Communication with patients and families can be difficult for novice nurses. Everyday conversation and small talk is easy for most. Novice nurses often struggle with sensitive dialogue in care of a patient with a terminal illness or a diagnosis that will strongly impact their life. Clinical Simulation can help learners develop communication tools to ease difficult talks with patients and families. This article written by Kathy Sokol, RN, MSN will explore the versatility of healthcare simulation to assist to embed core communication skills for health professionals.
Authors of clinical simulation cases should include the opportunity for therapeutic communication in all scenarios. Most Clinical Simulations add one or two comments by the patient to ensure the learner speaks to them. Unfortunately, much of the dialogue cues the learner to educate the patient/caregiver on diet, activity, or medication schedule rather than to utilize the opportunity to practice and enhance communication skills on more difficult topics.
Giving a Cue May Not Initiate Therapeutic Communication
Healthcare simulation scenarios occasionally have the patient express pain or a sense of loss. These cues expect learners to ask open-ended questions and obtain more information to help them care for the patient. Sadly, learners may miss the intent of the cue and respond with “I’ll get you a pain pill for that” or “I think we all feel that way at one time or another.”
End-of-life scenarios invite learners to ask the patient about their concerns about the prognosis or their thoughts on death. An experienced nurse understands how important it is to ask patients to discuss their fears and anxieties. A student nurse may try to comfort the patient and family but avoid discussion of the terminal diagnosis. Healthcare simulation is a useful utility to be able to extend the learning in a clinical simulation scenario to practice some more depth to these communication skills in difficult conversations with patients.
Suppose the scenario objective states: “Explore the patient’s thoughts with respect to their healthcare prognosis and diagnosis and how this may impact the patient’s life.” A learner could meet this learning objective goal once they ask, “Tell me how that makes you feel?” The learner may gloss over the patient’s response if they do not continue to ask questions to address the patient’s emotional needs in a curious manner. How can learners develop an arsenal of communication aids to assist with awkward nurse/patient dialogue through Clinical Simulation? Add an uncomfortable conversation element to the healthcare simulation scenario.
Complex Clinical Simulation Cases Can Stimulate Discussion
Consider a simulation for the care of a teen with a newly placed colostomy due to a ruptured bowel. The patient is a 16-year-old male with a history of inflammatory bowel disease. Three weeks ago, he needed surgery to place a colostomy in the lower colon. Since his discharge home, he has relied on his mom and older sister to do ostomy care. When the nurse enters the room at the start of the scenario, the patient complains of the smell from his ostomy bag, which fell off.
Throughout the simulation, the patient refuses to look at the ostomy or attempt to learn self-care. He asks the learner, “How can you stand the smell?” When the learners try to normalize the patient’s situation, he tells them, “I wish I could just die.”
This scenario calls out for effective communication and emotional intelligence on the part of the nurse. How the nurse deals with the patient’s concerns can make or break the opportunity for therapeutic rapport.
Student nurses may be afraid to engage patients in sensitive topics like the one in the above scenario. A learner may express:
- General discomfort in dialogue with the patient
- Fear of causing hopelessness
- Fear of wrong choice of words
- Fear their emotions will come out
In the above scenario, participants went silent as soon as the patient talked about his wish to die. Most groups tried to reassure the patient that an ostomy wasn’t the end of the world. Some tried to teach the patient how to hide their ostomy when they were out in public. They found pictures online of garments with built-in pockets to hold the pouch. Others were astonished that the young man couldn’t see the bright side of his situation: the ostomy saved his life. Still, others assured the patient that self-care for the colostomy wasn’t difficult to learn.
Only one learner urged the patient to talk more about why he wished he could die. All of the participants completely ignored the impact a colostomy could have on the lifestyle of a teenage boy. He had just learned how to drive, looked forward to his Junior Prom, and, while he didn’t talk about this, he was worried he couldn’t have sex when the time was right. Therapeutic communication failed miserably between the patient and the learners.
Help Learners Develop Stronger Communication Skills
Learners must prepare for the inevitable difficult conversations they will have with patients. The faculty can assist with this:
- Encourage and practice active listening on the part of the learner. Perhaps dedicate a few minutes in class to pair up students to ask scripted questions to each other.
- Teach the learner to ask the patient to reflect on their situation.
- Discourage learner self-talk (when a learner implies they know what the patient feels, “My grandmother had a colostomy.”) Teach learners what to say instead of the first thing that comes to mind. I always tell students to say, “Tell me more.”
- Consider the health literacy of the patient. Ask them what they understand about their diagnosis. Avoid medical-speak. Don’t assume just because a patient has a chronic illness, like the young man in the scenario, they know all about their disease.
- Provide only helpful input. Avoid judgment.
- Be aware of non-verbal communication (crossed arms, etc.)
Learners should discuss how they feel about the case in the pre-brief. Faculty can offer assurance and support. Learners must also be supportive of other participants in the Clinical Simulation.
Learners need time in debrief to describe personal emotions felt in the scenario. The student nurse may be embarrassed to admit they experienced sadness, hopelessness, or felt ill at ease. Participants may feel self-conscious because they shed tears in the clinical simulation scenario. An experienced Healthcare Simulation Facilitator will insist all participants behave professionally. No one would humiliate a colleague in the hospital who expressed sadness with tears; the same holds in the clinical simulation lab. Now is the ideal time to reinforce safety in the Clinical Simulation environment. Assure learners that what happens in the clinical simulation stays in the clinical simulation lab.
In conclusion, begin to prepare student nurses and other health professionals for the complex discussions they will face after graduation. Add conversations that are difficult, or may embarrass the learner, to every healthcare simulation. The more learners practice therapeutic communication about sensitive topics, the more comfortable they will be over their career in difficult conversations. Communication skills are essential to effective clinical care delivery in every part of healthcare. Clinical simulation is the perfect environment for student and novice healthcare professionals to be able to acquire these skills and perfect them as early as possible.
