To foster healthy lifestyle changes in their future patients, nursing students must first give their own communication skills a checkup.
Assistant Professor of Nursing, Pennsylvania College of Technology, Williamsport
DNP (Doctor of Nursing Practice), MS in Community Nursing, BS in Nursing
Before Joni Pyle began her career as a nursing professor, she witnessed firsthand the transformative power of motivational interviewing—a patient-centered style of conversation used to help people ignite lifestyle changes from within by identifying their deep-seated goals.
At the time, the majority of Pyle’s clients were low-income pregnant women, and their primary motivator was their love of the child they carried. “They had issues with poor decision-making and with relying on significant others who really weren’t that significant,” says Pyle. “But their overall motivator was that they really wanted to be good moms.”
Using this as a starting point, she used their aspirations as inspiration, asking them questions such as, “If you continue to do what you’re doing, where do you see yourself in a couple of years?” She could continue with questions relevant to a given individual, such as, “How likely is it that you are willing to change [a particular] behavior?” or “What might make you willing to change [a particular] behavior?”
The idea, says Pyle, whose doctoral dissertation on the efficacy of motivational interviewing was published in Home Healthcare Now, is not for nurses to see themselves as the drivers of change but to help their patients realize they have agency in their own healthcare. “Encourage them to be the owners of their destiny,” she advises students. “Tell them, ‘I’m here to help you, but I don’t own it—you own it.’”
Interestingly, in order to teach future nurses to inspire intrinsic motivation within their patients, Pyle begins by helping awaken it within them as students.
Challenge: A focus on single tasks, not the whole patient
Many of Pyle’s students currently practice in the healthcare field. She has seen that they are generally adept at the requisite hands-on tasks, but many of them struggle with one-on-one communication with patients.
“I think that we in healthcare [often] don’t treat the whole person or how they’re thinking,” says Pyle. “That’s why nurses are so comfortable in nursing school: Everything [there] is task-based. That’s [tied to] the nature of the job itself.”
This was even true when Pyle was pursuing her doctorate. She felt that it was centered around a concrete approach: “This is how you do it: This is the disease, this is when you intervene, this is the medical intervention. A lot of how we communicate was really lost in the shuffle.”
Even today, students are accustomed to having conversations with patients that steer toward efficient data-gathering (such as “What medicines are you taking?” and “When did your symptoms begin?”).
Pyle notes that students need a bit of guidance in taking patient conversations to a more personal level. “[Nursing students need to gain] a greater understanding of how [patients are] doing, how they’re feeling, what is happening—all of the [things that make up a] more holistic view,” she explains. “What I say to the students often is, ‘Someone taught you how to talk, but you don’t always know how to communicate.’”
Innovation: Enhance communication through introspection
Pyle wants her nursing students to identify when a patient is ready to entertain change and then realize the potential impact the nurse can have on a patient who is ready to change. She accomplishes this by introducing students to motivational interviewing and how it can be used to increase patient buy-in when it comes to the details of their healthcare plans.
The lesson Pyle uses with nursing students is based on an exercise she previously taught in a psychiatric nursing class. “We had students learn about the different psychiatric disorders, [then] they went in and talked to patients,” she explains. Then they wrote down an account of the interaction, called a process recording, and discussed the conversations in class.
By assessing how they talked to their patients, students are able to reflect on their communication skills, then identify ways to make adjustments to their delivery where needed.
“You really have to prepare your students,” she says. “You can’t just send them out there and tell them to start talking. They really need to have some basic information on what technique to use.”
“The thing I find coolest about this course is students can use what they learn right now. The things we talk about, they can—and are encouraged to—go out and utilize on patients, coworkers, family. Students often talk in their discussion posts about what worked and what didn’t, and how they will use these [insights] moving forward.”— Joni Pyle, DNP, RN
Course: NUR376 Communication Strategies for Nurse Leaders
Frequency: 8 weeks online
Class size: 20–28
Course description: Analysis of advanced communication principles in the healthcare arena to further nurses’ knowledge and skill with the spoken language. Emphasis on the skills and processes of communication, collaboration, and change strategies utilized by nurses as care providers and leaders. Designed for nurses to apply and evaluate the verbal communication processes increasing patient/provider collaboration and increased leadership and management skills.
See resources shared by Joni Pyle, DNP, RNSee materials
Lesson: Process recording of patient conversations
In her lesson with nursing students, Pyle incorporates different techniques to bring about desired actions in high-stakes conversations. These include motivational interviewing (see sidebar) and other strategies from the book Crucial Conversations: Tools for Talking When Stakes Are High, by Patterson, Grenny, McMillan, and Switzler.
A Quick Example of Motivational Interviewing
Gaining patient buy-in is an essential step in motivational interviewing. Pyle illustrates this to students with an example of a patient with diabetes who has been readmitted to the hospital for leg wounds. People do not generally respond to being scolded, shamed, or scared, she explains. Consider the differences between these statements:
Negative approach: “If you don’t fix your blood sugars, your health is going to get worse.”
This would likely make the patient feel defensive and cornered. Worse yet, they might be using scare tactics, such as mentioning they might lose the limb or go blind, if they continue on the current course.
Empathetic approach: “So, you have diabetes, and part of what’s happening with your legs is likely because your blood sugar hasn’t been very controlled. Tell me a little bit about that.”
Possible patient reply: “Well, I don’t always watch my diet.”
Or: “I’m having trouble remembering to take my medication.”
This sets the stage for the nurse to put motivational interviewing into action, asking the patient what they would want to be able to do if their health were better.
Motivational interviewing question: “What would you want to be able to do if your health was good?”
Possible answers: “Play with my grandkids, travel the world, work in my garden, dance with my spouse.”
By helping patients realize what they prize, the nurse can then help them “keep their eyes on the prize” as they adapt to a healthier lifestyle.
Pyle’s example shows students that a nurse can guide the discussion and build the patient’s understanding—but only after doing some preliminary work in getting to know them and earning their trust.
For this type of purposeful communication to really make an impact, Pyle believes it needs to become second nature. One of the ways to do that is to have students go out and collect data on their own interactions, do a critical appraisal of their current efforts, then make a plan to help them move forward in a more effective way.
To do this, Pyle uses a version of process recording: For five days, each student must keep a journal about their workplace conversations with patients (sometimes also with coworkers and family). “They’re to note what they said and what the patient’s response was,” says Pyle. At the end of the workweek, Pyle has the students reread all of their entries and do a self-critique.
Here is how she ensures that the revelations therein are helpful enough to drive her students to become better communicators:
Encourage them to embrace the uncomfortable
Though journal entries do not need to be very long, the conversations should have enough depth to be revealing. She encourages students to include their less-positive interactions—the ones that felt uncomfortable—not just their shining moments. “[Students] don’t have to give me every detail, but I want [at least] three conversations with a lot of meat in them,” says Pyle. “That’s where the learning takes place.”
Give them a trick for remembering more
Writing copious notes during the workday can be difficult (if not impossible), but a lot can be lost if students wait until a shift ends. So Pyle instructs students on a more efficient method: jotting down snippets of conversations right after they happen. “You can remember more of the conversation [if you] write down something to jar your memory,” she tells them. “When you go back to fill out your notes later, be as specific as you possibly can [with respect to] to key points and issues in the conversation.”
Grade them on self-reflection
Pyle does not evaluate students based on what they actually said to patients. Instead, she asks them to engage in a self-critique on the five days of journal entries. She is looking for evidence of introspection—whether they are able to identify areas for improvement. For example, she says, if they noted, “I really blew off this patient who wasn’t listening,” they would need to think about how to handle such an interaction in the future.
Make them rewrite their script
Where students see room for improvement, Pyle asks them to rewrite the script as if they could turn back time. Instead of getting frustrated, the student in this scenario might say, “I’d like to ask you to think about X. Would it be OK if I come back in an hour and a half, and we can talk about it then?”
Likewise, if a conversation showed they used an effective means to keep the communication open, they would note that, too.
Reframe the idea of “change”
Many patients with chronic conditions do not give much thought to making lifestyle changes until their symptoms become too serious to ignore. Why? “Change is really, really hard,” says Pyle.
Change is hard for students, too, so Pyle reframes it for them. Instead of talking about what students need to “change,” Pyle asks them to think about what they can “add” to their conversations. For instance, Pyle will tell them, “As you go about your tasks, think about ways you can use what you’re learning about communication to get to know your patient better.”
By focusing on patience and positivity as students work to better themselves, Pyle is also modeling the empathy she wants students to have for their patients.
Break “change” into bite-size pieces
If a patient just received a new diagnosis, chances are they have a lot to learn. That does not mean they are ready to hear or process it all at once. “You don’t go into a [conversation] with a patient and slam them with all this new stuff,” says Pyle. “You spread it out over a few days or a couple of conversations.”
Pyle uses the same idea when helping her students make improvements. One week, for example, a student might work on softening their approach (instead of diving right into a tough conversation with no warning). This can be as simple as asking a patient, “Is this a good time to talk about your meal plan and, if not, when would you like me to come back?” Another week, they may think about using wording that is inspiring, not scary.
Ask for a big-picture behavior change plan
The last assignment is for students to create a self-improvement plan in which they explain what they will do differently overall, based on what they have learned.
“We’ve learned this, we’ve had introspection, we’ve had critique—now what’s our plan to put it into place so it becomes usable and not put away in a [drawer] somewhere?” Pyle asks her students. “How will we move this forward?”
This exercise also helps build empathy for patients, who are often tasked with moving forward in a positive way with regard to their health. Expressing empathy helps the nurse to gain insight into the patient’s perspective, Pyle says. Expressing empathy in a nonjudgmental way sends the message that whatever is going on is the patient’s experience, not that of the nurse.
A nurse might say, “What you are saying is really important to me—can you tell me more?” For example, if a nurse is gaining information regarding the patient’s medications, and there are many, the nurse might choose to say, “You are taking a lot of medications, and I can see how hard it is to keep track of all of them.”
Encourage them to keep practicing
Pyle suggests students test out their motivational interviewing techniques on family and friends—both during the course and after it ends. They may want to apply their skills in a discussion with a grandparent who smokes or a friend who regularly drinks to excess, she suggests. “It doesn’t necessarily have to be with nurses or patients they work with,” says Pyle. “Motivational interviewing can be used really any time.”
In the beginning of the semester, some of Pyle’s students remark that changing their language feels “scripted,” to which she replies, “Well, you are [scripted]—for right now—but with time it will become more natural, and you’ll feel more comfortable with it. You’ll find different ways to influence the outcome of what it is that your patients do, and you’ll have a better bond to help your patients achieve a better [health] outcome.”
In the meantime, Pyle encourages students to be ready with what she calls a “back pocket” response, one that fills in that awkward gap that can arise when they know they should give something more than a quick, unthinking response, yet they are not ready with a more meaningful reply. “I’m so sorry for your loss” is an example phrase that Pyle notes may be suitable for such moments. “This kind response gives you time to think of a [more] therapeutic response,” Pyle explains.
As nurses become more and more comfortable framing conversations this way, those more therapeutic replies will eventually become second nature, adds Pyle.
In fact, many of her former students have reported that they have implemented motivational interviewing techniques with great success. “I have had students come back to me and tell me that they’ve been able to use the techniques in their real-life situations,” she says. “They tell me how helpful it is, and that they still use it.”