Nursing Students’ Perceptions of Small-Group Standardized Patient Simulations to Enhance Therapeutic Communication Skills

Abstract

Objective:

Therapeutic communication is essential to nursing practice, yet many pre-licensure nursing students report discomfort applying these skills in clinical settings. Standardized patient (SP) simulation offers a controlled environment for practicing communication, yet qualitative research describing students’ perceptions of these experiences remains limited. This study explored undergraduate nursing students’ perspectives on small-group, communication-focused SP simulations within a psychiatric-mental health nursing course.

Methods:

As part of a larger program evaluation, six in-person focus groups were conducted with 47 Bachelor of Science in Nursing students following participation in two series of SP simulations across nine scenarios. Discussions were audio-recorded, transcribed, and analyzed using inductive thematic content analysis. An audit trail and team debriefing supported rigor and consistency.

Results:

Three themes emerged. First, students reported that SP simulations increased their comfort and confidence in therapeutic communication, providing a safe space to practice navigating emotionally charged conversations and building rapport. Second, the simulations evoked ambiguity regarding the psychiatric-mental health nurse’s role, as students struggled to differentiate therapeutic communication from psychotherapy and acknowledged real-world time constraints that limit such interactions. Third, students identified high-quality, instructive feedback, particularly during debriefing, as essential to learning and expressed a desire for more structured guidance from SPs and faculty.

Conclusions:

Communication-focused SP simulations effectively enhance therapeutic communication skills among pre-licensure nursing students. To optimize learning, faculty should intentionally clarify nursing role boundaries and strengthen debriefing structures. Findings highlight the importance of targeted feedback and instructional support in maximizing the educational value of SP-based simulation.

Introduction

Therapeutic communication is a tenet of nursing practice and essential to delivering high-quality care. Many nurses report discomfort with therapeutic communication skills (Amoah et al., 2019; Xue & Heffernan, 2021). In pre-licensure nursing programs, therapeutic communication is often covered within psychiatric-mental health nursing courses (Donovan & Mullen, 2019; Martin & Chanda, 2016). Standardized patient (SP) simulation focused on communication is one method for teaching and reinforcing concepts in therapeutic communication and interpersonal skills.

A wealth of research has examined outcomes of SP simulation experiences within pre-licensure nursing curricula. Two systematic reviews evaluated the use of simulation in pre-licensure programs and found that simulation was associated with student satisfaction and self-confidence (Cant & Cooper, 2017; Olson et al., 2018). In psychiatric-mental health nursing courses, the use of SP simulation is associated with improvements in student satisfaction and self-confidence (Jawabreh et al., 2025) and improvements in student perceptions of individuals with mental health problems (Kameg et al., 2021).

Data suggest that pre-licensure students prefer the use of SPs to manikins when learning how to properly care for patients with mental health problems (Weidlich et al., 2024). Other data have supported SP simulation as an effective means of improving therapeutic communication skills among pre-licensure nursing students (Donovan & Mullen, 2019; Ross et al., 2024; Yuan, 2021). Most research on therapeutic communication as an outcome of SP simulation in pre-licensure nursing curricula has used a quantitative approach, leaving a current gap in the literature. Thus, the present study qualitatively examined nursing students’ perceptions of the usefulness of communication-focused small-group SP simulation experiences for therapeutic communication outcomes.

Methods

Design

A qualitative design was utilized, leveraging focus groups among students who participated in small-group SP simulation experiences focusing on therapeutic communication.

Setting

This study was conducted at a large, research-intensive university in Pennsylvania within the context of a pre-licensure psychiatric-mental health nursing course.

Sample

Inclusion criteria included students enrolled in a psychiatric-mental health nursing course who agreed to participate in the study. Students were recruited by their clinical course instructors to participate in the focus group, which was scheduled during the clinical post-conference. Students consented to participate, were advised that data would remain anonymous, and informed that their participation would not affect course grades. This study was reviewed by the Institutional Review Board and determined to be an exempt study.

Data Collection

This study was part of a larger program evaluation focused on nursing students’ perceptions of substance use education. The study team developed the interview guide with input from three qualitative research experts. The interview guide covered students’ perceptions of SP simulation experiences and feedback on how to improve the quality of simulation scenarios for future semesters. Focus groups were facilitated in person by study team members with qualitative research experience, recorded, and later transcribed. Data collection continued until saturation was reached.

Procedures

Pre-licensure students participated in nine SP simulation experiences throughout the semester. The first 6 simulation scenarios occurred during clinical time in the first half of the semester. These cases involved bipolar disorder, schizophrenia, borderline personality disorder, posttraumatic stress disorder, alcohol use disorder, and major depressive disorder with suicidality. In the latter half of the semester, students participated in another three simulation experiences during clinical time. These three cases involved substance use disorders, including opioid and stimulant use disorders. The simulation experiences used a small-group format, in which groups of five to eight students rotated through participation in the case series, so that at least two to three students interviewed each patient case. Debriefing occurred after each student interview, and students were provided feedback from their peers, the facilitator/instructor, and the SP. The cases focused on therapeutic communication, establishing rapport, and eliciting a psychosocial history. Within the month following the second simulation experience, we conducted six focus groups with undergraduate students who participated in both simulation activities. Focus groups were conducted with a study team member and clinical faculty who were not involved in the simulation experience and did not directly supervise the students.

Analysis

NVivo Version 15.1.0 was used to analyze data, utilizing an inductive thematic content analysis (Vears & Gillam, 2022). After agreement about first-round coding, line-by-line coding commenced. The team later worked collaboratively to identify themes and narratives. To ensure the rigor and reliability of data, an audit trail was maintained to ensure the validity and consistency of coding. Further, the project team met regularly to debrief the findings. In addition, the project team reviewed the study findings with clinical faculty who were present during the focus groups, but not directly involved in the study, to ensure the data’s trustworthiness.

Results

A total of 47 students participated in six focus groups, most of whom identified as female and Caucasian. The analysis identified three themes surrounding students’ perceptions of small-group, communication-focused SP simulations. Themes included: simulation as an effective means of increasing comfort and confidence in skillful therapeutic communication; simulation evoking perceived ambiguity about the role of psychiatric-mental health nurses in clinical care; and the need for high-quality, instructive feedback during simulation.

Simulation as Effective for Increasing Comfort and Confidence with Skillful Therapeutic Communication

Students described feeling inherently uncomfortable using therapeutic communication skills, despite recognizing their importance in facilitating the nurse-patient relationship. Students generally described psychiatric-mental health nursing clinical and simulation experiences as challenging, as the course relied heavily on interpersonal skills, such as therapeutic communication strategies, rather than on hands-on or technical skills students were accustomed to in medical-surgical courses. Students felt that it was often difficult to leverage these interpersonal skills in the clinical environment due to a lack of confidence and other setting-specific issues, such as patient acuity or limited patient availability. However, students felt that exposure to SPs enabled them to practice interpersonal and therapeutic communication skills in a safe, standardized environment. Furthermore, students reported that the opportunity to practice therapeutic communication and focus on rapport building allowed them to see the individual as “more than just a patient,” with one student stating:

Yeah, I think it [simulation] helps a lot with therapeutic communication. . .like, going into psych, in general. . .I was scared to even talk to the patients. Then, simulation made me realize they’re still people. . .I can just talk to them regularly. . .so it helped with therapeutic communication and validating their feelings. . .how they’re feeling that day, or what they’re going through. It made me feel better on how to approach them. So yeah, I think it really did help.

Students also felt that the simulation allowed them to “become comfortable with discomfort” through cases that included emotionally charged content. Furthermore, students described feeling that the utilization of therapeutic communication in addressing complex subjects was rewarding, with a student stating, “Unless you probe that deep, you’re not going to get any information. I think it really taught me that you have to ask those difficult questions, even if it’s slightly uncomfortable.”

Another student stated:

You have to speak to him [SP] like you can’t expect him to receive anything from you if you’re not gonna give anything. He kept me on track, instead of asking, “What are you here for?” I was asking about his family, where is he from? What does he like to do. . .I was getting to know him as a person rather than as a patient. . .It was difficult, but I learned a lot by having to give a little bit more. . .you had to work, I think, a little bit harder to build that rapport.

Simulation Evoking Perceived Ambiguity about the Role of Psychiatric-Mental Health Nurses in Clinical Care

Despite recognizing the importance of therapeutic communication and feeling more comfortable with these skills, students reported that participation in the simulation heightened their perceived ambiguity about the role of psychiatric-mental health nurses in clinical care. Specifically, students struggled to discern how the nurse’s role in therapeutic communication differs from that of a therapist. One student stated:

I definitely have carried some of what I learned into work, at least. . .I just felt very much like I was in the therapist role, and I feel like that’s not something that I can do as a patient care technician, student nurse, or as a bedside nurse.

In addition to feeling like some aspects of the simulation were beyond the nurse’s scope of practice, students also described feeling like the simulations highlighted restrictions on nursing staff’s time, with one student stating: “At work, I can’t really just sit down and talk to my patient for 20 minutes about what’s going on, because it does feel very [much like a] therapist. . .”

Despite this perceived ambiguity, other students felt that the simulation reinforced the importance of the nurse’s role and interpersonal connections within the context of the therapeutic relationship, with one student stating:

I really like the simulation cases, because I felt like the cases were kind of similar to what I deal with that at work. So, I was able to use them. . .Sometimes you have the chance to be that one [person who can impact a patient], like in that therapy role. I personally like that. . .

In general, participation in the simulation caused students to reflect not only on the nurse’s role in enhancing the therapeutic relationship but also on how they could be most impactful with patients despite the time constraints often seen in the clinical milieu.

Need for High-Quality, Instructive Feedback During Simulation

While students reported that the opportunity to engage in a simulated patient interaction helped them feel more comfortable with therapeutic communication, they also reported that the simulation debriefing or feedback was equally valuable to their learning. Students felt that having additional time for debriefing and feedback during the simulation experience would be helpful in the future, with one student stating:

She [SP] went into depth about how she, as a patient, would have responded if I asked this question, and then we talked about it for a while. I thought that was a really helpful discussion. I took a lot from that. If we were able to do that more, that’d be great.

During the simulation experience, students were instructed to ask the SP for specific feedback. However, students found this difficult, as they described feeling as though they “didn’t realize what they didn’t know,” with one student stating: “They [SPs] give really good feedback. I think I would appreciate for next time some ideas of what to ask them [for feedback].” In general, students felt they would benefit from more direct faculty instruction or guidance throughout the scenario, both during the scenario itself and during the debriefing process.

Discussion

Students enrolled in a psychiatric-mental health nursing course found that simulation helped enhance therapeutic communication skills. This is in line with past research, which has supported the use of SPs for strengthening pre-licensure nursing students’ confidence and competence in therapeutic communication and interpersonal skills (Arnone et al., 2021; Donovan & Mullen, 2019; Hong & Lee, 2022; Martin & Chanda, 2016). Despite finding simulation helpful in refining and reinforcing communication skills, students struggled to integrate these skills with their future role as nurses and to discern how therapeutic communication differs from the provision of psychotherapy. This potentially relevant students spent most of their psychiatric-mental health nursing clinical experience in acute inpatient settings, where staffing demands often left nurses managing acute emergencies, dispensing medications, and facilitating admissions and discharges, rather than having visibility into the milieu. This aligns with previous research, which suggests that the inpatient psychiatric-mental health nurse’s role has shifted into a more technical role due to staffing limitations, budgetary constraints, and higher bed occupancy within the health care system (Belsiyal et al., 2022; Hurley et al., 2022). Nursing faculty should be cognizant of this phenomenon and strive to provide pre-licensure students with diverse clinical experiences to expose them to the various roles and settings in which psychiatric-mental health nurses practice. Little research to date has examined students’ perspectives of inpatient psychiatric-mental health clinical experiences compared with outpatient experiences, and this is an area worthy of future exploration. Furthermore, nursing faculty should explicitly delineate how therapeutic communication differs from (and possibly resembles) psychotherapy to enhance students’ understanding. Recent research has highlighted the importance of clarifying therapeutic communication within the nurse-patient relationship as a process of information exchange between a nurse and a patient, grounded in mutual respect and engagement in the management of health issues of concern to the patient (Xue & Heffernan, 2021).

Students in the present study found that debriefing and receiving feedback were equally crucial to their learning as other simulation components. While previous research has examined student satisfaction with simulation, little research has examined students’ perceptions of debriefing and their preferences for debriefing or receiving feedback (Niu et al., 2021). Thus, this is an area where additional research is needed, particularly about how faculty or facilitators could best support students.

This study had several limitations. The nature of the focus groups, which were derived from a single institution and not diverse in race or gender, limits generalizability. In addition, social desirability bias may have influenced student feedback, despite reassurances that feedback would not affect course grades and that primary course faculty were not involved in the focus groups.

Conclusions

This study examined pre-licensure nursing students’ perspectives on small-group, communication-focused SP simulation. Students reported that the simulation enhanced therapeutic communication skills, though it created perceived ambiguity about the psychiatric-mental health nurse’s role. In addition, students found the debriefing a valuable part of the simulation experience. Psychiatric-mental health nursing faculty can leverage SP simulation in their courses to enhance therapeutic communication skills. In addition, all faculty should be cognizant of students’ preferences regarding simulation experiences while also adhering to best practices.