Effective communication is a critical skill in the role of a professional nurse to develop relationships, express thoughts, and effect change. The essential nature of communication is reflected in the definition of nursing (American Nurses Association [ANA], 2010), where the skill is requisite for the “diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (p. 1). In addition, aspects of communication are infused in many of the Standards of Practice. Standards of Professional Performance include communication as a discrete standard. Accrediting bodies and individual program outcomes mirror the ANA standards, typically addressing the importance of communication in various contexts—collaboration and team-work, safety situations, and relationship-based care. Communication skills are needed for clarity in the delegation of tasks, patient teaching, and in empathetic, compassionate person encounters. O’Hagan et al. (2014) also asserted the importance of effective communication in influencing patient outcomes.
Didactic courses can teach the theoretical principles of relationship building, group dynamics, conflict resolution, and communication with various groups or ages; however, communication needs actual practice to move to a professional and effective skilled level. With clinical sites shrinking, there is a higher reliance on simulation for experiential learning. Scenarios in medical–surgical settings often focus on problem-solving and psychomotor skills, with communication skills as a lower priority (Christoffersen, Barron, Lynch, & Caroline, 2010). Communication skills, when highlighted, more often occur in psychiatric–mental health settings or center around intraprofessional and interprofessional aspects. Christoffersen et al. (2010) stressed that effective communication skills are also required in medical–surgical settings, while also acknowledging that a focus on communication may be difficult when handling the complexities of current health care—a reason why building communication skills is often left to a psychiatric–mental health setting.
Students recognize the importance of learning communication skills through simulated learning and identifying how it helps with reinforcing the importance of communication, providing an opportunity to learn from mistakes, and assisting the student to become better prepared for real-life situations (Bambini, Washburn & Perkins, 2009; Spinner-Gelfars, 2013; Stewart, Kennedy & Cuene-Grandidier, 2010). As one midwifery student observed, “I think sometimes you are so focused on doing the right thing and carrying out the right thing that we don’t communicate with the…client who is involved” (Deegan & Terry, 2013, p. 593). McMillan and Shannon (2011) identified academic exposure and curricular emphasis as two predictors of a students’ perceived competence in empathetic communication skills. Therefore, opportunities to develop and refine communication skills throughout the curriculum should become a priority for nurse educators. Simulations designed to encourage therapeutic use of communication provide one avenue for building this skill.
The current study proposed to gain insight into the communication patterns of nursing students while undergoing a high-fidelity medical–surgical simulation. The goal of the study was to identify the degree and nature of communication with simulated patients, whether effective or ineffective. This, in turn, could highlight opportunities for developing scenarios and debriefing that emphasize the practice of communication skills in all patient care settings.
Research regarding simulated communication experiences varies from using high-fidelity manikins, to standardized patients or theater student actors, to static cases where the individual responds to a recorded video narration. In some sources, communication was the primary focus of study, whereas in others, communication was part of a group of variables or an incidental finding.
Previous studies (Kameg, Mitchell, Clochesy, Howard, & Suresky, 2009; Sleeper & Thompson, 2008; Szpak & Kameg, 2013) have demonstrated the impact of simulation on reducing anxiety and improving self-confidence and self-efficacy in communication situations. In a review of the literature, Foronda, Liu, and Bauman (2013) identified 11 studies of interdisciplinary simulations, with each identifying improved interdisciplinary communication as an outcome. Lewis, Strachan, and Smith (2012) also identified communication as a theme in simulation research, indicating there was minimal research on hand-off intraprofessional communication, referencing the one nursing study that supported an increase in both the quality and quantity of information exchanged after a simulation experience. The enhanced communication was deemed essential to patient safety.
Bringing the focus to simulated communication with patients, Bambini et al. (2009) identified outcomes of better formulated assessment questions, enhanced organization of questions, and improved awareness of nonverbal communication after a simulation experience. Caring behaviors, which included communication, also were self-identified or changed as a result of simulation (Blum, Hickman, Parcells, & Locsin, 2010; McMillan & Shannon, 2011).
O’Hagan et al. (2014) interviewed nurse educators and clinicians regarding their responses to videos of a nurse–patient interaction to gain insight into the nature of effective communication in nursing. Although not focusing on students, the findings of this study are relevant, as nurse educators are in the unique position of teaching and modeling effective nurse–patient communication. Thematic analysis of the responses revealed relevant areas of (a) approach, (b) manner, (c) techniques, and (d) communication. Comments from the participants regarding approach revolved around the task orientation or patient orientation of the communication in the scenario. Elements of awareness and sensitivity to patient needs, recognition of cues, use of lay or medical terminology, and involvement of the patient in decision making were identified. Aspects of the theme of manner centered on behaviors considering the engagement of the nurse with the patient. Conveying respect, empathy, or a distant, dismissive level of engagement were examples. Tone of voice was included in these behaviors. Use of communication tools comprised the theme of techniques with observation of techniques, such as clarifying, paraphrasing, and the use of open-ended questions. The final theme, communication, included comments regarding the effectiveness of nonverbal communication aspects, such as eye contact, touch, and use of space.
After obtaining institutional review board approval, baccalaureate students in the senior-level adult health course in a midwestern U.S. university were approached to solicit participation in the study and obtain permission for recording of a simulation. Recordings were viewed simultaneously by both researchers, and a verbatim transcript was generated for all salient interactions. Analysis of the data was performed with an initial start list consisting of therapeutic communication techniques. As the analysis progressed, data revealed emerging patterns that became apparent, and subsequent analysis focused on a thematic approach. As the iterative discussion ensued, revisions occurred as the emergent patterns and categories developed. Trustworthiness was established through the iterative process, which involved prolonged engagement with the data, thorough sampling, data saturation, and rich descriptions.
The convenience sample consisted of 25 recorded highfidelity simulation sessions lasting approximately 20 minutes each. Each session included two to four students, resulting in a total of 71 students involved in the study. Data collection occurred over three clinical rotations from the fall semester to the first half of the spring semester.
The scenario revolved around Gladys, a 64-year-old woman with burns from a house fire. Her injuries consisted of partial-thickness burns on her chest and cheek and a full-thickness burn on her upper left arm. The setting for the scenario was either in the emergency department or day 2 in a medical setting. Medical issues experienced by the patient included pain control, oxygenation issues, fluid resuscitation, and compartment syndrome. Presimulation preparation directed the students to review the physiological aspects of burn injury and consider priority nursing interventions, including psychological aspects. The scenarios were conducted with one instructor, not associated with the study, providing the voice of the patient, spontaneously responding to the student interactions and interventions.
In answering the research question regarding patterns of communication observed in a high-fidelity medical–surgical simulation, three patterns emerged from the data. These included (a) focusing on tasks, (b) communicating-in-action, and (c) being therapeutic (Figure). In addition, within each pattern were several categories. In the examples below, the patient and students are given numbers only to identify a different instance.
Patterns and categories of communication in high-fidelity simulation.
Focusing on Tasks
Missing Opportunities. Missing opportunities was a significant category within this pattern. In many stimulations, students became so engrossed with the physical aspects of caring for the patient that opportunities to respond in a therapeutic manner were overlooked, such as in the following examples:
Gladys 1: Oh, why does it hurt so much? [No response, students busy taking blood pressure and looking at computer.]
Gladys 2: Are the burns bad? Why do they hurt so much? [No response. Students working with monitor and oxygen supplies.]
In addition, the distraction of tasks interfered with identifying cues in patient statements and a missed opportunity where a more therapeutic response may have been provided. In some instances, this resulted in the use of trivial responses. In other simulations, students gave vague responses and empty phrases or false reassurance, such as in these examples:
Gladys 1: I feel so stupid…what I did at home…so stupid.
Student 1: Accidents happen…. You can’t blame yourself
Gladys 1: Oh, it hurts, so much!
Student 1: You’re in the right place…. We’re here to take care of you.
Gladys 2: It’s just really scary that anything that touches my skin really, really hurts.
Student 2: Okay…ahh…I understand.
Gladys 3: You need to listen to me…. I don’t feel like I am getting enough oxygen. I feel like I’m going to die!
Student 3: (Pause) Gladys, you’re not going to die. It’s going to be okay…. We’re taking good care of you.
Gladys 3: I’m scared.
Student 3: It’s okay.
Viewing the “Small Picture.” A second category within the pattern of focusing on tasks was viewing the small picture. A recurring observation consisted of students having a narrow focus. This narrowed field of vision limited the students’ ability to see larger issues raised in communicating with their patient in the scenario. Again, in many situations the small picture consisted of tasks consuming their focus. In other situations, the communication was limited to the immediate intervention, without providing the patient a context for the events that the patient was experiencing. One of the challenges the students faced that narrowed the focus to tasks was identifying the telemetry patch placement, given the burns on Gladys’ chest.
Gladys 1: Does it look really bad?
Student 1: There’s some blistering…. The doctor wants us to put telemetry on you, which monitors your heart…and we’re going to find the best way to do that…. That usually goes on your chest.
Gladys 2: Can you get those cords off me? [referring to electrocardiography wires]
Student 2: Well, we need to see what your heart is doing, real quick.
The narrow view could also be seen in responses to patients, where an explanation to a patient question emphasized only the current situation, in this case the fluid overload, and not the reason the fluids were needed initially.
Gladys 3: I feel like I’m going to die.
Student 3: [No response. Students busy with assessing lungs, giving medications.]
Gladys 3: What’s going on?
Student 3: Well, we’ve been giving you a lot of fluids, maybe we gave you too many.
The pattern of communicating-in-action related to the predominant communication styles that emerged as the students engaged in the activities involved in the scenarios. These included (a) relying on information, (b) speaking in “medical tongues,” and (c) offering choices…okay? Communication in these categories was effortless and flowed smoothly in most instances.
Relying on Information. Answering patient questions by informing was a common communication technique used by the participants. In some situations, reliance on the simple provision of information reflected a lack of insight into potential deeper meanings in the patient queries. Informing also reflected a lack of insight into health literacy considerations, as this category overlaps the category of speaking in “medical tongues,” where medical terminology is used inappropriately.
Gladys 1: Why was my blood pressure a problem? I don’t usually have a problem with my blood pressure.
Student 1: The morphine can lower your blood pressure, and through your burns, you’re losing a lot of fluid.
Gladys 2: What happened to my arm?
Student 2: Well, where it is burned…the reason you are having all that pressure is because the burned tissue won’t let it expand when there’s swelling underneath. And so it is putting pressure on your blood vessels and nerves. That’s why you have the tingling.
Gladys 3: It hurts…how bad…what do they [the burns] look like? How bad is it?
Student 3: You have full thickness burns on your arm, and some blistering areas on your chest and face. These are the ones giving you the pain.
Speaking in “Medical Tongues.” As demonstrated by the use of the term “full thickness” in the previous example, speaking in medical tongues also emerged as a category. Medical terminology, a way of communicating intraprofessionally, was unconsciously inserted into the communication with the patient.
Gladys 1: Oh, all those alarms…. Is everything okay?
Student 1: Your oxygen saturation is better. That’s what we were hoping for.
Student 2: We’re going to give you a bolus of fluid.
Student 3: Also I’m going to give you some oxygen, just to bump your O2 sats up a bit. You’re going to need plenty of oxygen if it’s going to heal these wounds. So it’s [the nasal cannula] going to go in your nose and around your ears, okay? I’m going to be real gentle here.
Offering Choices…Okay? The category of offering choices… okay? was a surprising finding that generated significant discussion during analysis regarding how often this occurred in the simulations and in practice. The category reflected a pseudo-choice provided in the communication, simultaneous to the action being completed.
Student 1: We’re just going to put the blood pressure cuff on here so we can monitor you better…okay?
Student 2: We’re going to put some compression devices on your legs…okay?
Student 3: I’m going to get you hooked up on the heart monitor…okay?
Student 4: I’m going to put this through your nose, okay. It’s going to give you more oxygen.
Although intended to inform the patient of a proposed activity, the addition of the “okay?” implies a choice not provided, as the action was already occurring. The patient in the scenario did not object, therefore giving implied consent; however, the opportunity to decline the intervention was not truly an option either.
The pattern of being therapeutic reflected categories where communication with the patient reflected relationship building and techniques for therapeutic communication. This pattern also highlighted the discomfort with finding “the right words to say” in responding to the patient.
Feeling Uncomfortable. Feeling uncomfortable, one category in this pattern, demonstrated this discomfort as students struggled for a response. This resulted in halted, disconnected phrases, vague affirmations and clipped responses, and minimal periods of silence.
Gladys 1: Have you seen it? [Referring to the arm burn.] How bad is it?
Student 1: There is a dressing on it right now…. I’m not going to remove it.
Gladys 1: Is that going to…ouch! Is that going to leave a big scar?
Student 1: Ah…. [pause] There’s a possibility of that…. [pause] Yeah….
Gladys 2: It’s scary….
Student 2: Yeah, your husband will be here soon.
Student 3: Has anyone been in to visit you?
Gladys 3: Yes, my husband has been here most of the time.
Student 3: Okay.
Gladys 3: I don’t really want my kids to come yet.
Student 3: Yeah.…
Using Therapeutic Techniques. Therapeutic communication techniques reflecting presence and comforting behaviors also comprised a category. Building the relationship through the introduction of self and calling the patient by her preferred name was seen in all simulations. The use of touch, proximity, and facial expressions are not reproducible in narrative form. Other responses expressed empathy and support. Techniques such as clarification, rephrasing, reflection, and validation were noted.
Student 1: I’m going to be right here. You can squeeze my hand if you need to.
Gladys 2: I hope you’re going to have time to wash my hair soon. It smells smoky to me.
Student 2: It smells smoky?
Gladys 3: I was making lunch for him when it happened. It was so stupid.
Student 3: It must have been scary for you.
Student 4: We’re just going to do an assessment. I’m going to listen to your chest, heart, and lungs. I’ll be really careful around your chest area, because I know that’s going to be pretty painful.
Although not patterns of communication, other interesting aspects of communication were observed. In many of the simulations, the voice quality was emotionless or incongruent with the words being spoken. Many responses were monosyllabic, such as “okay,” “yeah,” or “uh-huh.” Although touch was observed as a part of the use of therapeutic techniques, it was not as common as what might be expected in a situation involving anxiety and pain. Eye contact with the manikin was minimal during communication. The major communication technique observed for anxiety consisted of instructions for deep breathing or distraction. Closed-ended questions were the predominant style of questioning used in the simulations, and multiple people were talking to Gladys simultaneously. Problem-solving communication occurred in front of the patient in some instances. Nonverbal communication in the form of facial expressions reacting to a patient response or recognition of an inappropriate response could be seen on occasion, as well as behaviors such as placing hands on the hips, a position suggesting inattention when not engaged in a specific activity.
When viewing the patterns of communication in this highfidelity medical–surgical simulation, it is apparent that not all communication with the simulated patient would be considered therapeutic. Yet, communicating with patients is a large component of nurses’ daily experiences. Refining therapeutic communication is a skill that requires practice because it is easy to revert to simple conversation used in daily living, especially in times of high stress or anxiety. High-fidelity simulation has the advantage in providing a complex, potentially high-stress environment for developing not only psychomotor and problem-solving skills but also therapeutic communication skills.
It is important to note that despite senior-level standing, these students are still novice nurses. Benner (1984) pointed out the black-and-white nature of novices, which limits their ability to see a situation holistically and assemble a complete picture of all the nuances and dynamics occurring in the scenario. The focus on tasks may also be related to the novice status, as the participants felt the need to develop competence in the area of their skills and psychomotor tasks. Thus, the pattern of focusing on tasks with categories of viewing the small picture and missing opportunities may reflect the perspective of students—and potentially faculty—who place a value on psychomotor skill development. However, given the competencies set forth by the Quality and Safety Education for Nurses (QSEN) Institute (Cronenwett et al., 2007), the emphasis on developing expertise in communication for relationship-based care should also be an area of priority for students.
The lack of comfort and experience in situations of patient distress was exhibited through many missed opportunities to explore the patient’s feelings. Gladys’ question regarding the extent of her burns was answered with information, when the intent of the questions may have had a deeper meaning—as in “will I have scars?” or “will I be disfigured?” Discomfort with silence as a therapeutic technique resulted in students feeling that a response was needed for every patient comment and that every moment needed to be filled with the spoken word.
The complexity of the scenario may have influenced the communication patterns. It was noted that in some simulations, an inordinate amount of time was spent in problem-solving patch placement for the telemetry or the best placement of the oxygen cannula with the facial burn, leaving little time to focus on other aspects of the situation. Reflecting back on the novice status, their ability to multitask may limit their ability to integrate all aspects of physiology, nursing interventions, and therapeutic communication into a 20-minute simulation. Variable ability levels among the participants also may play a role in the results seen, as some students demonstrated a higher level of problem-solving and psychomotor skills, thereby freeing time for an intentional focus on communication.
Many of the patterns and categories resemble the findings of O’Hagan et al. (2014), lending validity to the findings of this study. Patterns and categories such as focusing on tasks, missed opportunities, speaking in medical tongues, and offering choices…okay align with the theme of approach in the study by O’Hagan et al. Likewise, relying on informing and using therapeutic techniques parallel aspects of manner, techniques, and communication themes.
The use of an instructor as the voice of Gladys in this scenario allowed for a spontaneous interaction and a more realistic feel for the participants. However, in providing this realism, the results of the study may have been influenced because the scenario varied slightly with each student group. Although a basic script was used for each simulation, the scenario progressed tangentially as a result of student responses. In addition, communication is supported, in part, by nonverbal aspects, not just the spoken word. Simulation technology, at this point, is not robust enough to provide the type of nonverbal communication sufficient to simulate the perception of reality. Finally, the issue of performance anxiety may be a factor in communication during simulation. Despite the assurances of a safe, learning environment where students are instructed that mistakes are acceptable, students often place high expectations on themselves for their performance, thus creating an anxiety-provoking experience.
Continual opportunities to practice any skill is crucial in developing mastery, and communication skills are no different. Unfortunately, nursing education often prioritizes the development of psychomotor skills. Both faculty and students often share this priority, leaving communication with patients in practice situations, such as simulation, as a secondary consideration. The results of this study support the importance of integrating patient communication aspects in all simulations, not just those that may occur in a mental health situation. With this insight, a recommendation can be made to consider designing specific scenarios in settings other than mental health, where patient communication is the priority. In addition, it is recommended to enhance the use of task trainers and skill blitzes for the mastery of psychomotor skills, with inclusion of issues involving problem solving during work with the task trainers. This would eliminate the focus on tasks and challenges during a simulation, allowing for more time for therapeutic communication and in clinical decision making.