Communication is a concept that is integral to nursing education, theory development, and practice. Traditionally, nursing education has defined communication as the transfer of information during the nursing process. This has resulted in investigation into the behavior of nurses, methods used in communicating, and the content of messages in the communication process. Studies have evaluated the efficacy of computerassisted instruction, process recording, audiotaping, and video instruction as methods to teach and evaluate student communication in the clinical setting. Most studies on communication in baccalaureate nursing education investigate communication from the fragmented senderreceiver-message perspective, which breaks communication into parts. These studies offer a limited view of communication, use methods that evaluate student performance out of the context of the clinical area, and promote artificial means to teach communication (Anderson & Gerrard, 1984; Browning & Campbell, 1987; Daniels, Denny, & Andrews, 1988; Davis & Kurtz, 1991; Johnson, 1994; Walker & Ross, 1995).
A contrasting position conceptualizes communication as a dynamic, interactive process influenced by symbolic meanings in an environment. King's General Systems framework (1971, 1981) offers insight into nursing education as an interactive process in a social system supported by communication. The classic work of Benner (1984) suggests that students will pass through different stages of development and that their communication ability will change throughout their professional development. Further, Carper (1978) presented the idea that ways of knowing in nursing are developed in four realms- empirical, ethical, aesthetic, and personal.
Carper described personal knowledge in terms of the therapeutic use of the self in interpersonal situations. Chinn and Kramer (1999) pointed out that the realm of personal knowing does not occur in isolation but that nurses know more about the self as they interact with others, reflect on the interaction, and are open to change. The collective work of these nurse scientists supports a qualitative method and suggests that research be conducted of students being observed communicating with patients in naturalistic settings (Byrne & Heyman, 1997).
What is needed in nursing education is communication research based on the actual interactions of students and their patients. This would enable faculty to help students communicate with patients, point out pitfalls in the communication process, and contribute to the education of professional nurses skilled in communication. In addition, nursing programs could use this research to evaluate methods of teaching communication in clinical contexts. Limited studies have been conducted that evaluate student nurse-patient communication in a clinical setting (Hanna, 1993; Johnson, 1993). The most notable exceptions are studies conducted in Great Britain, which involves a different context than that of the United States (Byrne & Heyman, 1997; Leathart, 1994) and are not generalizable. Therefore, the focus of this study is baccalaureate nursing students' communication with patients in a clinical setting.
CONCEPTUAL FRAMEWORK AND ASSUMPTIONS
King's General Systems framework (1971, 1981) provided a perspective of communication and suggested the qualitative method. In this framework, the work of nursing is conceptualized as three interacting systems- personal, interpersonal, and social. King considered communication to be a key concept of the social system. Communication is defined as the means "whereby social interaction and learning take place" (King, 1971, p. 101). It is the author's assumption that King's framework can be applied to the domain of nursing education to explain student nurses' relationships with self, important others, and their position in organizations, such as the clinical environment.
In nursing education, the communication process is influenced by the interrelationships of students' goals, needs, and expectations in a given context. Nursing education operates as a social system in which communication, student role development, organizational structure, and student autonomy are operating concepts. Students interact in multiple interpersonal systems with patients, instructors, other students, and nurses to learn nursing. The personal system incorporates students' perception of self, reflection about events, and internalization of key events. Another of the author's assumptions was that communication is a symbolic event and that individuals create the meaning of an event while engaged in the event. Students are engaged in creating a meaning of nursing based on their interpretation of symbolic events.
The context of the study was clinical nursing education. Crucial elements of the context include the participants, physical setting, and social climate. The primary participants in the study were generic third-year and fourth-year baccalaureate nursing students attending a university in the northeastern United States. Students enrolled in the program took general courses for the first 2 years of the program, entered their first nursing course in the fall of their third year, and graduated after 4 years. The author was not employed at the university. The settings were clinical agencies in suburban and urban areas. Student-patient interactions were observed in hospital units, community nursing units, and patient homes.
Theoretical sampling is a technique of grounded theory method that leads the researcher to the sample of desired participants (Glaser, 1978) and was used to create the sampling plan for this study Initially, fourth-year nursing students who were about to graduate were approached for the study because they were thought to possess the attributes of professional communication. Subsequently, third-year nursing students were sought for interviews, particularly to shed light on student communication with "my first patient."
A total of 22 students were interviewed for the study, and 14 students were observed in various clinical settings, some more than once. Of the 22 students, 19 were White and 3 were Asian American; 19 students were women and 3 were men. The age range of students was 22 to 40, and the average age was 28.5. Students were identified as the primary participants of the study. Patients of the students and faculty were identified as secondary participants (Packard, 1981).
Procedures for Data Collection
During an academic year, the author spent approximately 2 days a week with students in various clinical and university locations. Students were approached at the university before or after class and invited to participate in the study. Informed consent was obtained prior to student interviews, which occurred in a classroom at the university. Interviews lasted between 30 and 90 minutes. All formal interviews were audiotaped, and notes were taken during the interview. The interviews started with the statement, "Tell me about a time you communicated with a patient." After the interviews were under way, it became clear that additional questions such as, "Tell me about the first time you communicated with a patient," also were important. Many informal interviews occurred with students in clinical areas, which were written up into field notes.
After each interview was complete, an appointment was made to observe the student in the clinical setting. Informed consent was obtained from faculty and patients of the student prior to observation. The author spent between 1 and 6 hours in a clinical setting on a given day. On some days, many student-patient interactions were observed. Despite the busy atmosphere of the hospital clinical units, the author was able to become a part of the social scene of the unit. Two interactions in which the patient or student drew the author into the conversation were discounted from the study.
Data Generation and Analysis
Data were recorded in the form of field notes or transcribed audiotapes. The 22 audiotapes yielded 617 pages of data. One hundred pages of handwritten field notes were recorded. Data were analyzed according to the procedures described by Glaser (1978) and Glaser and Strauss (1973):
* Generating categories through open coding of data.
* Applying theoretical codes to the data.
* Collapsing and expanding categories reflective of the data.
* Memoing and uncovering the core category of the data.
The constant comparative method of data analysis allowed the author to engage in a cyclical process of interviewing participants, coding and analyzing data, and producing memos.
After four interviews were coded, patterns of student behavior became apparent. Therefore, codes could be grouped into categories. For example, an early code was "ways to communicate with difficult patients." Related codes were "ways to communicate with different types of patients," "ways to communicate in different settings," and "ways to handle atypical communication." By attempting to group these more specific low-level codes together into a broader category, "ways to communicate with patients," the author realized that more coding categories were needed.
In addition, comparative and contrasting incidents were sought. For example, the code "ways to communicate with difficult patients" led to a search for patients who were considered "good" by students. The six Cs coding family described by Glaser (1978), in which the data are examined for causes, conditions, contingencies, core behaviors, and consequences in a context, was applied. The process continued until no new categories emerged, and saturation was reached.
The findings of the study reflected the two purposes of the method of discovering grounded theory -to identify a problem that needs to be solved and to identify the process used to solve the problem. First, the basic social psychological problem was identified from the perspective of the students. Analysis of the data indicated that students had a problem "saying the right things to patients." Key components of the problem included role development, emotion, behavior, and the personal nature of communication.
Second, the basic social psychological process that students used to overcome the problem was identified as "learning a personal communication repertoire." Four stages of the process were identified:
* Affirming the self.
* Engaging the patient.
* Experiencing communication breakdown.
* Refining the repertoire.
The grounded theory discovered in this study was that students learn a personal communication repertoire to say the right things to patients in a clinical setting. The significance of the study lies in understanding the components of the repertoire, identifying how students use it with patients, and how nursing faculty can help students develop components of the repertoire for use in clinical practice.
Students encountered the problem of saying the right things to patients. This problem had to be addressed so students could progress through the day. A student succinctly summarized the problem and its attributes, saying:
I try to weigh what I am going to say first. Ever since, from my other work experiences, I realize it is important to be conscious of what you are saying.... Conscious of not to say the wrong thing.... I would always make it a point in my mind to know that I was going to be sure to say, to say the right things.. .well, not put my foot in my mouth, or try not to.
As this example indicates, students were aware of their own personal style of communication and previous experiences that affected current communication.
In the clinical setting, students experienced two roles- that of learner and neophyte nurse. In the student role, students realized that learning involves making mistakes and trying again. However, in the role of neophyte nurse, students recognized the effect of a mistake on a patient's well-being. This dual role emphasizes the importance of the problem to students.
Having limited experience as nurses and being in the role of learners, there is a high probability that students will say the wrong thing on occasion. The probability that students will say the wrong thing is compounded by the unpredictable nature of the interaction. Students entered the clinical area armed with correct things to say to patients, derived from their course lectures. Unfortunately, students often had difficulty applying what they learned in class to real patient situations. In the clinical setting, students identified that instructors were more likely to help them with clinical skills than communication skills. The nature of the problem led students to engage in a process to solve the problem so they could be confident of their communication ability.
Four stages were identified in the process of learning a communication repertoire. Students passed through these stages in a sequential manner, and each stage included communication strategies and patterns. Communication strategies were identified as the smallest element of communication and could be used with any pattern of communication. The communication strategies students used in communicating with patients included:
* Asking questions.
* Telling patients what they were doing.
* Spending time with patients.
* Using nonverbal strategies.
Communication patterns were more complex and represented integration of personal style, context, and time. Five different patterns were identified:
* Social talk.
* Professional talk.
* Personal talk.
* Real nurse talk.
The four stages of the basic social psychological process identified from the data (i.e., affirming the self, engaging the patient, experiencing communication breakdown, refining the repertoire) were named for representative student experiences, which occurred during the time students were in the upper division of their baccalaureate program. Because students were engaged in interpreting symbolic meanings, as well as learning behaviors, the stages occurred in a fluid manner and were not associated with course beginnings or ends. The process is summarized according to the coding scheme in the Table.
Stage 1: Affirming the Self
This stage occurred early in the students' clinical experience and occurred prior to each time the students entered a new clinical area. Even before entering the clinical area, students engaged in the behaviors of this stage. Prominent behaviors of this stage were self-reflection, anticipation, and expectations. Student engaged in self-talk as they encouraged themselves to communicate with patients. Selftalk was defined as a communication pattern in which students communicated with their own selves about events or performance. It was encouraging or evaluative in nature. One student was apprehensive about caring for her first patient. She asked herself many questions about the unknown patient, including, "Would the patient be receptive to me?" and "Would the patient resent being helped?" The student attempted to answer these questions by "putting myself in the patient's shoes." Students validated themselves by making statements such as, "The patients like me" and "patients love talking to me."
Subsequently, as students gained more skill in communicating with patients, their confidence increased. One student said this about her next rotation in a maternity unit, "My first day in maternity, I could do it, I could go in there and help a postpartum patient and not appear like I didn't know what I was doing, the patient respected me." The outcome of the stage was that students began to communicate with patients from the perspective of self. They viewed patients in light of their own apprehensions and expectations. Students returned to the pattern of self-talk when they needed encouragement or when they critiqued their own communication style.
Stage 2: Engaging the Patient
In the second stage of engaging the patient, students encountered uncertainty, overcame the feeling they were intruding on patients, and advanced in their role as nurse by caring for the "good patient." Uncertainty was related to feeling as if they were intruding on a patient and that they, as students, did not have "the right," which comes with position, to engage a patient. A fourth-year nursing student in the community health rotation expressed uncertainty and fear of intruding, saying:
Going to the house where I really didn't know what is acceptable, if you knock, and it is open, can you walk in, or if it is acceptable to comment on the home itself. Whether or not that would be too intrusive, or whether or not it is my place. I didn't know what is acceptable, and what isn't in talking with the patient.
Students were searching for the correct boundaries of behavior.
Students related to patients as people, and because of this, they were reluctant to interrupt patients' television watching or telephone conversations to provide care. However, students were acutely aware that they must embrace the role of nurse and see the patient as a patient, not a person. One student explained, "It was a new role, I wasn't going in there as a man talking to a man. I was going in there as a nurse talking to a patient, so this was a role I hadn't had any experience in. I was going to be observed in the role of nurse not as in the role of one adult talking to another adult."
A key aspect of engaging the patient was caring for a patient who made the student "look good." "Good" patients acted like ideal patients and helped the student "look like a nurse" by virtue of their knowledge and compliance with the patient role. As described by one student, "He knew where everything was, he knew everybody, the nurses, where things were that I didn't even know." Good patients were easy to talk to, maintained a conversation, and helped the student in their duties. Unusual events did not happen when a student cared for a good patient.
As students engaged patients in communication, they learned and used three communication patterns- social talk, professional talk, and personal talk. Social talk served to begin the communication. It was easy and familiar social chitchat. Professional talk contained the rules of communication the students had learned from their instructors. Personal talk was used in special circumstances when the student and patient shared a common experience. Overall, the stage of engaging patients contributed to building a relationship and rapport with patients. Students defined rapport in terms of the self, which helped them look good to instructors and others.
Stage 3: Experiencing Communication Breakdown
Communication breakdown was characterized by rampant emotions, unclear boundaries of behavior, and instability in the student-patient relationship. Control of communication was the source of a struggle between the student and patient. Students needed to maintain control of the situation to be professional, complete their academic work, and care for their patients. Patients exerted control of the situation through behaviors, words, and actions to which students did not know how to react. One student explained how a patient exerted control of communication, saying:
First thing I had to communicate was "I'm here." Unfortunately, he was the communicator; he would go on, took control. I would see him as the director, and I was the player. That was not the role that I thought I was going to go in for. I thought I was the professional, and he was the one who was going to heed my directions. But it didn't turn out that way.
In this stage patients exhibited behaviors that were emotional, inappropriately angry, or extreme. Patients would cry, yell obscenities, or physically lash out at the students. Carefully established behavior boundaries broke down. Whoever was in control of the situation would get the results they wanted. The students experienced crisis because they had to complete the tasks of nursing. One student fell behind in her nursing care because of a difficult patient. She said, "I had one patient, he was very sick, he didn't speak English, he would tell me to go away, and yell 4NO NO NO!' at everything I tried to do. I'm like I guess I shouldn't touch him." So she left him alone.
The most important condition of the stage of experiencing communication breakdown was the difficult patient. Difficult patients could be found on every unit. All students encountered a difficult patient at some point in their clinical experiences. Difficult patients were patients who had language barriers, were neurologically impaired, or were victims of trauma. These patients possessed attributes uncommon to the patient population on the unit; they were different. For example, a difficult patient could have a psychiatric illness, as well as a medical problem, and be on a medical unit. The difficulty in caring for the patient stemmed from the psychiatric illness, not the medical problem. Difficult patients frequently had families that made demands on students. These patients were not predictable and challenged the communication ability of students. The challenge was not unwelcome, as one student explained, "I just tend to like the difficult patients, it is the challenge, it gives me a sense of accomplishment, and if I handle a situation no one wants, I get in to it."
Students learned to keep going with difficult patients, incorporating previous strategies, and particularly using the pattern of real nurse talk. This pattern developed as a result of students observing the interactions of the RN with the patient. Students evaluated how "real nurses" communicated with their patients and made decisions based on these observations. In general, the staff nurse on the floor was a source of help for the students. For example, one student observed that in communicating with difficult patients, "I guess with the nurse, when you have a nurse in there who is used to this, who has experience, it just makes it easier."
Stage 4: Refining the Repertoire
In this stage, students worked to resolve the communication breakdown, which occurred in the previous stage. The students had to continue communicating and used different strategies tailored to their personality to communicate with patients. Even if the interaction did not proceed easily, students did not retreat but continued forward. The students considered the resources available and used them selectively. The problem was subsequently resolved to varying degrees of student satisfaction. Students learned from the communication crisis and reflected on the process of communication. Integration of the elements of the problem contributed to refinement of the repertoire and resolution of the problem.
The emotions that students experienced in the third stage came under control in the fourth stage as students learned "don't take it personally." Students understood that patients were not attacking them as people but in their role as nurses. Boundaries were reestablished by students as they considered how to manage inappropriate behavior. Students decided how much they would bend to the patients' wishes and what would be considered off limits. This was partially achieved through role development as students saw themselves as "almost a nurse."
Students in this stage used a variety of communication patterns to communicate with patients. If one pattern was not helpful, they switched to others. Students had the flexibility to do this without the fear of "saying the wrong thing." All the communication patterns previously mentioned were used (i.e., self-talk, social talk, personal talk, professional talk, real nurse talk). The communication repertoire helped students "say the right things." Tb communicate as professional nurses, students came to understand the dynamic nature of interaction in the clinical setting, built a repertoire to help them, increased their confidence in themselves, and enjoyed patient trust. One student explained how she knew how to say the right things to a patient:
I guess it is on an individual basis, but it has to do with being assertive.. .and persistent. Lots of times if I request the patient to do something or give them instructions, and they say no, or if they have a problem with it, then I take that as the end. A lot of times, they don't want to do something because they don't think that they can, or maybe they are scared, so you have to give them the reassurance. Because sometimes you have to do things that you feel are hard in order to get better or gain independence. You have to push to a degree, because some of the time, it is an easy way out to do things for the patient.
The previous remark serves as a metaphor for student experiences communicating with patients. Students experienced the hard reality of difficult patients. They realized they must continue communicating, not take the easy way out. The easy way out would be not to communicate, to keep things superficial, or to allow the RN to handle the difficult patient. Still, students recognized the benefit to themselves- when they persisted in communicating they could do it.
This study detailed the process that students go through as they learn to communicate with patients. It explained students' perspective of developing a communication repertoire and adds to the work of Beck (1993) and Wilson (1994) in explaining students' experience in the clinical setting. Similar to descriptions in the work of Wilson (1994), students derived meaning from their experiences and reacted to the meaning on symbolic and behavioral levels. The symbolic nature of communication was described by students in terms such as "my first patient," communicating with "good patients," "difficult patients," and being in the position of "almost a nurse." The meanings inherent in these terms were created from the students' experiences with patients, staff, and faculty in the clinical setting. This study described the array of behaviors in which students engage when communicating with patients in clinical settings. More than a catalog of skills, the behaviors discussed in this article were presented within the meaning of communication. In the clinical context, student experiences were influenced more by the behaviors of RNs on the unit, rather than nursing faculty. Students spent considerable effort evaluating RNs' communication and its effect on patients, and accepting or rejecting what they saw.
King's General Systems framework (1971, 1981) suggested to the author the study of the concept of communication in the nurse-patient relationship. In the framework, communication is a concept that is imbedded in the interpersonal system. This study suggests communication also should be included in the personal and social systems. Self-reflection and self-talk on the part of students support that students communicated with themselves in the personal system. The larger context of the clinical environment, with students observing the nurse on the floor, supports the inclusion of communication in the social system.
This study contributes to theoretical knowledge development in nursing in the substantive area of clinical nursing education. Hartrick (1999) suggested moving beyond a behaviorist approach and viewing communication within the larger context of the educational experience. In this study, the realm of communication knowledge developed by students is an example of personal knowing, as described by Carper (1978). "Personal knowledge is concerned with the knowing, encountering, and actualizing of the concrete individual self (Carper, 1978, p. 18). Personal knowledge involves knowing the self and realizing the effect one has on others during the transactions that occur between nurse and patient.
In this study, baccalaureate nursing students were observed and interviewed during the process of discovering personal knowledge within their realm of nursing. Students were concerned and reflective about the effect they had on patients. The development of personal knowledge was heightened when they experienced communication breakdown. As a result of the breakdown process, students learned about themselves, as nurses and people, and they learned a repertoire of strategies and patterns to be used with patients. An element of personal knowledge discovered in the communication breakdown stage was uncovered as students considered the extent to which patient behavior and environmental variables can and should be manipulated. The aspect of personal knowledge, which is knowing things for yourself and about yourself, was apparent as students spoke about themselves. Students would preface comments with strong "I" statements, indicating they were integrating their knowledge of the personal self with their emerging nursing self.
On a larger scale, Benner (1984) described the knowledge that is imbedded in nursing practice. Benner (1984) identified four stages of skill acquisition and grouped nursing competencies within 10 larger domains. This study identified strategies similar to some of the competencies of the helping role identified by Benner (i.e., presencing or being with a patient, providing comfort and communication through touch, and providing emotional and informational support to patients). As described by Benner (1984), nurses are engaged in a process of refining and enlarging their practice repertoire. This study indicates that these behaviors start during the student years.
Nursing faculty can use the information gained in this study in several ways. First, nurses should be sensitized to the complex nature of student-patient communication. Second, nurses must prepare students for communication breakdowns and help them develop a communication repertoire. Finally, ongoing research into the nature of communication in nursing and nursing education must be conducted by nursing faculty to facilitate student learning, promote the communication process, and expand the theoretical base of nursing education.
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