Evaluating the therapeutic communication skills of nursing students in the clinical setting: The experiences of students, patients and patients’ relatives

Abstract

Background

This study aimed to determine the therapeutic communication skills of nursing students, examine their experiences of communication during care, and evaluate the views of patients and their relatives.

Methods

This study was designed using the convergent parallel mixed method and was conducted in Türkiye. The therapeutic communication skills of 112 nursing students were examined using the Therapeutic Communication Skills Scale. Qualitative data were obtained in focus group interviews with 18 nursing students and in individual interviews with 10 patients and 10 of their relatives. Number, percentage, mean ± standard deviation and minimum-maximum values were calculated from the quantitative data. The thematic method was used to analyze the qualitative data.

Results

The mean scores of the 112 nursing students for Therapeutic Communication Skills 1 (reflecting, summarizing, restating, verbalizing the implied, focusing, and stating the observed) and Therapeutic Communication Skills 2 (active listening, offering self, and asking questions) were 26.18 ± 6.52 and 15.68 ± 3.03, respectively. The mean score for non-Therapeutic Communication Skills (warning, downplaying emotions, advising, vague reassurance/cliché response, changing the subject, defending, and judging) was 18.59 ± 7.60. As a result of the analysis of the qualitative data, three main themes emerged: “challenges in mastering and applying therapeutic communication”, “the positive impact of therapeutic communication”, and the “patients' and relatives’ views of the nursing students' communication skills”.

Conclusion

Despite challenges in applying therapeutic communication techniques, this study highlights the benefits of doing so for both patients/relatives and nursing students. Nevertheless, since the individual and cultural factors affecting the results of this study could not be controlled, further studies in different cultures and further studies are needed. On the basis of the results of this study, educators should support the internalization of students' communication skills by employing methods such as simulated patients, standardized patients, and peer education. It is recommended that the knowledge and skills of nurses working with students in clinical settings be improved to ensure they are able to serve as adequate role models.

1. Introduction

Therapeutic communication (TC) is an important tool in establishing interpersonal relationships, in the process of knowledge transfer, and in providing patient-centered care, and is an indicator of nurses' competence in clinical practice [1]. This communication begins with the nurse-patient interaction and progresses toward patient recovery [2]. Among the outcomes of this process are that the patient feels that they are benefiting from TC, their satisfaction increases, and it becomes easier for them to cope with their pain and suffering [1,[3], [4], [5]]. TC techniques, which are important factors that shorten the patient's recovery time, include giving information, asking questions, and listening [4]. When a nurse uses these techniques well, this not only contributes to clinical recovery but also has a positive effect on the daily life of the patient, helps them cope with life difficulties, and improves their interpersonal relationships [3,6]. These communication techniques also facilitate the gathering of correct information, support the achievement of care goals, and establish an emotional bond between the patient and the nurse [4]. When a therapeutic relationship cannot be established between the nurse and the patient, this increases the latter's anxiety and unhappiness and prevents the desired quality of care from being attained [7].

Within the scope of global nursing practices, TC helps ensure cultural sensitivity and diversity, patient-centered and holistic care, and open discussion. In this way, it contributes to enhancing the quality of healthcare services, improving patient satisfaction and treatment outcomes. Additionally, TC skills can be considered a means of reducing the commonly observed issues of burnout and attrition by fostering a sense of professionalism among nurses [8,9]. Although nurses' ability to use TC skills and to apply them effectively can have a positive effect on the nurse as well as the patient, it is often not possible to develop these communication skills perfectly. Therefore, new studies are needed which evaluate the results of national and international studies and the use of these techniques by nurses. Several studies [1,10] have highlighted the need for educational interventions to improve TC skills among nursing students. Coelho et al. [10] stated that nurses should benefit from programs using technology during the education process in order to make these techniques a part of their professional lives, and Abdolrahimi et al. [1] suggested that educators be given the opportunity to develop TC skills and adopt student-centered teaching methods in a safe environment before entering the clinical environment. In addition, it has been stated that it is important to have case discussions in the laboratory and in the post-clinical evaluation in order to improve communication with patients who have difficult but similar conditions [11].

Since evaluating the results of TC techniques is as important as teaching them, self-report scales were developed by Karaca et al. [12] to determine these communication skills in student nurses, and various results were reported in the literature [[12], [13], [14]]. In these studies, it was stated that student nurses had deficiencies in applying TC techniques. Similarly, Martin and Chanda [4] stated that students misused body language, avoided eye contact, were not able to use silence appropriately, and felt compelled to constantly talk and ask questions when communicating with patients and their relatives. Nayak et al. [14] emphasized that students' communication skills related to self-confidence, anxiety, and identifying risks were weak, and that these skills could be improved with better education. Many studies conducted with nurses have identified problems in this regard [[14], [15], [16], [17]]. Feedback from patients and their relatives is also crucial in evaluating healthcare professionals' communication skills [18].

Despite the fact that the clear benefits of TC are emphasized in the nursing curriculum in Türkiye, students often have difficulty mastering these skills. For this reason, researchers have stated that the evaluation of students' communication skills by patients and their relatives is useful in teaching therapeutic techniques [19,20]. This study thus aimed to determine the TC skills of nursing students, examine their communication experiences, and evaluate feedback from patients and their relatives.

2. Materials and methods

This mixed research study was conducted from 22 April to 22 June 2022 in Türkiye. The study was designed using the convergent parallel mixed method. In this method, qualitative and quantitative data are collected simultaneously. The analysis of the data was conducted separately, and the findings were then interpreted by integrating them, ensuring equal emphasis on both the quantitative and qualitative results [21].

2.1. Study 1

2.1.1. Quantitative participant and data collection process

The study was conducted with 112 fourth-year nursing students selected through the purposive sampling method from among students studying in the Department of Nursing of a university in Türkiye in the 2021–2022 academic year. Purposive sampling is a non-probability, non-random sampling approach. In this approach, it is preferable to work with one or more special cases that meet certain criteria or have certain characteristics [22]. For the sample in this study, fourth-year nursing students were chosen in order to use the researchers’ expert knowledge and limited resources in the most effective way. The researchers' familiarity with this student population and their interactions with the students allowed them to assess the students' degree of readiness and ability to participate, which influenced the choice of this method. The students involved received courses on TC techniques from experts in psychiatric nursing for 16 h in the spring semester of their first year, 16 h in the fall semester of their second year, 16 h in the spring semester of their second year, and 16 h in the fall semester of their fourth year. The fourth-year students who were included in the study had completed all these courses. At the time of the study, there were a total of 123 fourth-year nursing students. In the sample calculation, it was found that at least 94 individuals should be included in the sample, with a known universe (n = 123), a margin of error of .05 and a confidence interval of 95 % [23]. The exclusion criterion of the study was not agreeing to participate. Before collecting the data, the researchers explained the nature and purpose of the study to the students in the classroom environment. The students were asked whether they wanted to volunteer to take part in the study, and written and verbal consent was obtained from each student who met the inclusion criteria. All participants gave their informed consent before they participated. The participants were informed that they could withdraw from the study whenever they wished and that this would not affect their course grades. The study was completed with 112 nursing students.

2.1.2. Instruments

The data were collected with the Information Form and the Therapeutic Communication Skills Scale in the classroom environment through Google Forms.

Information Form: This form included socio-demographic information about the nursing students.

Therapeutic Communication Skills Scale: This scale was developed by Karaca et al. [12] in 2019. It is a seven-point Likert scale (from 1 = "Never" to 7 = "Always), consisting of three dimensions and 16 items. The non-TC Skills (warning, downplaying emotions, advising, vague reassurance/cliché response, changing the subject, defending, and judging) sub-dimension consists of seven items (max score: 49; min score: 7). The TC Skills 1 (reflecting, summarizing, restating, verbalizing the implied, focusing, and stating the observed) sub-dimension consists of six items (max score: 42; min score: 6), while the TC Skills 2 (active listening, offering self, and asking questions) sub-dimension consists of three items (max score: 21; min score: 3). The score obtained from each dimension evaluates the skills included in that dimension, and as the score increases, the students demonstrate better skills in that dimension [12]. The Cronbach's alpha value of the non-TC Skills sub-dimension was determined as .805 in the study. The Cronbach's alpha value of TC Skills 1 sub-dimension was determined as .826. The Cronbach's alpha value of TC Skills 2 sub-dimension was determined as .509.

2.1.3. Data analysis

The SPSS for Windows 21.0 package program was used to analyze the data. Number, percentage, mean ± standard deviation, and minimum-maximum values were calculated.

2.2. Study 2

2.2.1. Qualitative participants

Qualitative data were collected through focus-group meetings with 18 nursing students and individual interviews with 10 patients and 10 of their relatives.

The nursing students participating in the research were involved in patient care under the supervision of nurses working in the clinic and under the guidance of educators. Clinical practices are conducted for 14 weeks each semester for 16 h each week. In this process, the students, accompanied by a clinical nurse, are involved in the care of at least one patient. The patient being cared for is present for all nursing activities, and the student carries out their care until that patient is discharged from the clinic. When the patient is discharged, the educator, in coordination with the clinical nurses, assigns the student to a new patient. As a result, students are expected to develop responsibility for the individual care of patients and communication with their relatives. In this study, the students' experiences of communicating with patients and their relatives were examined through focus groups.

While focus-group meetings were conducted with students, individual interviews were conducted with 10 patients who had received care from the students and 10 of their relatives. These enabled the patients and their relatives to give their feedback about their communication with the students. Individual interviews were used to ensure the comfort of the patient and their relatives, to safeguard their privacy, and to reduce the risk of infection.

Eighteen students from among the 112 who took part in the quantitative data collection were included in the qualitative part of the study. The 112 students included in the first part of the study all undertook clinical practice in internal medicine and surgery clinics. During this period, nurses recommended nursing students who could effectively participate in the second part of the study. These recommendations were determined as the inclusion criteria for the focus groups. The students were informed that participating in the focus groups would not affect their course grades. The exclusion criterion was not agreeing to participate in the study. Before the focus-group meetings with the nursing students, they were informed about the study and their written consent was obtained.

Individual interviews were conducted with 10 patients and 10 of their relatives. The purposeful sampling method was used to select the sample. Purposive sampling is a technique widely used in qualitative research to identify and select cases rich in information for the most effective use of limited resources. This method involves identifying and selecting individuals or groups who are most knowledgeable and experienced about the subject of interest. In the present study, patients and relatives who were able to evaluate the communication skills of the students and who were in good general health were determined by the nurses. Additional inclusion criteria for the patients and relatives were being able to communicate in Turkish, not having any psychological symptoms that would prevent communication (such as depression, anxiety, delusions and hallucinations), and having received at least 8 h of care from the nursing student. All the participants determined by a nurse responsible for that patient's care gave their informed consent for inclusion before they participated in the study.

Repetition of the data was taken into account when determining the number of students, patients and their relatives to be reached. When data saturation was reached, the data collection process was stopped. The researchers decided that data saturation had been reached when the data became repetitive, the new data collected did not offer new insights into the research topic, and it was determined that no more categories could be produced. The experiences and opinions of the participants were revealed by asking semi-structured questions. Each participant answered these questions in full in order that all of the participants’ experiences could be ascertained.

2.2.2. Qualitative data collection process

Focus-Group Interviews with Nursing Students: The researchers conducted a series of focus groups with the nursing students in the clinical meeting room. This room had been tested by the researchers and found to be suitable in terms of heat, light, and noise levels. The focus group started with the moderator (SM) and reporter (NM) introducing themselves. At the beginning of the focus groups, the moderator explained the purpose of the study and the ethical issues. The moderator created rules of conduct for the focus groups in collaboration with the participants. These rules were to listen when someone spoke, not to judge other people's thoughts and feelings, to be able to leave the study if required, and to protect each other's privacy. Since the seating plan is important in conducting focus groups, a U-shaped arrangement was used. The moderator and the reporter sat opposite each other. Data from the focus groups were recorded for later analysis. These meetings were held with three groups of six individuals and for a total of three sessions with each group. Each session lasted 30 min. A 15-min break was given between each session. During the breaks, refreshments were provided for the students. A warning sign was affixed to the door of the room where the focus groups were conducted so that they would not be interrupted. The moderator avoided expressing her own views in order to be objective. Each participant had the right to speak and it was confirmed that all the issues that needed to be discussed had been raised. The focus-group sessions lasted 90 min in total. The meetings were audio-recorded with the permission of the participants.

Individual Interviews with Patients and Their Relatives: The individual interviews with the patients and their relatives were conducted by the other researcher in the patient's room (NM). For privacy, no one other than the individuals included in the interview was present in the room, and the healthcare professionals working in the clinic were informed that the interviews were taking place in order to prevent interruptions. It was explained to the patients and their relatives that the results of this study would not have any effect on the grades of the students. The participants were also informed that the interviews would not be used improperly or for any other purpose than this study. The shortest interview lasted 40 min and the longest 60 min. During the interviews, the patients were sitting up in their beds, while their relatives and the researcher were sitting on chairs. The participants were able to guide the direction of the interviews, provided that they did not deviate from the research framework.

Throughout the focus groups and interviews a voice recorder was used to record the data, with the consent of the participants. Points that were considered particularly important were also written down by the researchers and each interview continued until data saturation was reached. The recordings were listened to and the data were converted into written text. While transcribing to the audio recording, any nonverbal communication that had also been noted, including gestures, facial expressions and eye contact were written down alongside the statements made. The researchers checked the written documents for accuracy by listening repeatedly to the audio recordings.

2.2.3. Instruments

The qualitative data were collected using an Information Form and semi-structured questions.

Information Form: This form included questions about the socio-demographic characteristics of the nursing students, patients and their relatives.

Semi-Structured Interview Form: This form was created by the researchers as a result of a literature review and expert evaluations. The questions in the form were designed to evaluate the nursing students' TC skills in a clinical setting. The aim was to construct more specific questions through a process of deduction from general questions [24]. A roadmap was created within the framework of the questions given below, and the different dimensions of the subject were explored by expanding the questions within this general framework according to the characteristics of the group interviewed and the individuals present [25].

The nursing students were asked the following semi-structured questions:.

• 1.Can you tell us about your experiences when using TC techniques?
• 2.What are your views and suggestions for facilitating the use of TC techniques and making this a habit?

The patients and their relatives were asked the following semi-structured questions:

• 1.Can you tell us about your communication experience with the student?
• 2.How do you feel about your communication with the student?

2.2.4. Data analysis

The qualitative data were analyzed inductively by the research team through the continuous comparison of the interview documents. The researchers employed thematic analysis to identify themes in the data and to uncover meaningful categories, their relationships, and the underlying concepts. In this thematic analysis, the focus was on identifying recurring patterns in the data, allowing for greater flexibility and interpretability. This allowed the data to be coded without considering themes established by previous researchers. Here, the focus was on the data itself, and a close relationship was established between the data and the themes. The steps followed to interpret the research data through thematic analysis included transcription, familiarization with the data, selection of quotes and keywords, coding, theme development, conceptualization through interpretation of keywords, codes and themes, and, finally, developing a conceptual model [26].

The evaluation of the qualitative data was carried out manually. First, each researcher independently reviewed the recordings of the focus-group interviews with the students and transcribed the audio recordings. The transcribed interviews were read several times and important statements were underlined; then, semantic units were determined from the participants' conversations and the researcher's observations, documents and notes. The quantitative results were reported first, followed by the qualitative results. In this process, the quantitative data obtained from the scale evaluating the students' TC techniques were evaluated by side-by-side comparison with the qualitative data obtained from the focus-group interviews. In the literature, this method is known as “combining” (variation) [27]. This method brings both quantitative and qualitative data together. The purpose of analyzing both datasets and comparing the results is to confirm the results of one dataset with those of another [27]. Each researcher coded all the statements determined to be meaningful. Then, the two researchers met with each other to work on the data together. In this way, the attempt was made to determine the most appropriate codes, categories and themes. The accuracy of the data was tested by two psychiatric nurses with doctorates. The results obtained from the data were then shared with the students in a meeting and they were asked whether the findings reflected their own perspectives. After reaching a consensus, the themes were finalized.

The individual interviews with patients and their relatives were examined separately by each researcher. First, the transcribed interviews were read several times and important statements were underlined; then specific semantic units were determined from the conversations and the researcher's observations, documentation and notes. The codes to identify similarities and differences were reviewed and compared. Similar codes were combined and categorized according to the similarity and relevance of the categories. In order to ensure the accuracy of the codes, the categories were reviewed and compared. The accuracy of the data was tested by two psychiatric nurses with doctorates. Then, the results obtained from the data were shared with the patients and their relatives in individual interviews and they were asked whether the findings reflected their own perspectives. After reaching a consensus, the themes were finalized.

Prior to publishing the study, it was translated into English by two professional linguists. Subsequently, two different experts back-translated the text from English to Turkish. Finally, these translations were reviewed individually by all researchers and then collectively. The final version was decided upon. The views of the students, patients and relatives as they reflected the themes determined in the study were quoted in the text.

2.2.5. Rigor of the study

Reliability, validity, transferability, consistency, and confirmability criteria were put in place to ensure the rigor of this study [28].

For reliability, long-term interaction, continuous observation, and the member-checking method were used. One of the researchers had been using the hospital where the study was conducted for student practices for 12 years (SM) and the other for seven years (NM). They were thus familiar with the inpatients, their relatives, and the clinical culture. They had previously had the opportunity to observe patients, relatives, and students in the clinical setting during clinical practice. There had thus been long-term interaction and continuous observation. Member-checking was used during the focus-group meetings and individual interviews, and the participants were asked whether the study's findings accurately reflected their own thoughts and feelings. In addition, presenting the details of the study here has the aim of increasing its internal reliability, so that different researchers can reach similar conclusions using the same dataset in the future [29].

Explaining the data collection tools, data collection process, how the data were analyzed and how the researchers reanalyzed them at different time periods contributes to reliability [30]. The details of this study are presented in a simple and understandable way: how the sample was selected, the characteristics of the participants and the environment, the study questions and the participants’ statements are shared in a clear manner. In order to test the invariance of the findings of this study over time, independent of the researchers' feelings, thoughts and experiences [31], the analysis was repeated one month later with the steps specified in the section on analysis and similar results were obtained. Thus, the reliability of the study was ensured.

In order to share experiences and better ensure the validity of the research results, the research data were examined by the researchers and two experts. First, the statements obtained from the interviews and transferred to written form were presented to the experts. After the experts examined these texts and created themes, these were compared with the themes created by the researchers. Different themes were evaluated and revised together by the experts and the researchers. The emerging themes were then shared with the students and patients/relatives and they were asked whether the findings reflected their own views. After reaching a consensus, the final version of the themes was determined. Thus, the validity of the analyses was increased. It has been stated in the literature that expert evaluation is important in ensuring the validity of qualitative research [32].

In order to apply the findings of this study to other contexts and studies (transferability), the results and materials were explained in detail. For verifiability, the audio recordings were transcribed, contemporaneous notes were meticulously kept, and quotes from the participants' statements were added. The Criteria for Reporting Qualitative Research (COREQ) checklist was used in reporting the study [33].

2.3. Ethical approval

The study was conducted according to ethical principles, and ethical approval for this study was obtained from the Ethics Committee of Bilecik Şeyh Edebali University (dated 24 September 2021; No. 5/3). The necessary permissions were obtained from the institution where the study was conducted. In addition, the participating students, patients, and relatives were informed about the purpose of the study and interviewed individually. The study was conducted in accordance with the Declaration of Helsinki and ethical principles were applied.

3. Results

3.1. Study 1

3.1.1. Quantitative socio-demographic characteristics and scale scores

The mean age of the 112 nursing students participating in the study was 22.77 ± 1.61 (min: 21; max: 30); 77.7 % were female and 22.3 % were male. The mean Non-TC Skills (warning, downplaying emotions, advising, vague reassurance/cliché response, changing the subject, defending, and judging) score of the students participating in the study was determined as 18.59 ± 7.60 (7–49). Examining the TC Skill Scale's sub-dimensions, the mean TC Skills 1 (reflecting, summarizing, restating, verbalizing the implied, focusing, and stating the observed) score was 26.18 ± 6.52 (6–42), while the mean TC Skills 2 (active listening, offering self and asking questions) score was 15.58 ± 3.03 (3–21).

3.2. Study 2

3.2.1. Qualitative socio-demographic characteristics and themes and sub-themes

Of the 18 nursing students participating in the focus-group interviews, 77.8 % were female. The students' mean age was 21.61 ± .69 (min: 21; max: 23). Among the patients and their relatives who were interviewed individually, 40 % of the patients were male. The patients' mean age was 60.90 ± 10.99 (min: 45; max: 78). All the patients' relatives were first-degree family members (daughter, daughter-in-law, or spouse) and of these only four were male. The relatives’ mean age was 39.00 ± 12.46 (min: 23; max: 58).

After analyzing the interview data in the study, three main themes and seven sub-themes were identified as follows:

• 1
  Challenges in Mastering and Applying Therapeutic Communication

  • 1.1
    Inability to Internalize
  • 1.2
    Insufficient Role Models
  • 1.3
    Concern over Feeling Inadequate
• 2.
  The Positive Impact of Therapeutic Communication

  • 2.1
    Contributions to the Profession
  • 2.2
    Enhancing Collaboration between Patients and Nurses
• 3.
  Patients' and Relatives' Views of the Nursing Students' Communication Skills

  • 3.1
    Specialized Competency
  • 3.2
    Human-Centered Philosophy
• 1Challenges in Mastering and Applying Therapeutic Communication

The nursing students stated that they had difficulties in internalizing what they had learned regarding TC and its transfer to practice. According to them, communication methods with patients and their relatives were taught and discussed in both theoretical and practical courses, and they stated that they expected to apply these in practice, but that it was difficult. In addition, the students reported that a lack of role models prevented them from feeling they had adequate support. Another difficulty was the anxiety they experienced in using TC in practice. The students stated that applying these techniques was hard and they believed that it required taking risks. Three sub-themes were determined regarding the difficulties in learning and applying their knowledge: inability to internalize, insufficient role models, and concern over feeling inadequate.

• 1.1Inability to Internalize

The nursing students explained the necessity of internalizing TC after it is taught in order to reflect it in their practice. Some of the students’ statements were as follows:

“I think it's very difficult to really apply TC techniques, because we learn these techniques through certain patterns in the lessons. However, since every individual is different, when I try to apply them like we learned in the lesson when communicating with the patient, I realize that the patient's need is not exactly the same as technique I am trying to apply.” (Nursing student 2).

“TC is very important, yes. In fact, it is important not only in our relationship with patients, but in our entire lives. However, I can find myself engaging in false behavior when applying these techniques. It feels like I'm ‘cutting-and-pasting’ what we've learned. I don't like this very much, because I don’t believe in my own ability.” (Nursing student 8).

“TC is important in nursing care and I think it should be. Yes, everything is fine…But it seems to me that it’ll be very difficult for this to become a habit, because I don’t have any flexibility in this matter. I remember what our educator gave as an example when communicating with a patient. Nothing else comes to mind.” (Nursing student 3).

• 1.2Insufficient Role Models

The nursing students highlighted the lack of role models to follow when using TC techniques in practice. Some of the students’ statements were as follows:

“We often witness nurses using daily communication rather than TC when talking with the patient. This creates the impression that the techniques we learned are not very valid in practice.” (Nursing student 8).

“How can TC techniques be taught better and become habits in practice?... I don’t know. I think for this, nurses need to believe that it is necessary a little more.” (Nursing student 17).

“Our educators teach TC techniques in classes. They emphasize these and ask questions. When I learned that these topics would be covered, I assumed that these techniques were popular and necessary for nursing nowadays. Before I received my nursing training, I didn’t know that the nurse had this information when I was sick, and I didn’t see her applying these techniques. I often saw the nurse refer us to the doctor and give us generally short answers. So, when we were taught these things, we were first of all surprised.” (Nursing student 13).

“TC techniques are necessarily applied throughout our education, because we have to get a pass mark for the lessons. However, I believe that some of my friends will not use their communication skills.” (Nursing student 14).

• 1.3Concern over Feeling Inadequate

Six nursing students reported feeling inadequate and therefore experiencing concern. Some of the students’ comments were as follows:

“I also always think that I should say something when I’m taking to patients. Our teacher emphasized the importance of remaining silent while teaching us these techniques. However, it seems that the patient maybe doesn’t trust me if I remain silent.” (Nursing student 12).

“When I’m talking with my friends, we discuss this. This can lead to funny situations developing…Before applying the therapeutic techniques, we think about them and wait a little. We decide what we’re going to say. Of course, time passes. So, it can be a little strange when you do respond.” (Nursing student 7).

• 2The Positive Impact of Therapeutic Communication

The nursing students explained the many benefits of TC, emphasizing its positive aspects, such as how it supports professionalism, increases their sense of professional dignity and makes them feel competent. They stated that TC increased their self-confidence and helped them maintain communication with patients and their relatives. Two sub-themes were determined regarding the positive impact of TC: contributions to the profession and enhancing collaboration between patients and nurses.

• 2.1Contributions to the Profession

The nursing students felt that therapeutic communication improved their professionalism when they practiced it. Some of the students’ statements were as follows:

“Even though we start by introducing ourselves, they’re surprised when we use these techniques because they don’t think that the nurse knows about them. The patients and their relatives don’t expect that we’ll communicate in such a detailed and understandable way. Knowing these techniques is a good thing for nursing.” (Nursing student 7).

“I consider myself to be like a graduate nurse when I’m using TC techniques as a student. I say to myself, ‘Well done!’…I think that after all the training we have received applying what we have learned is a requirement of our profession.” (Nursing Student, 5).

“Patients and their relatives trust us when we communicate with them. Apart from their current illnesses, they also ask questions about their previous health problems. They try to take advantage of our knowledge. In short, I think they trust us.” (Nursing student 15).

“I feel special when I use TC techniques. My communication with the patient is better. It also seems that the patient’s relative feel that the patient will be safe. This also makes me feel good.” (Nursing student 9).

• 2.2Enhancing Collaboration between Patients and Nurses

As a result of analyzing the students' statements, it was determined that the use of communication techniques by students increases the duration of communication with patients and their relatives, thereby facilitating their participation in care. Some of the students’ statements on this topic were as follows:

“Patients and their relatives support us while we’re using these techniques and are pleased to see me when I return to the clinic. One of them said, ‘I told my family what you said to me and our conversation.’ Another said that when she needs something, she’ll ask for me to participate in her nursing care.” (Nursing student 10).

“I can sometimes easily see the benefit of using these techniques when collecting data from the patient. The patient and/or their relatives answer my questions. They don't reject me and continue to communicate with me as if I were the main nurse. They says that if there are any other problems, I should just ask them.” (Nursing student 7).

“These techniques teach us what to do when we have difficulty communicating. I understand that I don't always have to talk. I keep quiet. The patient and his family appreciate this. I don't push them. Since I’ve been using these techniques consciously, I think that the patient and his relatives have treated me with respect.” (Nursing student 2).

• 3Patients' and Relatives' Views of the Nursing Students' Communication Skills

The patients and their relatives stated that they learned about different aspects of nursing when they realized that students were trying to use TC techniques. They felt that the communication used by the students was contributing to their healing and sense of feeling comfortable in the hospital environment. Two sub-themes were determined regarding this improved understanding of the profession of nursing: specialized competency and human-centered philosophy.

• 3.1Specialized Competency

The patients and their relatives stated that nursing involves special skills. Some of their statements were as follows:

“I liken what the student says to an expert speaking in the media. The student uses some words and phrases to keep the communication going, as if he were an expert. He talks to me in a very eloquent and careful manner.” (Patient 3).

“I wish all nurses talked to us like that.” (Relative 2).

“The student gave me information about my illness while paying attention to me. They answered all my questions. They showed interest in me. I was very happy. This is how I thought nurse should communicate. ‘Thank God!', I say.” (Patient 6).

“Knowing that the student is sensitive to me...and I understand this through the words chosen and the kindness that I’ve been shown. I think nursing this is what nursing is.” (Patient 8).

• 3.2Human-Centered Philosophy

The patients and their relatives felt that students who were able to be patient and kind and could listen and make them feel special and unique were demonstrating a sense of humanity. Their statements were as follows:

“Professor, when I see that your students are patient while listening to us, I also feel the strength to persevere through my difficulties.” (Relative 4).

“Some of the students make me feel special. This is something special.” (Patient 10).

“I think that the student's being patient, smiling at me, not leaving me alone, and making an effort to answer my questions are all indicators that they’ll be a good nurse in the future.” (Patient 9).

“I was in a lot of pain. The student nurse had come to perform vascular access. He was so kind to me that my pain went away. The way he touched me, talked to me and understood that I was in pain helped me psychologically.” (Patient 5).

“I learned a lot from the student. I gained information that made my father's life easier. The student's ability to answer our questions and their attitudes and behavior when doing so made us feel that we were in safe hands.” (Relative 8).

“I feel valuable when someone smiles at me, does something for me. When I needed something, hearing the sentence ‘I’m here’ helped me feel less lonely.” (Patient 2).

“He could have turned me down or not be able to look at me. He didn't do either of these. On the contrary, he took my hand and looked me in the eyes. He waited patiently for my reaction and then helped me.” (Patient 5).

“It was the hardest night I ever had. I had fallen from the fifth floor and then ‘come back from the dead’. The student didn’t leave me alone during the day and didn’t get tired. He made me feel like he was part of my loving family. I thank him very much. It's good that they exist.” (Patient 1).

4. Discussion

This study aimed to determine the TC skills of nursing students, examine their experiences when communicating, and evaluate the views of patients and relatives about these communication skills. The results obtained from this study are discussed below with reference to the literature.

4.1. Study 1: quantitative discussion

The study examined the average scores obtained from the TC Skill Scale's sub-dimensions. The students' TC Skills 1 (reflecting, summarizing, restating, verbalizing the implied, focusing, and stating the observed) and 2 (active listening, offering self and asking questions) were moderate and high, respectively. Similar to the findings of this study, Mercan [20] found that nursing students had a high level of skill in active listening, offering self and asking questions. In one study, after training with simulated patients, more than half of students found their therapeutic skills to be sufficient [34], while in another study, it was determined that almost all of the students had sufficient or better than sufficient TC skills [14]. Given that these results were obtained by the students' self-evaluation, it is thought that feeling themselves to be adequate in this area is likely to have a positive effect on their communication with patients and their relatives. In addition, in the present study, it was observed that the average score for non-TC skills was at a moderate level. This result shows that the students used some non-therapeutic techniques in communication with patients. However, when studies using a similar scale are examined, it is observed that the nursing students participating in the present study used non-TC skills less often than other nursing students [35,36]. Still, it is not surprising that the students used non-therapeutic techniques since they were still involved in the learning process. Similar to this study, in the study of Martin and Chanda [4], it was determined that the students used non-therapeutic techniques in communicating with simulated patients.

4.2. Study 2: qualitative discussion

In the analysis of the data obtained from the focus groups with students, the main theme of “challenges in mastering and applying TC” emerged. The students participating in the study focused on the difficulties of learning and applying TC techniques. They stated that they had problems using these techniques and making this use into a habit.

One sub-theme of “challenges in mastering and applying therapeutic communication” was “inability to internalize”. The students stated that it was difficult to transfer theoretical knowledge into practice and expressed their views on their inability to internalize this knowledge. In the literature, this result has been cited as evidence of insufficient experience and the theory-practice gap in clinical settings [37,38]. In the study conducted by Tretow-Fish et al. [39], it was found that students' learning styles and levels of preparation affected their ability to apply their knowledge. If students are not prepared to learn and cannot develop adequate strategies when applying their theoretical knowledge makes this transfer difficult. This is one of the most important factors affecting the students’ ability to internalize. It has been stated in the literature, that there is a need for training on how to internalize communication techniques, and the importance of practicing on the patient has been emphasized [10,11]. Rosenberg and Gallo-Silver [11] reported that students were tense and stressed in TC with patients, that if this occurred they should be released from the process of communicating with patients and their relatives, that it is important to understand anger and frustration, and that students need guidance about how to communicate. Coelho et al. [10] reported that TC is not necessarily innate and is a learned skill. They emphasized that although communication strategies are powerful tools for nurses, they still need more thought and research in terms of their teaching and application because they are not used enough in professional practice. Brown [40] stated that when nursing students apply what they have learned to patients, they can see their own deficiencies and develop professional values through their experience, and that, as a result, they will gain cognitive and behavioral competence. In addition, it has been stated that it is important to develop attitudes, beliefs and values for professional practice and to integrate skills such as a human-centered approach, empathy and interaction into the curriculum [40].

Another sub-theme was “insufficient role models”. The students stated that there was a lack of role models showing them how to overcome difficulties. The students explained that there were techniques that they did not see and did not actively witness in practice, and that this caused difficulties in their learning and negatively affected their development of skills. In addition, they stated that some educators placed more emphasis on physical care. In the literature, student nurses have stated that role models have a great impact on learning in the clinical setting and that they see both nurses and educators as role models [38]. In this regard, educators, nurses and students need to focus on the same goal. Modeling desired aspects of behavior and pedagogical skills can be achieved when there is good working relationship between a supportive educator and a student [41]. However, sufficient numbers of educators and nurses are needed in order to provide continuous support, constructive feedback and encouragement [42].

Another sub-theme that emerged was the students' “concern over feeling inadequate”. The students stated that they feared making mistakes and that they lacked the necessary information when communicating with patients, which caused them to experience concerns about their own inadequacy. It has been similarly determined elsewhere that the difficulties experienced by nursing students in the clinic caused them to feel inadequate [43]. In another study, it was reported that nursing students experienced uncertainty, anxiety about harming patients, insufficient theoretical knowledge, lack of skills, limited practical experience, communication problems with patients/relatives, and incompatibilities between theory and practice during their clinical practices. It was reported that these experiences caused them to feel anger, sadness, anxiety and a sense of inadequacy [8].

When the students' statements were evaluated, another main theme was “the positive effect of therapeutic communication”. The students said that TC had many benefits for themselves and the individuals they cared for and their relatives. Moreover, some students explained that patients responded to them in supportive ways, which motivated them and made them feel good. It is known that nurses who are better equipped with TC skills are better able to achieve the care goals for each patient. Feeling comfortable when communicating allows nurses to feel better equipped to achieve these goals [44]. It is important that students realize that practices are beneficial to themselves, their patients and their patients' relatives when they are evaluating their own development. It has been stated in the literature that patients' opinions should also be taken into account in terms of assessing students' learning during clinical practice, and that these assessments should be included in the student's file [45]. On the other hand, it is also important that student nurses self-evaluate in their nursing practices, and that this process increases students' awareness that good nursing involves a combination of the intellect and the emotions. Student nurses can become more aware of how they feel, think and behave in the clinical environment by understanding how their patients react to them. Understanding this can also increase students' confidence and self-esteem by helping them appreciate what they do well and in a mature manner, and helping them acknowledge what needs improving. Student nurses who are more at peace with themselves as human beings and healers will be more flexible and act in a more natural way towards their patients while fulfilling their professional responsibilities [11].

In the present study, the “contributions to the profession” sub-theme also emerged within the theme of “the positive effect of therapeutic communication”. The students stated that their practice contributed positively to the recognition of the nursing profession by society in general, as well as to the development of their own professional values. They also stated that the patients and relatives had learned information from them. In fact, although the students said that they were primarily focused on passing the course, they stated that being appreciated by others as a result of their TC and their behavior contributed to improving the reputation of their future profession. This may inspire them to engage in positive activities such as setting new goals and devoting time and effort to become more professional. In one study, it was determined that nursing students wanted to see nursing as a respected, professional endeavor, and they believed that to achieve this it was necessary for them to develop their theoretical and practical competencies and for the profession to be appreciated by patients [46]. Cao et al. [47] stated that higher levels of professionalism could enhance nurses' autonomy and sense of empowerment, increase their public recognition, establish standards of nursing care, and positively contribute to providing high-quality care.

In this study, the sub-theme of “enhancing collaboration between patients and nurses” also emerged from the theme of “the positive impact of therapeutic communication”. The students' statements revealed that their use of communication techniques not only extended the duration of their interactions with patients and their relatives but also enhanced engagement and promoted a more active participation in the care process. Research has emphasized that collaboration between nurses and patients is crucial for improving healthcare outcomes [47,48]. Effective partnerships foster better communication, patient satisfaction, and care continuity, while also promoting shared decision-making and enhancing treatment adherence. Collaborative efforts not only empower patients but also help healthcare professionals address complex needs more efficiently, leading to improved safety and quality of care [48]. According to Gutiérrez-Puertas et al. [49], TC, being holistic and patient-centered, ensures that the patient receives adequate care, reduces their anxiety, supports compliance with treatment and symptom management, and provides psychosocial and spiritual support. A nurse's ability to communicate effectively is essential for developing therapeutic relationships with patients and achieving greater patient satisfaction. It also minimizes treatment errors and increases the quality of nursing care.

In this study, the main theme of “patients' and relatives’ views of nursing students' communication skills” was determined after the individual interviews with patients and their relatives. The interviewees said that they had the opportunity to learn about nursing when they observed students applying TC techniques. They stated that being a nurse required specific skills in addition to nursing knowledge. They also added that it was valuable to them to feel that students were sensitive to their needs and that they had been understood. Abraham et al. [50] reported that TC involves prioritizing patients' needs, creating a supportive environment, and using interpersonal skills such as empathy, understanding, and active listening to establish meaningful connections with patients, and that ultimately, when implemented effectively, TC improves patient care, emotional well-being, and clinical outcomes.

One of the sub-themes obtained from this theme was “specialized competency”. The patients and their relatives emphasized that effective nursing requires specialized communication skills, expressing appreciation for students who engaged attentively, provided clear information, and demonstrated genuine interest and sensitivity, all of which led to positive interactions and improved patient experiences. Nurses possess specific capabilities essential for effective TC, which is critical for delivering high-quality patient care [51]. These include active listening, empathy, and the ability to establish a trusting relationship with patients. Such skills enable nurses to meet patients' physical and emotional needs while facilitating open dialogue, which is vital for successful healthcare outcomes [12]. It is known that TC is an important tool in interventions to accelerate the recovery of the patient and increase their quality of life [52,53]. In the study, it was determined that through TC the student nurses provided information that helped accelerate the patients’ recovery and improve their quality of life, and that they did not leave their patients alone during their most difficult times. Similarly, it has been reported in other studies that the therapeutic relationship is an effective foundation for achieving healing, the main purpose of the profession, as well as for reaching the desired quality of care and increasing patient satisfaction [5,54].

Another sub-theme that emerged was “human-centered philosophy”. The patients and their families noted that students who demonstrated qualities such as patience, kindness, active listening, and the ability to make others feel special embodied the essential human qualities. The interviewees also stated that the students engaged in humane behaviors while caring for them, and that this had a positive effect on their recovery. The patients and their relatives who participated in the study saw themselves as valuable and respectable as a result of their interactions with the students. Similarly, one study defined the therapeutic relationship as consisting of “human-to-human” contact [2]. It is known that good practices applied in a professional manner will lead to a more humane approach [55,56]. It has been reported that such an approach includes elements such as respect, empathy, coping with stress, recovery, a holistic perspective, and patient-centeredness. This humane approach has been viewed as the foundation of the individualized care provided to patients by nurses, emphasizing respect for each patient's subjectivity and uniqueness, as well as the importance of compassion, empathy, honesty, and respect for the dignity and beliefs of both healthy and ill individuals [57].

5. Conclusion

This study found that students' skills in using therapeutic communication techniques were determined to be medium and high, non-TC techniques were also used. These results are in line with the findings obtained from the interviews.

The results of this study demonstrated that the students encountered challenges in learning and applying TC techniques. To help students address these difficulties, educators should support the internalization of pre-clinical training by implementing methods such as the use of simulated patients, standardized patients, and peer education. These approaches can enhance students' experiences, help them integrate their knowledge with their values, improve the retention of communication techniques, and increase their effectiveness in practice. In response to the difficulties expressed by students regarding a lack of role models, it is important that the knowledge and skills of nurses working with students in the clinical setting be better supported. In this regard, it may be useful to include TC techniques in in-service training. Additionally, it is recommended that measures be taken to prevent the feelings of inadequacy and concern that students may experience. This may require increasing students' self-awareness and self-compassion. When students become more aware of their own abilities, they are better able to recognize their contributions to the profession and notice improvements in how they communicate with their patients. This underscores the importance of establishing cooperation between schools and hospitals to set common goals. Providing nursing students with opportunities to enhance their competencies, paying special attention to high-stress areas, and creating a positive work environment is vital for improving TC and fostering professionalism. TC serves as a means for students to express themselves to patients and their families. The positive aspects of this process enhance the perception of nursing professionals within society, enriching the general understanding of nursing's significance. Therefore, to effectively prepare nursing students to address societal needs and fulfill their roles, it is crucial to emphasize the sense of belonging as a key element of the clinical learning environment, recognizing it as essential for student success and nursing excellence. In addition, future curriculum studies on how to apply and master TC should take into account the views of student, patients and their relatives. In conclusion, follow-up studies should be conducted with the aim of evaluating the improvement of TC skills in nursing students throughout their education.

5.1. Limitations

Obtaining data from only one university limits the generalizability of the results. The findings are specific to the nursing students in one particular setting. While obtaining the data, both students and nurses communicated with the patients and their relatives during their care, which is thought to have affected the experience of communicating with the students. Another limitation is that socio-demographic and cultural differences may have affected students, patients, and their relatives differently. The use of self-evaluation might have introduced bias into the reporting of the students’ therapeutic skills. In addition, the physical and psychological factors that may affect individuals could not be monitored. This is also among the limitations of the study.

CRediT authorship contribution statement

Neşe Mercan: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Resources, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Sevinç Mersin: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Resources, Methodology, Investigation, Formal analysis, Conceptualization.

Data availability statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declaration of competing interest

This study is mixed methods research. The authors stated whether the goal is to describe a particular situation (case study), to explain it (what mechanisms are involved), and to evaluate it (is it of any use or importance).

On behalf of all the contributors, I will act as guarantor and will correspond with the journal from this point onward.

No support is given to the research financially or in another manner.

There is no conflict of interest to declare between authors.

We, the authors give permission for reproducing pre-published information/material.

We hereby transfer, assign, or otherwise convey all copyright ownership, including any and all rights incidental thereto, exclusively to the journal, in the event that such work is published by the journal.