutic and nontherapeutic responses. However, students must be able to practice such skills in order to become effective. Practicing communication skills in class can be difficult because of barriers, such as class size and class duration (Rosenberg & Gallo-Silver, 2011). Simulations outside of class time may be another method for allowing students to practice and assimilate communication skills. Simulations can include such methods as high-fidelity mannequins, computerized simulations, gaming, and role-play (Dearmon et al., 2013). Simulation, when provided prior to a clinical practicum, has been shown to improve knowledge levels and self-efficacy, resulting in decreased anxiety The purpose of this study is to test the following hypothesis. Hypothesis A simulation exercise will improve the self-efficacy of nursing students related to their ability to perform therapeutic communication.
Students were required to complete a pretest and an identical posttest designed by the researcher, each consisting of five questions related to their self-efficacy related to therapeutic communication. Content validity and interrater reliability were established by two university simulation experts. Each question required students to use a 5-point Likert scale, with 1 being the least confident and 5 being the most confident in their communication abilities. The survey was presented in the following format: The dialog for the simulation was developed from an actual process recording completed by a previous student in the mental health course. In place of the nursing student's response, the dialog was left blank, indicating that the nursing students in the simulation were required to respond to the patient's statements. The main idea focused around a young adult female who was hospitalized after a suicide attempt. The nursing students completing the interview were required to do an admission assessment and establish progression of problem areas for the patient. As noted in the rubric (Table 2), the students who are the raters are required to follow along with the script, and give credit under any applicable box for therapeutic and nontherapeutic statements or actions. To score the rubric, each pertinent box receives 1 point. Points are then summed under each of the “therapeutic” and “nontherapeutic” categories, and totals are recorded for each student. (See Table 1.) In Table 3, the student raters summarize the communication strengths of each of the students playing the role of the nurse completing the interview. There is space provided to list communication strengths, as well as areas for improvement. After the simulation is completed, the faculty member reviews the results with the raters for consistency. A debriefing is then completed with the student
Table 1 Student questionnaire 1 2 3 4 5 1. I am comfortable talking with patients. 2. I feel like I can communicate therapeutically with patients. 3. My patients are able to confide in me. 4. I can accurately assess my therapeutic and nontherapeutic skills during assessment. 5. I am able to list my personal objectives for improving my therapeutic communication skills. Note. Assessing student self-efficacy in therapeutic communication. Pretest/posttest: 1 = least confident, 2 = not very confident, 3 = indifferent, 4 = somewhat confident, 5 = most confident.
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Table 2 Therapeutic communication rubric. Effective communication Nonverbal communication Faces patient within an appropriate concern for personal space Relaxed posture Hands, arms open Discussion takes place in a private area. Conveys caring attitude Verbal Tone of voice is calming or soothing. Assures confidentiality within treatment setting Attentive to patient needs (i.e., hunger, thirst, cold or heat, fatigue) Focus remained primarily on patient, mostly patient disclosure Use of open-ended questions Able to listen to patient without interjecting personal bias or views Including patient ideas in resolution of issues Active listening
Noneffective communication Comments Turns away from patient. Inappropriate concern for personal space. Appears tense or demonstrates an intimidating posture Hands folded or arms crossed Discussion takes place when other people are within a short distance. Appears disinterested, frightened, or uncomfortable. Tone of voice is loud, harsh, or pressured. No discussion of confidentiality with the patient Continues to ask questions that are causing emotional distress in the patient Interviewer focuses on him or herself, instead of the patient. Mostly closed-ended questions that required only one-word responses (i.e., yes-or-no answers) Makes statements that demonstrate personal opinions or biases. Giving advice to patient
Does not appear to pay attention to the patient Clarify Does not attempt to clarify vital information from the patient Providing vital information Missed opportunities for teaching Complete lack of or too much selfAppropriate use of selfdisclosure disclosure (establishing rapport and trust) Using silence Engages in superficial verbal banter Focusing Unable to assess patient's nonverbal cues Total Total
Comments
group to review the communication strengths and areas for improvement of the students completing the assessment, as well as eliciting input from the students within the group. On this form, the raters were responsible for listing the nursing students' communication strengths and communication areas for improvement. The findings were then discussed in the debriefing section of the simulation. Study Design and Data Collection To test the hypothesis of improved self-efficacy in therapeutic communication after the completion of clinical simulations, a quasiexperiment using a one-group, pretest/posttest design was used. The treatment consisted of a simulation exercise during a weekly laboratory simulation focusing on communication skills. Weekly laboratories comprised a portion of the curriculum for the course, which covered a number of topics including elements of communication. The 32 students were provided a pretest questionnaire consisting of
five questions focusing on self-efficacy of therapeutic communication skills. All students were part of the scheduled laboratory. Students were randomly divided into groups, four of which consisted of five students and two groups having six students. Each group was then placed in the simulation. There were three faculty members who moderated each of the simulations; these faculty members met to discuss the moderation process to improve consistency across each simulation. Detailed discussion among faculty involved key points for leading the simulation, as well as grading the rubric given to students who were assigned the role of raters during the simulation. Each faculty member compared their results with the raters to assure that rubric scores were the same. Students in each group were randomly assigned roles to enact in the simulation. One student was assigned the role of the patient and was provided with a script to follow. It is worth noting that the data collection from the simulation is not to show that each student is able to demonstrate the ability to communicate therapeutically, but rather that each student is feels more self-confident in his or her ability to communicate therapeutically. Student 2 was assigned the role of the nurse in charge completing a therapeutic dialog with the patient. Students 3 and 4 were assigned as raters who were responsible for evaluating the therapeutic techniques utilized by the nursing student conducting the therapeutic dialog. The rating of student's ability to communicate is simply part of the simulation. The raters utilized a rubric that outlined therapeutic and nontherapeutic responses. Therefore, the raters were simply following the directions of the rubric. Again, the overall purpose of gathering data for this simulation was to determine if students were more confident in their communication abilities after completing the simulation. These students were provided with a rubric outlining therapeutic and nontherapeutic techniques. The rubric consisted of five nonverbal techniques (therapeutic or nontherapeutic) and 13 verbal techniques (therapeutic and nontherapeutic). Each technique was worth 1 point per item. After completing the rubric, the raters totaled up all therapeutic points (worth a possible 18 points) and nontherapeutic points (worth a possible 18 points). Students in the program receive classroom instruction pertaining to therapeutic communication throughout the program. This begins in fundamentals and continues throughout the program in different courses. In the mental health course, students receive considerable content on therapeutic communication, as well as 42 hours of clinical time to develop communication skills with patients. Each simulation also included one nursing faculty member who also completed the rubric as part of the evaluation. At the conclusion of the simulation, the faculty member and students discussed the simulation as part of a debriefing session. During the debriefing, the raters and the faculty discussed their findings of the nursing students' therapeutic communication skills demonstrated during the simulation. The students who played the parts of the nurse commented on their strengths and areas for improvements as the “nurse.” The students who played the role of the patient do not demonstrate the ability to communicate therapeutically, because they are following a script. However, the purpose of the study was to determine if the simulation had an effect on the student's self-confidence related to therapeutic communication. When all students were finished with the simulation, they were provided with a posttest consisting of the same five questions found on the pretest. Results
Table 3 Therapeutic communication Care provider strengths/areas for improvement Communication strengths Communication areas for improvement
After the simulation, students responded that they could communicate more therapeutically with their patients, as well as believing their patients could confide in them. The students who played the part of the patient were also part of the debriefing, where strengths
T. Blake, T. Blake / Teaching and Learning in Nursing 14 (2019) 260–264
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Table 4 Estimates for the mean increase in Likert score from pretest to posttest Question 1 ^ Δ 99% CI
1.000 [0.0003, 4.000]
Question 2 1.000 [1.000, 4.000]
Question 3 1.000 [0.500, 4.000]
Question 4 1.000 [1.000, 4.000]
Question 5 1.500 [1.000, 4.000]
CI, Confidence Interval.
and weaknesses of their classmates were discussed. All students took part in the discussion and offered their own thoughts and feelings pertaining to being able to therapeutically communicate. Students also felt like they were better able to assess their therapeutic and nontherapeutic skills, as well as develop personal objectives for improving their communication skills. Fig. 1 shows the distribution of students' survey responses for both pretest and posttest. Wilcoxon tests for an improvement in student self-efficacy in therapeutic communication skills after the course simulation as indicated by the five questions were all signifi^ the estimated incremental cant with p b .01. Table 4 displays Δ; change in students' scores after the completion of the simulations for each question and the corresponding 99% confidence interval for the true change in self-efficacy. The laboratory simulation shows improvement over all five questions regarding students' self-efficacy of therapeutic communication, although it is noted that the scores from pretest to posttest are lower for Question 1 than for any of the other questions. This is likely because of the average pretest response for Question 1 being higher than the pretest average for the other questions. When rating on a fixed scale, it is inherently more difficult to observe a large improvement. The remaining four questions demonstrated the largest differences from pretest to posttest responses.
Limitations This study carries several limitations, including the data is subjective in nature and student self-reporting. In addition, this is a convenience sample; therefore, the findings may not be able to be extrapolated to larger populations. Students involved in role-play generally lack experience with acting and may have difficulty communicating therapeutically with real-life situations. Therefore, it can be questioned if any kind of role-play can truly impart the material to be considered. Lastly, the researcher-designed pretest and posttest are simple measures for this study. However, two nursing simulation experts established the content validity and interrater reliability of the assessment. Congruency percentage (Average congruency percentage), a measure of content validity, was established for the pretest and posttest to be 90%, whereas the interrater reliability was determined to be R = .8. Implications for Further Research In addition to studying self-efficacy, studying the relationship between this communication simulation and scores on standardized examination related to communication could be completed. Other areas for research could include comparing a role-play simulation
Fig. 1. Student pretest/post - test results.
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strategy to other strategies that seek to educate students about therapeutic communication skills, such as using a high-fidelity simulator. Which strategy would prove to be more effective? Would student's clinical communication performance actually improve after utilizing these simulations? Conclusions The laboratory simulation shows improvement over all five questions regarding students' self-efficacy of therapeutic communication. Implications for practice include adding a mental health simulation focusing on therapeutic communication before students graduate from their nursing program. Ideally, this simulation could also be completed during an orientation to a mental health clinical. Such simulations could be added to any course, including fundamentals to advanced medical–surgical courses. Once a simulation is developed, it could be tailored to any course. The simulation could be altered to be more complex or less complex, depending upon the level of difficulty of the course (i.e., an introduction to therapeutic communication vs. a communication simulation in a capstone course). There are a magnitude of issues associated with communication in health care. Therefore, a need exists for more formalized education regarding effective communication skills. Such skills are necessary for working with patients, as well as nursing students and other health care professionals. References Cowen, K., Hubbard, L., & Hancock, D. (2016). Concerns of nursing students beginning clinical courses: A descriptive study. Nurse Education Today, 43, 64–68. Dearmon, V., Graves, R. J., Hayden, S., Mulekar, M. S., Lawrence, S. M., Jones, L., & Farmer, J. E. (2013). Effectiveness of simulation-based orientation of baccalaureate nursing students preparing for their first clinical experience. Journal of Nursing Education, 52, 29–38. Flood, L., & Robinia, K.. (2014). Bridging the gap: Strategies to integrate classroom and clinical learning. Nurse Education In Practice. August 14/4. Accessed from https://
www.researchgate.net/publication/260168439_Bridging_the_gap_Strategies_to_ integrate_classroom_and_clinical_learning. Halter, M. J. (2014). Varcarolis' foundations of psychiatric mental health nursing: A clinical approach (7th ed.). St. Louis, MO: Elsevier, 154–156. Heron, M. (2016). Deaths: Leading causes for 2014. National Vital Statistics Report., 65 (5) Accessed from https://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_05.pdf. James, J. (2013). A new, evidence-based estimate of patient harms associated with hospital care. Journal of Patient Safety, 9(3), 122–128. Jarvis, C. (2016). The interview. Physical examination & health assessment (pp. 27–48) (7th ed.). St. Louis, MO: Elsevier. Jointcommision.org (2012). Joint commission center for transforming healthcare releases targeted solutions tool for hand-off communications. Accessed from http://www. jointcommission.org/assets/1/6/TST_HOC_Persp_08_12.pdf. Kourkouta, L., & Papathanasiou, I. (2014). Communication in nursing practice. Materia sociomedica. Journal of Academy of Medical Sciences of Bosnia and Herzegovina, 26(1), 65–67 Accessed from https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC3990376/. Kulczycki, M. (2012). New targeted solutions tool available for hand-off communications—Ambulatory customers pilot tested. Accessed from https://www. jointcommission.org/musingsambulatory_patient_safety/new_targeted_ solutions_tool_availble_for_hand-off_communications%e2%80%93ambulatory_ customers_pilot_tested/ Laffan, S. (2011). A therapeutic communication and behavioral management. Accessed from http://www.ncchc.org/cnp-therapeutic-communication. Neese, B. (2015). Effective communication in nursing: Theory and best practices. Accessed from http://online.seu.edu/effective-communication-in-nursing/#stha sh.PeMQXqJU.dpuf Rosenberg, S., & Gallo-Silver, L. (2011). Therapeutic communication skills and nursing students in the clinical setting. Teaching and Learning in Nursing, 6, 2–8. Ross, J., Bruderle, E., Meakim, C., Willens, J., & Holmwood, J. (2016). Development of formative capstone simulations to prepare novice students for initial clinical practicum. Journal of Nursing Education, 55(10), 587–589. Starmer, A., Spector, N., Srivastava, R., West, D., Rosenbluth, G., Allen, A., ... Landrigan, C. (2014). Changes in medical errors after implementation of a handoff program. New England Journal of Medicine, 371, 1803–1812. https://doi.org/10.1056/ NEJMsa1405556 Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMsa 1405556. Stimpfel, A. W., Sloane, D. M., McHugh, M. D., & Aiken, L. H. (2016). Hospitals known for nursing excellence associated with better hospital experience for patients. Health Services Research, 51(3), 1120–1134. https://doi.org/10.1111/1475-6773. 12357. Varcarolis, E. (2013). Communication skills: Medium for all nursing practice. Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (pp. 116–132) (2nd ed.). St. Louis, MO: Elsevier.
Contents lists available at ScienceDirect
Teaching and Learning in Nursing journal homepage: www.jtln.org
Improving therapeutic communication in nursing through simulation exercise Tim Blake, RN, MS a,⁎, Tayler Blake, PhD b a b
Ohio University-Zanesville, Ohio 43701, USA Department of Statistics, The Ohio State University, Columbus, Ohio 43201, USA
a r t i c l e
i n f o
Article history: Accepted 6 June 2019 Keywords: Therapeutic communication Nursing Simulation exercise
a b s t r a c t Becoming proficient in therapeutic communication requires adequate educational preparation, as well as ongoing practice and personal reflection about one’s ability to communicate. This article discusses a study that examines the effects of a nursing lab simulation used to increase the self- efficacy of 32 nursing students with their ability to utilize effective communication skills. We concluded that the lab simulation was helpful in improving student self-efficacy regarding their therapeutic communication skills. © 2019 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
Introduction Nursing is both an art and a science that involves numerous subspecialties. We often think of mental health nursing as an area that involves effective communication skills as a prerequisite for a nurse to be effective in providing patient care. However, communication skills are paramount in all fields of nursing in order for the nurse to be successful. Teaching therapeutic communication to nursing students assists them to become competent in communicating not only with patients but also with other health care professionals. Background Laffan (2011) defines therapeutic communication as a face-toface interaction that focuses on improving the emotional and physical welfare of the patient. Using therapeutic communication, nurses can provide emotional support and vital information to the patient. To accomplish these goals, a variety of techniques should be used when communicating with the patient. The ability to communicate effectively can foster healthy professional relationships with patients and health care professionals alike. Therapeutic communication can help establish and build relationships, prevent mistakes, and provide an improved level of patient care (Neese, 2015). According to James (2013), up to 440,000 people die annually because of preventable medical errors. This number represents a significant portion of the fourth leading cause of death, ⁎ Corresponding author. Tel.: +1 740 588 1470; +1 740 328 9075 (Cell). E-mail address: [email protected]. (T. Blake).
which is unintentional injuries (Heron, 2016). Furthermore, the Joint Commission estimates that 80% of serious medical errors involve miscommunication (Kulczycki, 2012). The Joint Commission's analysis of 2012, 2013, and first quarter data of 2014 revealed that communication was one of the top three leading causes of unanticipated events in a health care setting that results in death or serious physical or psychological injury (Neese, 2015; Jointcommision.org, 2012. Therapeutic communication is generally referred to as a dialog between the nurse and the patient with the purpose of improving the patient's health, safety, and comfort as well as building well-being and trust. It is necessary for the nurse to be able to effectively communicate with other health care professionals in order to achieve those same goals. Improvements in communication among nurses and allied health can decrease medical errors and increase positive patient outcomes. Starmer et al. (2014) concluded that medical error rates in nine children's hospitals decreased 23% after the implementation of a handoff program designed to enhance and standardize communication. Growing evidence reveals that improving communication between nurses and patients, and involving patients more closely in their care, results in greater adherence to the care plan, fewer hospital readmissions, and better patient health (Stimpfel, Sloane, McHugh, & Aiken, 2016). In order to be successful communicators, nurses must study communication skills and the dynamics of interpersonal communication as part of their education process (Kourkouta & Papathanasiou, 2014). It is important to emphasize the communication between patient and nurse as well as the communication between the nurse and other members of the health care team. Therapeutic communication
https://doi.org/10.1016/j.teln.2019.06.003 1557-3087/© 2019 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
T. Blake, T. Blake / Teaching and Learning in Nursing 14 (2019) 260–264
between the nurse and the patient requires the use of empathy, which is distinctly different from sympathy. Empathetic communication denotes an understanding of the patient's perception (Jarvis, 2016; Varcarolis, 2013). Another facet of therapeutic communication is the use of active listening. (Jarvis, 2016; Varcarolis, 2013). Active listening requires nurses to pay full attention to the patient's message, while blocking out other concerns and disturbances that may detract from the interchange. Active listening requires nurses to interpret the patient's messages and provides clarification when necessary (Jarvis, 2016; Varcarolis, 2013). By using personal reflection, nurses can come to understand their own feelings and values, thus making the communication process more effective. Self-awareness of one's own values is necessary when working with patients who may have a different value system. Nurses must also be able to demonstrate genuineness and honesty in order to facilitate therapeutic communication. Knowing how one communicates allows nurses to make improvements in their communication skills.
261
Simulation Objectives • Students will participate in a simulation exercise utilizing previously learned communication skills. • Students will explore their communication strengths and areas for improvement in a postsimulation setting. • Students will explore their own self-efficacy related to their ability to communicate therapeutically. Participants The subjects for this study consisted a convenience sample of 35 nursing students in their capstone course of a nursing program located in the midwest of the United States. The simulation received exempted status from Institutional Review Board because no identification was used when collecting data. Description of Instruments
Teaching Therapeutic Communication to Nursing Students Using Standardized Patients Many nursing students consider communication skills a challenge, and many students express their concerns about therapeutic communication, particularly with psychiatric patients. This concern often begins before clinical rotations in psychiatric/mental health nursing. Even after mental health nursing, students continue to feel a lack of confidence regarding their communication skills. Students often feel anxious about communicating with psychiatric patients prior to entering mental health clinical (Cowen, Hubbard, & Hancock, 2016). Students voice concern that they will say the wrong thing to their patients or are uncertain how to respond to patients in certain situations, resulting in patients harming themselves (Halter, 2014). Henceforth, clinical skills may be adversely affected by high levels of anxiety, leaving students unable to safely administer care to patients (Ross, Bruderle, Meakim, Willens, & Holmwood, 2016). The importance of teaching therapeutic communication cannot be overstated. However, nursing students may feel there is a gap between classroom experiences and experiences in the clinical setting (Flood & Robinia, 2014). In other words, students must become proficient in utilizing open-ended and closed-ended questions, as well as being able to use clarifying, exploring, validating, and paraphrasing. These are all critical verbal skills to learn. It is also imperative to develop a skill in interpreting nonverbal communication. The classroom is one place utilized for teaching communication skills as well as laboratories, where simulations may be utilized. Classroom activities may include theory related to therapeutic communication, as well as examples of therapeutic and nontherapeutic responses. However, students must be able to practice such skills in order to become effective. Practicing communication skills in class can be difficult because of barriers, such as class size and class duration (Rosenberg & Gallo-Silver, 2011). Simulations outside of class time may be another method for allowing students to practice and assimilate communication skills. Simulations can include such methods as high-fidelity mannequins, computerized simulations, gaming, and role-play (Dearmon et al., 2013). Simulation, when provided prior to a clinical practicum, has been shown to improve knowledge levels and self-efficacy, resulting in decreased anxiety The purpose of this study is to test the following hypothesis. Hypothesis A simulation exercise will improve the self-efficacy of nursing students related to their ability to perform therapeutic communication.
Students were required to complete a pretest and an identical posttest designed by the researcher, each consisting of five questions related to their self-efficacy related to therapeutic communication. Content validity and interrater reliability were established by two university simulation experts. Each question required students to use a 5-point Likert scale, with 1 being the least confident and 5 being the most confident in their communication abilities. The survey was presented in the following format: The dialog for the simulation was developed from an actual process recording completed by a previous student in the mental health course. In place of the nursing student's response, the dialog was left blank, indicating that the nursing students in the simulation were required to respond to the patient's statements. The main idea focused around a young adult female who was hospitalized after a suicide attempt. The nursing students completing the interview were required to do an admission assessment and establish progression of problem areas for the patient. As noted in the rubric (Table 2), the students who are the raters are required to follow along with the script, and give credit under any applicable box for therapeutic and nontherapeutic statements or actions. To score the rubric, each pertinent box receives 1 point. Points are then summed under each of the “therapeutic” and “nontherapeutic” categories, and totals are recorded for each student. (See Table 1.) In Table 3, the student raters summarize the communication strengths of each of the students playing the role of the nurse completing the interview. There is space provided to list communication strengths, as well as areas for improvement. After the simulation is completed, the faculty member reviews the results with the raters for consistency. A debriefing is then completed with the student
Table 1 Student questionnaire 1 2 3 4 5 1. I am comfortable talking with patients. 2. I feel like I can communicate therapeutically with patients. 3. My patients are able to confide in me. 4. I can accurately assess my therapeutic and nontherapeutic skills during assessment. 5. I am able to list my personal objectives for improving my therapeutic communication skills. Note. Assessing student self-efficacy in therapeutic communication. Pretest/posttest: 1 = least confident, 2 = not very confident, 3 = indifferent, 4 = somewhat confident, 5 = most confident.
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Table 2 Therapeutic communication rubric. Effective communication Nonverbal communication Faces patient within an appropriate concern for personal space Relaxed posture Hands, arms open Discussion takes place in a private area. Conveys caring attitude Verbal Tone of voice is calming or soothing. Assures confidentiality within treatment setting Attentive to patient needs (i.e., hunger, thirst, cold or heat, fatigue) Focus remained primarily on patient, mostly patient disclosure Use of open-ended questions Able to listen to patient without interjecting personal bias or views Including patient ideas in resolution of issues Active listening
Noneffective communication Comments Turns away from patient. Inappropriate concern for personal space. Appears tense or demonstrates an intimidating posture Hands folded or arms crossed Discussion takes place when other people are within a short distance. Appears disinterested, frightened, or uncomfortable. Tone of voice is loud, harsh, or pressured. No discussion of confidentiality with the patient Continues to ask questions that are causing emotional distress in the patient Interviewer focuses on him or herself, instead of the patient. Mostly closed-ended questions that required only one-word responses (i.e., yes-or-no answers) Makes statements that demonstrate personal opinions or biases. Giving advice to patient
Does not appear to pay attention to the patient Clarify Does not attempt to clarify vital information from the patient Providing vital information Missed opportunities for teaching Complete lack of or too much selfAppropriate use of selfdisclosure disclosure (establishing rapport and trust) Using silence Engages in superficial verbal banter Focusing Unable to assess patient's nonverbal cues Total Total
Comments
group to review the communication strengths and areas for improvement of the students completing the assessment, as well as eliciting input from the students within the group. On this form, the raters were responsible for listing the nursing students' communication strengths and communication areas for improvement. The findings were then discussed in the debriefing section of the simulation. Study Design and Data Collection To test the hypothesis of improved self-efficacy in therapeutic communication after the completion of clinical simulations, a quasiexperiment using a one-group, pretest/posttest design was used. The treatment consisted of a simulation exercise during a weekly laboratory simulation focusing on communication skills. Weekly laboratories comprised a portion of the curriculum for the course, which covered a number of topics including elements of communication. The 32 students were provided a pretest questionnaire consisting of
five questions focusing on self-efficacy of therapeutic communication skills. All students were part of the scheduled laboratory. Students were randomly divided into groups, four of which consisted of five students and two groups having six students. Each group was then placed in the simulation. There were three faculty members who moderated each of the simulations; these faculty members met to discuss the moderation process to improve consistency across each simulation. Detailed discussion among faculty involved key points for leading the simulation, as well as grading the rubric given to students who were assigned the role of raters during the simulation. Each faculty member compared their results with the raters to assure that rubric scores were the same. Students in each group were randomly assigned roles to enact in the simulation. One student was assigned the role of the patient and was provided with a script to follow. It is worth noting that the data collection from the simulation is not to show that each student is able to demonstrate the ability to communicate therapeutically, but rather that each student is feels more self-confident in his or her ability to communicate therapeutically. Student 2 was assigned the role of the nurse in charge completing a therapeutic dialog with the patient. Students 3 and 4 were assigned as raters who were responsible for evaluating the therapeutic techniques utilized by the nursing student conducting the therapeutic dialog. The rating of student's ability to communicate is simply part of the simulation. The raters utilized a rubric that outlined therapeutic and nontherapeutic responses. Therefore, the raters were simply following the directions of the rubric. Again, the overall purpose of gathering data for this simulation was to determine if students were more confident in their communication abilities after completing the simulation. These students were provided with a rubric outlining therapeutic and nontherapeutic techniques. The rubric consisted of five nonverbal techniques (therapeutic or nontherapeutic) and 13 verbal techniques (therapeutic and nontherapeutic). Each technique was worth 1 point per item. After completing the rubric, the raters totaled up all therapeutic points (worth a possible 18 points) and nontherapeutic points (worth a possible 18 points). Students in the program receive classroom instruction pertaining to therapeutic communication throughout the program. This begins in fundamentals and continues throughout the program in different courses. In the mental health course, students receive considerable content on therapeutic communication, as well as 42 hours of clinical time to develop communication skills with patients. Each simulation also included one nursing faculty member who also completed the rubric as part of the evaluation. At the conclusion of the simulation, the faculty member and students discussed the simulation as part of a debriefing session. During the debriefing, the raters and the faculty discussed their findings of the nursing students' therapeutic communication skills demonstrated during the simulation. The students who played the parts of the nurse commented on their strengths and areas for improvements as the “nurse.” The students who played the role of the patient do not demonstrate the ability to communicate therapeutically, because they are following a script. However, the purpose of the study was to determine if the simulation had an effect on the student's self-confidence related to therapeutic communication. When all students were finished with the simulation, they were provided with a posttest consisting of the same five questions found on the pretest. Results
Table 3 Therapeutic communication Care provider strengths/areas for improvement Communication strengths Communication areas for improvement
After the simulation, students responded that they could communicate more therapeutically with their patients, as well as believing their patients could confide in them. The students who played the part of the patient were also part of the debriefing, where strengths
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Table 4 Estimates for the mean increase in Likert score from pretest to posttest Question 1 ^ Δ 99% CI
1.000 [0.0003, 4.000]
Question 2 1.000 [1.000, 4.000]
Question 3 1.000 [0.500, 4.000]
Question 4 1.000 [1.000, 4.000]
Question 5 1.500 [1.000, 4.000]
CI, Confidence Interval.
and weaknesses of their classmates were discussed. All students took part in the discussion and offered their own thoughts and feelings pertaining to being able to therapeutically communicate. Students also felt like they were better able to assess their therapeutic and nontherapeutic skills, as well as develop personal objectives for improving their communication skills. Fig. 1 shows the distribution of students' survey responses for both pretest and posttest. Wilcoxon tests for an improvement in student self-efficacy in therapeutic communication skills after the course simulation as indicated by the five questions were all signifi^ the estimated incremental cant with p b .01. Table 4 displays Δ; change in students' scores after the completion of the simulations for each question and the corresponding 99% confidence interval for the true change in self-efficacy. The laboratory simulation shows improvement over all five questions regarding students' self-efficacy of therapeutic communication, although it is noted that the scores from pretest to posttest are lower for Question 1 than for any of the other questions. This is likely because of the average pretest response for Question 1 being higher than the pretest average for the other questions. When rating on a fixed scale, it is inherently more difficult to observe a large improvement. The remaining four questions demonstrated the largest differences from pretest to posttest responses.
Limitations This study carries several limitations, including the data is subjective in nature and student self-reporting. In addition, this is a convenience sample; therefore, the findings may not be able to be extrapolated to larger populations. Students involved in role-play generally lack experience with acting and may have difficulty communicating therapeutically with real-life situations. Therefore, it can be questioned if any kind of role-play can truly impart the material to be considered. Lastly, the researcher-designed pretest and posttest are simple measures for this study. However, two nursing simulation experts established the content validity and interrater reliability of the assessment. Congruency percentage (Average congruency percentage), a measure of content validity, was established for the pretest and posttest to be 90%, whereas the interrater reliability was determined to be R = .8. Implications for Further Research In addition to studying self-efficacy, studying the relationship between this communication simulation and scores on standardized examination related to communication could be completed. Other areas for research could include comparing a role-play simulation
Fig. 1. Student pretest/post - test results.
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strategy to other strategies that seek to educate students about therapeutic communication skills, such as using a high-fidelity simulator. Which strategy would prove to be more effective? Would student's clinical communication performance actually improve after utilizing these simulations? Conclusions The laboratory simulation shows improvement over all five questions regarding students' self-efficacy of therapeutic communication. Implications for practice include adding a mental health simulation focusing on therapeutic communication before students graduate from their nursing program. Ideally, this simulation could also be completed during an orientation to a mental health clinical. Such simulations could be added to any course, including fundamentals to advanced medical–surgical courses. Once a simulation is developed, it could be tailored to any course. The simulation could be altered to be more complex or less complex, depending upon the level of difficulty of the course (i.e., an introduction to therapeutic communication vs. a communication simulation in a capstone course). There are a magnitude of issues associated with communication in health care. Therefore, a need exists for more formalized education regarding effective communication skills. Such skills are necessary for working with patients, as well as nursing students and other health care professionals. References Cowen, K., Hubbard, L., & Hancock, D. (2016). Concerns of nursing students beginning clinical courses: A descriptive study. Nurse Education Today, 43, 64–68. Dearmon, V., Graves, R. J., Hayden, S., Mulekar, M. S., Lawrence, S. M., Jones, L., & Farmer, J. E. (2013). Effectiveness of simulation-based orientation of baccalaureate nursing students preparing for their first clinical experience. Journal of Nursing Education, 52, 29–38. Flood, L., & Robinia, K.. (2014). Bridging the gap: Strategies to integrate classroom and clinical learning. Nurse Education In Practice. August 14/4. Accessed from https://
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