Teaching and Learning in Nursing 14 (2019) 260e264

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Teaching and Learning in Nursing

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teaching-and-learning-in-nursing

Improving Therapeutic Communication in Nursing Through

Simulation Exercise
Tim Blake, RN, MS a,*, Tayler Blake, PhD b
a
Ohio University-Zanesville, Ohio 43701, USA
b
Department of Statistics, The Ohio State University, Columbus, Ohio 43201, USA

a r t i c l e i n f o a b s t r a c t

Article history: Becoming proficient in therapeutic communication requires adequate educational preparation, as well as
Accepted 6 June 2019 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
Keywords: students with their ability to utilize effective communication skills. We concluded that the lab simulation
Therapeutic communication
was helpful in improving student self-efficacy regarding their therapeutic communication skills.
Nursing
Simulation exercise
© 2019 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.

Introduction which is unintentional injuries (Heron, 2016). Furthermore, the Joint

Commission estimates that 80% of serious medical errors involve mis-
Nursing is both an art and a science that involves numerous sub- communication (Kulczycki, 2012). The Joint Commission’s analysis of
specialties. We often think of mental health nursing as an area that 2012, 2013, and first quarter data of 2014 revealed that communica-
involves effective communication skills as a prerequisite for a nurse tion was one of the top three leading causes of unanticipated events
to be effective in providing patient care. However, communication in a health care setting that results in death or serious physical or psy-
skills are paramount in all fields of nursing in order for the nurse to chological injury (Neese, 2015; Jointcommision.org, 2012. Therapeu-
be successful. Teaching therapeutic communication to nursing stu- tic communication is generally referred to as a dialog between the
dents assists them to become competent in communicating not nurse and the patient with the purpose of improving the patient’s
only with patients but also with other health care professionals. health, safety, and comfort as well as building well-being and trust.
It is necessary for the nurse to be able to effectively communicate
Background with other health care professionals in order to achieve those same
goals.
Laffan (2011) defines therapeutic communication as a face-to-face Improvements in communication among nurses and allied health
interaction that focuses on improving the emotional and physical can decrease medical errors and increase positive patient outcomes.
welfare of the patient. Using therapeutic communication, nurses Starmer et al. (2014) concluded that medical error rates in nine chil-
can provide emotional support and vital information to the patient. dren’s hospitals decreased 23% after the implementation of a handoff
To accomplish these goals, a variety of techniques should be used program designed to enhance and standardize communication.
when communicating with the patient. Growing evidence reveals that improving communication between
The ability to communicate effectively can foster healthy profes- nurses and patients, and involving patients more closely in their
sional relationships with patients and health care professionals care, results in greater adherence to the care plan, fewer hospital
alike. Therapeutic communication can help establish and build rela- readmissions, and better patient health (Stimpfel, Sloane, McHugh,
tionships, prevent mistakes, and provide an improved level of patient & Aiken, 2016).
care (Neese, 2015). According to James (2013), up to 440,000 people In order to be successful communicators, nurses must study com-
die annually because of preventable medical errors. This number munication skills and the dynamics of interpersonal communication
represents a significant portion of the fourth leading cause of death, as part of their education process (Kourkouta & Papathanasiou,
2014). It is important to emphasize the communication between
* Corresponding author. Tel.: þ1 740 588 1470; þ1 740 328 9075 (Cell). patient and nurse as well as the communication between the nurse
E-mail address: [email protected] (T. Blake). and other members of the health care team. Therapeutic

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) 260e264 261

communication between the nurse and the patient requires the use Simulation Objectives
of empathy, which is distinctly different from sympathy. Empathetic
communication denotes an understanding of the patient’s perception  Students will participate in a simulation exercise utilizing pre-
(Jarvis, 2016; Varcarolis, 2013). Another facet of therapeutic commu- viously learned communication skills.
 Students will explore their communication strengths and areas for
nication is the use of active listening. (Jarvis, 2016; Varcarolis, 2013).
Active listening requires nurses to pay full attention to the patient’s improvement in a postsimulation setting.
 Students will explore their own self-efficacy related to their ability
message, while blocking out other concerns and disturbances that
may detract from the interchange. Active listening requires nurses to communicate therapeutically.
to interpret the patient’s messages and provides clarification when
necessary (Jarvis, 2016; Varcarolis, 2013). By using personal reflec- Participants
tion, nurses can come to understand their own feelings and values,
thus making the communication process more effective. Self-aware- The subjects for this study consisted a convenience sample of 35
ness of one’s own values is necessary when working with patients nursing students in their capstone course of a nursing program
who may have a different value system. Nurses must also be able to located in the midwest of the United States. The simulation received
demonstrate genuineness and honesty in order to facilitate therapeu- exempted status from Institutional Review Board because no identifi-
tic communication. Knowing how one communicates allows nurses cation was used when collecting data.
to make improvements in their communication skills.
Description of Instruments

Teaching Therapeutic Communication to Nursing Students Using Students were required to complete a pretest and an identical
Standardized Patients posttest designed by the researcher, each consisting of five questions
related to their self-efficacy related to therapeutic communication.
Many nursing students consider communication skills a chal- Content validity and interrater reliability were established by two
lenge, and many students express their concerns about therapeutic university simulation experts.
communication, particularly with psychiatric patients. This concern Each question required students to use a 5-point Likert scale, with
often begins before clinical rotations in psychiatric/mental health 1 being the least confident and 5 being the most confident in their com-
nursing. Even after mental health nursing, students continue to feel munication abilities. The survey was presented in the following
a lack of confidence regarding their communication skills. Students format:
often feel anxious about communicating with psychiatric patients The dialog for the simulation was developed from an actual pro-
prior to entering mental health clinical (Cowen, Hubbard, & Hancock, cess recording completed by a previous student in the mental health
2016). Students voice concern that they will say the wrong thing to course. In place of the nursing student’s response, the dialog was left
their patients or are uncertain how to respond to patients in certain blank, indicating that the nursing students in the simulation were
situations, resulting in patients harming themselves (Halter, 2014). required to respond to the patient’s statements. The main idea
Henceforth, clinical skills may be adversely affected by high levels focused around a young adult female who was hospitalized after a
of anxiety, leaving students unable to safely administer care to suicide attempt. The nursing students completing the interview
patients (Ross, Bruderle, Meakim, Willens, & Holmwood, 2016). were required to do an admission assessment and establish progres-
The importance of teaching therapeutic communication cannot sion of problem areas for the patient.
be overstated. However, nursing students may feel there is a gap As noted in the rubric (Table 2), the students who are the raters
between classroom experiences and experiences in the clinical set- are required to follow along with the script, and give credit under
ting (Flood & Robinia, 2014). In other words, students must become any applicable box for therapeutic and nontherapeutic statements
proficient in utilizing open-ended and closed-ended questions, as or actions. To score the rubric, each pertinent box receives 1 point.
well as being able to use clarifying, exploring, validating, and para- Points are then summed under each of the “therapeutic” and “non-
phrasing. These are all critical verbal skills to learn. It is also impera- therapeutic” categories, and totals are recorded for each student.
tive to develop a skill in interpreting nonverbal communication. (See Table 1.)
The classroom is one place utilized for teaching communication In Table 3, the student raters summarize the communication
skills as well as laboratories, where simulations may be utilized. strengths of each of the students playing the role of the nurse com-
Classroom activities may include theory related to therapeutic com- pleting the interview. There is space provided to list communication
munication, as well as examples of therapeutic and nontherapeutic strengths, as well as areas for improvement. After the simulation is
responses. However, students must be able to practice such skills in completed, the faculty member reviews the results with the raters
order to become effective. Practicing communication skills in class for consistency. A debriefing is then completed with the student
can be difficult because of barriers, such as class size and class dura-
tion (Rosenberg & Gallo-Silver, 2011).
Simulations outside of class time may be another method for
Table 1
allowing students to practice and assimilate communication skills. Student questionnaire
Simulations can include such methods as high-fidelity mannequins,
1 2 3 4 5
computerized simulations, gaming, and role-play (Dearmon et al.,
2013). Simulation, when provided prior to a clinical practicum, has 1. I am comfortable talking with patients.
been shown to improve knowledge levels and self-efficacy, resulting 2. I feel like I can communicate therapeutically with patients.
3. My patients are able to confide in me.
in decreased anxiety The purpose of this study is to test the following 4. I can accurately assess my therapeutic and nontherapeutic
hypothesis. skills during assessment.
5. I am able to list my personal objectives for improving my
therapeutic communication skills.
Hypothesis
Note. Assessing student self-efficacy in therapeutic communication. Pretest/posttest:
A simulation exercise will improve the self-efficacy of nursing stu- 1 ¼ least confident, 2 ¼ not very confident, 3 ¼ indifferent, 4 ¼ somewhat confident,
dents related to their ability to perform therapeutic communication. 5 ¼ most confident.
262 T. Blake, T. Blake / Teaching and Learning in Nursing 14 (2019) 260e264

Table 2 communication. The 32 students were provided a pretest question-

Therapeutic communication rubric. naire consisting of five questions focusing on self-efficacy of thera-
Effective communication Noneffective communication peutic communication skills. All students were part of the scheduled
Nonverbal communication Comments
laboratory. Students were randomly divided into groups, four of
Faces patient within an Turns away from patient. which consisted of five students and two groups having six students.
appropriate concern for Inappropriate concern for Each group was then placed in the simulation. There were three
personal space personal space. faculty members who moderated each of the simulations; these
Relaxed posture Appears tense or demonstrates
faculty members met to discuss the moderation process to improve
an intimidating posture
Hands, arms open Hands folded or arms crossed consistency across each simulation. Detailed discussion among
Discussion takes place in a Discussion takes place when faculty involved key points for leading the simulation, as well as grad-
private area. other people are within a short ing the rubric given to students who were assigned the role of raters
distance. during the simulation. Each faculty member compared their results
Conveys caring attitude Appears disinterested, frightened,
with the raters to assure that rubric scores were the same.
or uncomfortable.
Verbal Students in each group were randomly assigned roles to enact in
Tone of voice is calming or Tone of voice is loud, harsh, or the simulation. One student was assigned the role of the patient
soothing. pressured. and was provided with a script to follow. It is worth noting that the
Assures confidentiality No discussion of confidentiality
data collection from the simulation is not to show that each student
within treatment setting with the patient
Attentive to patient needs Continues to ask questions that is able to demonstrate the ability to communicate therapeutically,
(i.e., hunger, thirst, cold or are causing emotional distress in but rather that each student is feels more self-confident in his or
heat, fatigue) the patient her ability to communicate therapeutically.
Focus remained primarily Interviewer focuses on him or Student 2 was assigned the role of the nurse in charge completing
on patient, mostly patient herself, instead of the patient.
a therapeutic dialog with the patient. Students 3 and 4 were assigned
disclosure
Use of open-ended Mostly closed-ended questions as raters who were responsible for evaluating the therapeutic techni-
questions that required only one-word ques utilized by the nursing student conducting the therapeutic dia-
responses (i.e., yes-or-no log. The rating of student’s ability to communicate is simply part of
answers)
the simulation. The raters utilized a rubric that outlined therapeutic
Able to listen to patient Makes statements that
without interjecting demonstrate personal opinions or
and nontherapeutic responses. Therefore, the raters were simply fol-
personal bias or views biases. lowing the directions of the rubric. Again, the overall purpose of gath-
Including patient ideas in Giving advice to patient ering data for this simulation was to determine if students were more
resolution of issues confident in their communication abilities after completing the
Active listening Does not appear to pay attention Comments
simulation.
to the patient
Clarify Does not attempt to clarify vital These students were provided with a rubric outlining therapeutic
information from the patient and nontherapeutic techniques. The rubric consisted of five nonver-
Providing vital information Missed opportunities for teaching bal techniques (therapeutic or nontherapeutic) and 13 verbal techni-
Appropriate use of Complete lack of or too much
ques (therapeutic and nontherapeutic). Each technique was worth 1
self-disclosure (establishing self-disclosure
rapport and trust)
point per item. After completing the rubric, the raters totaled up all
Using silence Engages in superficial verbal therapeutic points (worth a possible 18 points) and nontherapeutic
banter points (worth a possible 18 points).
Focusing Unable to assess patient’s Students in the program receive classroom instruction pertaining
nonverbal cues
to therapeutic communication throughout the program. This begins
Total Total
in fundamentals and continues throughout the program in different
courses. In the mental health course, students receive considerable
group to review the communication strengths and areas for improve- content on therapeutic communication, as well as 42 hours of clinical
ment of the students completing the assessment, as well as eliciting time to develop communication skills with patients.
input from the students within the group. On this form, the raters Each simulation also included one nursing faculty member who
were responsible for listing the nursing students’ communication also completed the rubric as part of the evaluation. At the conclusion
strengths and communication areas for improvement. The findings of the simulation, the faculty member and students discussed the
were then discussed in the debriefing section of the simulation. simulation as part of a debriefing session. During the debriefing, the
raters and the faculty discussed their findings of the nursing students’
Study Design and Data Collection therapeutic communication skills demonstrated during the simula-
tion. The students who played the parts of the nurse commented on
To test the hypothesis of improved self-efficacy in therapeutic their strengths and areas for improvements as the “nurse.” The stu-
communication after the completion of clinical simulations, a quasi- dents who played the role of the patient do not demonstrate the abil-
experiment using a one-group, pretest/posttest design was used. ity to communicate therapeutically, because they are following a
The treatment consisted of a simulation exercise during a weekly script. However, the purpose of the study was to determine if the
laboratory simulation focusing on communication skills. Weekly simulation had an effect on the student’s self-confidence related to
laboratories comprised a portion of the curriculum for the course, therapeutic communication. When all students were finished with
which covered a number of topics including elements of the simulation, they were provided with a posttest consisting of the
same five questions found on the pretest.

Table 3 Results
Therapeutic communication

Care provider strengths/areas for improvement After the simulation, students responded that they could commu-
Communication strengths nicate more therapeutically with their patients, as well as believing
Communication areas for improvement
their patients could confide in them. The students who played the
 T. Blake, T. Blake / Teaching and Learning in Nursing 14 (2019) 260e264 263

Table 4
Estimates for the mean increase in Likert score from pretest to posttest

Question 1 Question 2 Question 3 Question 4 Question 5

b
D 1.000 1.000 1.000 1.000 1.500
99% CI [0.0003, 4.000] [1.000, 4.000] [0.500, 4.000] [1.000, 4.000] [1.000, 4.000]

CI, Confidence Interval.

part of the patient were also part of the debriefing, where strengths Limitations
and weaknesses of their classmates were discussed. All students
took part in the discussion and offered their own thoughts and feel- This study carries several limitations, including the data is subjec-
ings pertaining to being able to therapeutically communicate. Stu- tive in nature and student self-reporting. In addition, this is a conve-
dents also felt like they were better able to assess their therapeutic nience sample; therefore, the findings may not be able to be
and nontherapeutic skills, as well as develop personal objectives for extrapolated to larger populations. Students involved in role-play
improving their communication skills. generally lack experience with acting and may have difficulty com-
Fig. 1 shows the distribution of students’ survey responses for municating therapeutically with real-life situations. Therefore, it can
both pretest and posttest. Wilcoxon tests for an improvement in stu- be questioned if any kind of role-play can truly impart the material
dent self-efficacy in therapeutic communication skills after the to be considered. Lastly, the researcher-designed pretest and posttest
course simulation as indicated by the five questions were all signifi- are simple measures for this study. However, two nursing simulation
cant with p < .01. Table 4 displays D b ; the estimated incremental experts established the content validity and interrater reliability of
change in students’ scores after the completion of the simulations the assessment. Congruency percentage (Average congruency per-
for each question and the corresponding 99% confidence interval for centage), a measure of content validity, was established for the pret-
the true change in self-efficacy. est and posttest to be 90%, whereas the interrater reliability was
The laboratory simulation shows improvement over all five ques- determined to be R ¼ .8.
tions regarding students’ self-efficacy of therapeutic communication,
although it is noted that the scores from pretest to posttest are lower Implications for Further Research
for Question 1 than for any of the other questions. This is likely
because of the average pretest response for Question 1 being higher In addition to studying self-efficacy, studying the relationship
than the pretest average for the other questions. When rating on a between this communication simulation and scores on standardized
fixed scale, it is inherently more difficult to observe a large improve- examination related to communication could be completed. Other
ment. The remaining four questions demonstrated the largest differ- areas for research could include comparing a role-play simulation
ences from pretest to posttest responses. strategy to other strategies that seek to educate students about

Fig. 1. Student pretest/post - test results.

264 T. Blake, T. Blake / Teaching and Learning in Nursing 14 (2019) 260e264

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integrate_classroom_and_clinical_learning.
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