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“I couldn't even talk to the patient”: Barriers to communicating with cancer patients as perceived by nursing students

Communication is closely related to safe practice and patient outcomes. Given that most clinicians fall into routines when communicating with patients, it is important to address communication issues early. This study explores Taiwanese nursing students' experiences of communication with patients with cancer and their families. Senior nursing students who had cared for cancer patients were recruited to participate in focus group interviews. These semi-structured interviews were recorded and transcribed for content analysis. Among the 45 participants, about 36% of them never received any communication training. Up to 76% of the participants stated that their communication with cancer patients was difficult and caused them emotional stress. Subsequent data analysis revealed four themes: disengagement, reluctance, regression and transition. Students' negative communication experiences were related to the patients' terminally ill situation; the students' lack of training, low self-efficacy and power status, poor emotional regulation, and cultural considerations. The findings of this study provide a deeper understanding of nursing students' communication experiences in oncology settings within the cultural context. Early and appropriate communication training is necessary to help students regulate their emotions and establish effective communication skills. Further studies are needed to examine the relationship among students' emotional labour, communication skills and outcomes.


Introduction
Escaping. Rather than trying to break the communication block, students run away from the conversation topics and avoided approaching patients again.
'He (patient) answered simply and briefly; eyes closed, and waved his hands asking me to leave… I felt embarrassed… After that, I was afraid to approach him...afraid of being rejected again. ' (A012) 'I didn't feel comfortable entering oncology wards… the depressing atmosphere… and the sight of my hepatica cancer patient, with his mouth half open and being so fragile… I just wanted to run away. ' (C008) 'I felt uncomfortable opening a discussion of sexual issues, particularly because the patient was such an elderly person that I did not know how to start. ' (B014) The terminally ill atmosphere or the interpersonal tension generated by patients' verbal and nonverbal cues hindered students' attempts to approach cancer patients. These factors influenced their confidence and caused hesitation in further communicating with the patient.
The tension resulted in a desire to escape from the communication by avoiding the patient.
Maintaining boundaries. Some of the communication block were caused by caregivers' protection behaviours. These protection behaviours made approaching patients extremely difficult for students.
'The nurse's aide (who is hired by the family) answered the question I asked the patient as if she were the representative. Then she changed the subject without noticing the patient was trying to say something slowly. I couldn't even talk to the patient.' (A005) 'Because of frequent vomiting, my patient wouldn't take the medicine. She only waved her hands to express her refusal… However, her family strongly insisted that she take the medicine… I disagreed with the family since it was against the patient's will, but I didn't know how to explain it and persuade the family not to force her again. ' (B013) Family plays an important and unique role in caring for patients in Asian culture. The social norms regarding the power and obligations of taking care of illness in the family greatly affect family's attitude toward care and communication and health care provider's practice. Students must cope with negative displays of this kind of power or authority. In these circumstances, students' first attempts at communication were marginalized by these boundaries.

Reluctance
As nursing students endeavoured to initiate communication to build relationships with cancer patients, they were rejected. Patients and families thought students were too young to understand their situation or withdrew despite student's behaviours. Students were barred in achieving a therapeutic relationship. Students adopted a passive mode, awaited acceptance and were reluctant to communicate. Two subthemes were identified: devaluation and rejection. The patient-student relationship was undermined with some families claiming dissatisfaction with the interaction.

Regression
Although students had established superficial relationships using basic communication skills, the students encountered other barriers to communication. Difficulties in applying advanced skills or patients' negative perceptions hindered students from further understanding patients' concerns or providing emotional support. Three subthemes were identified: disconnectedness, fear of losing control, and avoiding a taboo. The nursing students were equipped with basic communication skills; however, in the clinical environment, they struggled to perform and failed to achieve an understanding with patients.

Disconnectedness
The student-patient relationship fluctuated because the students were unsuccessful in communicating despite their self-expectations of success. Although the students had learned that phrases such as "cheer up" would not be helpful in comforting patients, they could not help but use such statements to avoid embarrassment. Such inappropriate communication resulted in an apparent disconnect between students and patients. The students were incapable of probing or directing focused communication when patients tried to change topics.
Fear of losing control. When students tried to manage the communication as a profession, they also needed to deal with their own emotions which affected their communication ability. When encountering the emotion-laden responses of patients or family members, the students were frightened and worried about losing control of such situations. The students tended to view a patient's crying as a negative behaviour that triggered the students' uneasiness and self-blame. The students reflected that they had failed to perceive patients' psychological cues and need for comfort and reassurance. Consequently, the students struggled to provide care and responded passively. Students were hesitant to address ambivalent situations, including breaking bad news or telling the truth. In the Taiwanese culture, some families insist that patients are too vulnerable to receive bad news and choose to hide the prognosis from patients. Wishing to respect families' decisions conflicted with notions of patient-centred care and created a dilemma in nursing students. One student reported that when families requested that she conceal the diagnosis, she became anxious regarding the assigned task and cautious regarding her conversations with the patient.
Incapability. Students reflected on their incompetence in regard to communicating with cancer patients and their families.
'After talking to them, I found that they had lots of problems that needed to be solved. In response to frustrating experiences, the students attempted to solve problems and determine how best to proceed. For example, when the students observed that their communication resulted in patient displeasure, these nurses tried to remedy the situation by fulfilling the patients' needs and soliciting a more favourable impression.

Discussion
To our knowledge, this is the first study exploring communication experiences with cancer patients from the perspectives of nursing students in Taiwan experience. These barriers reduced the nursing students' confidence to initiate and maintain a therapeutic relationship with cancer patients. Consequently, the nursing students were passive, afraid and oversensitive during communication. They became hesitant and self-conscious while simultaneously struggling to overcome barriers and develop strategies to enhance communication.
The students' communication barriers may be associated with multiple interrelated factors, such as insufficient training, low self-efficacy, poor emotional regulation, student identity, and the special cultural care model.

Insufficient Trainings in Communication Skills
Although approximately half of the participating students had some form of communication training, the majority of the students mentioned the gap between knowledge and practice as described in the theme of transition. Insufficient training in communication and the knowledge gap are consistent with findings from a literature review (Chant et al., 2002). Furthermore, although half of the students did not receive any formal cancer communication training, their clinical placement forced them to interact with vulnerable cancer patients and families with special communication considerations and needs. Disengagement was the initial obstacle when students tried to maintain clear boundaries between themselves and cancer patients. Their initial communication attempts ended in interpersonal stagnation, which is consistent with a prior study of medical students. Lin and colleagues (2001) observed that skills in approaching patients and initiating conversations were the primary difficulties for medical students (Lin et al., 2001). After an unsuccessful opening, some students fled from the conversation, which is consistent with the findings of Hjörleifsdóttir and Carter (2000). Like registered nurses and medical students, nursing students also experienced communication difficulties regarding special conditions, such as delivering bad news (Supiot andBonnaud-Antignac, 2008, Malloy et al., 2010). Although it is not students' or nurses' responsibility to deliver bad news, it does not permit them to avoid the social pressure of this kind of difficult communication. Nursing students felt trapped between patient autonomy, medical paternalism and family protectionism (Sheu et al., 2006). Our findings suggest that nurses sensed and experienced these communication difficulties early in their careers.
Addressing these communication issues early in the student stage, when the nursing students are forming their professional identities and establishing a communication style, may be more appropriate.
Insufficient training in communication skills may be the most obvious and universal problem; however, the lack of training is only one cause of ineffective communication. Our findings revealed a wide variation of nursing students' communication experiences, from completely blocked (disengagement) to conducting more effective communication (transition). We concluded that the blocked status (e.g., disengagement and reluctance) may be more relevant to students' emotional regulation, power status and cultural considerations than communication knowledge and skills. In other words, students must effectively regulate their own emotions before applying their cancer communication knowledge and skills. However, emotional regulation appears to have received less attention in studies examining health communication.

Poor Emotional Regulation
Our findings showed that nursing students had difficulties in regulating their own and patients' emotions. As described in the themes of disengagement, reluctance and regression, the students tended to escape and avoid emotional situations. They felt significant emotional fluctuation and feared losing control when being devalued or rejected by patients, nursing aides or families. These feelings, in addition to the perceived severity of the topic (e.g., death as a taboo issue) and low feelings of efficacy, impeded students from probing and achieving a deeper mutual understanding with their patients. This finding supports the results of studies conducted in Turkey and the United Kingdom that revealed nursing students' fear of addressing emotion and their use of blocking or distancing strategies (King-Okoye and Arber, 2014, Kav et al., 2013). Moreover, considering the different performance levels of emotional regulation, our findings indicated that the students regulated their emotions on a more surface, response-focused level (e.g., escaping from the emotional situation based on patients or families' negative responses) rather than at a deep, antecedent-focused level (Mark and Mann, 2005).

Culture Considerations
Compared with most Western cultures, health care and communication in cultures such as those in Japan, China and Mexico are more family-focused (Harris and Long, 1999;Hicks and Lam, 1999;Frank et al., 2002). In these cultures, family caregivers believe that they have the responsibility to protect the patients by filtering information and assisting with making decisions (Frank et al., 2002). Similarly, in Taiwan, family caregivers are allowed and expected to provide bedside care and to participate in communication and decision-making. Some Taiwanese families hire nurses' aides for bedside care (Lin, 2000;Sung et al., 2005); these nurses' aides may have more experience and familiarity with cancer patients than nursing students. Similar to other Taiwanese studies that found that families perceive themselves to be decision-makers and gatekeepers who are ethically responsible for safeguarding their vulnerable members (Sheu et al., 2006;Lin, 2000;Fan and Li, 2004), our subtheme of maintaining boundary delineated how family caregivers participate in or even dominate communication in order to protect patients. Because family members perceived student nurses to be inexperienced health care providers, the family tended to take the lead in the patient-student conversations. It is important for educators and students to understand the meanings and health beliefs behind family-dominant conversations.
Although the involvement of families in patient care is a particularly important family centred care model, understanding and responding to families' needs and emotions are always challenging, particularly for students, when caring for terminally ill patients worldwide (Charalambous and Kaite, 2013;Sanford et al., 2011;Huang et al., 2010). Our findings showed the importance of preparing students to communicate with families and recognize their concerns and needs before assigning nursing students to terminally ill patients. Although the majority of textbooks and caring models were developed and tested in Western cultures that focus on individuality, our findings noted the importance of developing culturally appropriate care and education.
Early and comprehensive communication training is imperative. In the short term, such training can reduce the pressure of working in an oncology setting, which can frustrate students and drain their energy (Basso Musso et al., 2008). Over the long term, training enhances students' positive clinical experience, which is positively related to future job satisfaction (Wu and Norman, 2006). Adequate communication training for nursing students thus has the potential to promote positive nurse-patient relationships and enhance nurse retention.

Conclusion
The findings of the current study provide a deeper understanding of nursing students' communication experiences in Taiwanese oncology settings, further advancing insights into a student's progress from novice to qualified nurse. Unfortunately, our results did reveal that students experience traumatic communication experiences that prohibit these nursing students from communicating effectively with cancer patients. The lack of preparation, including communication knowledge, skills and emotional regulation, before clinical placement in cancer settings contributes to nursing students' negative communication experiences. Special communication training programmes targeting patient populations with different needs and considerations may be 18 necessary for nursing students or novice nurses who will care for unfamiliar patient populations.
Moreover, culture-specific considerations such as families' protective behaviour should be identified and discussed openly. Ideally, educators and clinical preceptors must communicate with and educate families before assigning students to patients. Other strategies such as role-playing, case scenarios or exposure in a less stressful environment are recommended to enhance students' feelings of self-efficacy (Sanford et al., 2011). Examples from the current study (e.g., reluctance or regression scenarios) can be used as cases to raise awareness or facilitate discussion.