In hospital and clinic settings, nurses implement therapeutic communication strategies with patients experiencing mental health concerns. As educators and preceptors, are we also using these same strategies with nursing students who exhibit sadness, anxiety, negative thoughts, depression, and stress? The innocent question, “If you can't take care of yourself, how are you going to take care of patients?” must make us ponder whether we, as instructors of the art and science of nursing, have become the ostrich described in Job 39:13-17:
. . . For she leaves her eggs to the earthand lets them be warmed on the ground,forgetting that a foot may crush themand that the wild beast may trample them.She deals cruelly with her young, as if they were not hers;though her labor be in vain, yet she has no fear,because God has made her forget wisdomand given her no share in understanding. (Job 39:13-17, ESV)
The content of this article describes the subtle signs associated with sadness, anxiety, negative thoughts, depression, and stress (SANDS) and the therapeutic communication strategies faculty and nurse preceptors can implement to promote healthy relationships and positive academic outcomes for nursing students.
The SANDS mnemonic was created by one of the authors after noticing that many nursing students in counseling sessions were experiencing similar symptoms. Students who presented with stress, depression, or anxiety as the primary concern almost always also reported experiencing periods of sadness and negative thoughts that interfered with their ability to study. Instead of writing each of the words sadness, anxiety, negative thoughts, depression, and stress in counseling notes or in discussions with students or other professionals, the mnemonic SANDS was coined.
During the first 2 years of college, many students successfully manage symptoms associated with poor mental health (Reeve et al., 2013). Unlike other undergraduate programs, nursing school has been cited for inducing higher levels of mental health issues as a result of the challenging curriculum and high-stakes learning environment (Reeve et al., 2013). This perceived increase in stress can trigger an imbalance in the student's ability to manage mental and emotional health and interfere with previously well-managed symptoms. In such cases, students tend to experience a downward spiral of academic difficulty, unhealthy stress, and maladaptive coping behaviors.
University faculty are confronted with how to respond when students show signs and symptoms of SANDS. The American College Health Association's (ACHA) 2016 fall survey found that students who experienced stress (34%), anxiety (26.5%), and depression (16.4%) were more likely to have lower exam scores, have lower grades in a course, receive an incomplete, or drop the course entirely (ACHA, 2016). Students in this same study reported feeling hopeless (52.7%), overwhelmed by all they had to do (87.3%), exhausted from something other than physical activity (83.3%), very lonely (62.3%), very sad (67.3%), so depressed that it was difficult to function (39.1%), overwhelming anxiety (61.9%), and overwhelming anger (42.3%). Many students seriously considered suicide (11.2%), and 2.1% attempted suicide (ACHA, 2016).
Chernomas and Shapiro (2013) conducted a cross-sectional descriptive exploratory study investigating stress, depression, and anxiety. Using an online survey, they collected data from 437 students at a midwestern Canadian university. Of the total respondents surveyed, 10% of students had scores in the severe and extremely severe categories of depression; 16% had scores ranked within the severe and extremely severe categories of anxiety; and 10% had scores in the severe and extremely severe categories of stress (Chernomas & Shapiro, 2013).
Although research on nursing students' experiences of stress, anxiety, and depression has been well documented, little research has been conducted on recognizing the signs of SANDS and identifying Scriptural or therapeutic communication interventions that might address and minimize these issues.
Although nursing instructors are familiar with some mental health concerns, many may not recognize warning signs or symptoms in students experiencing SANDS (Kucirka, 2017). Some markers may be more explicit than others and may be expressed differently by different students. Unmanaged SANDS can interfere with student and patient safety, student and instructor relationships, and academic success. Unmanaged SANDS can appear in the classroom, the clinical setting, or social environments as persistent tardiness, excessive absenteeism, neediness or avoidance of the instructor, inappropriate and adversarial verbal or written interactions with instructors or peers, ostracism by peers, social withdrawal, and decline in academic performance (Kucirka, 2017; Mills et al., 2017). For the purpose of early identification of students who may be experiencing these difficulties, Table 1 contains brief descriptions and examples of SANDS.
Table 1. -
Potential Signs and Symptoms of SANDS
|More Visible Signs and Symptoms
||Less Visible Signs and Symptoms
||Trouble learning new information
|Inappropriate and adversarial verbal or written interactions with self, instructor, or peers
|Decline in academic performance
|Difficulty with making decisions
|Disorganization and forgetfulness
||Social withdrawal and isolation
|Neediness or avoidance of instructor
||Ostracism by peers
|Nail biting and picking
|Sudden attacks of life-threatening panic
||Chest pain, palpitations, rapid pulse
|Nervous habits, fidgeting, feet tapping
|Changes in appearance
||Constant tiredness, weakness, fatigue
||Feeling overloaded or overwhelmed
||Feelings of being out of control
||Frequent use of over-the-counter drugs
According to Lokko and Stern (2014), “Sadness is a normal and universal emotional expression of grief, loss, hopelessness, stress, discouragement, or loneliness” (para. 23). A nursing student might normally experience sadness after receiving a failing grade or losing a friend. Although sadness can be related to a specific event, it doesn't have to be. Students may experience sadness for no apparent reason. Research suggests that the feeling of sadness can take an average of 120 hours to lift (Westlund, 2017). Although sadness is not a depressive disorder, prolonged or persistent sadness is unhealthy and can be a sign of depression (Forgas, 2017).
Example: Nurse B. notices that a student who is typically upbeat and happy did not smile when she spoke. Upon being asked if she was okay, the student responded, “I don't know; I just feel sad for some reason today.”
For many students, anxiety is a normal part of life. Students with excessive anxiety or an anxiety disorder may have trouble controlling their worries or recognizing that they worry more than they should (National Institute of Mental Health [NIMH], 2016). Students with anxiety may startle easily, feel on edge, experience a pounding heartbeat, trembling, excessive sweating, difficulty breathing, swallowing, or concentrating, and need more frequent bathroom visits. Headaches, muscle aches, stomachaches, and unexplained pain also have been identified as symptoms of anxiety. In addition, nail biting and picking, difficulty falling or staying asleep, and feelings of being out of control have been reported by students with anxiety.
Example: Right before an exam, Instructor K. notices a group of peers surrounding a shaking classmate and coaching her to breathe. When Instructor K. asks the student, “What is wrong?” the student states, “I feel like my heart is racing and is going to jump out of my chest; I'm so worried about failing this exam.”
Scripture encourages us to think good thoughts: whatever is true, right, pure, admirable, and praiseworthy, among others (Philippians 4:8). However, students who experience negative thoughts may become caught up in negative self-talk. “Negative thoughts are cognitions about the self, others, or the world in general that are characterized by negative perceptions, expectations, and attributions and are associated with unpleasant emotions and adverse behavioral, physiological, and health outcomes” (Hawkley, 2013, para. 2). It is reasonable to assume that unmanaged negative thoughts can impact students' academic outcomes and lead to other concerns such as anxiety and depression.
Example: Following an exam review, Instructor M. hears a student say, “Before every test, I'm always thinking I'm going to fail no matter how much I study. I keep choosing the wrong answer. I'm obviously stupid and can't understand what they are looking for.”
Diagnosed as a common mood disorder, depression can interfere with one's academic success and affect a person's feelings, thinking, behavior, and physical well-being (NIMH, 2018). An estimated 6.7% of U.S. adults experienced at least one major depressive episode in 2016, with a higher prevalence among adult females (8.5%) and individuals aged 18 to 25 (10.9%). Depressive symptoms can include difficulty concentrating, remembering, making decisions, or sleeping; early-morning awakening; oversleeping; decreased energy or fatigue; changes in personal hygiene and grooming; and weight loss or gain (NIMH, 2018).
Example: Instructor V. notices a student at the clinical site with unusually poor grooming and wearing wrinkled clothes. The student looks tired and doesn't engage in teamwork with peers. In addition, the student's scrubs are noticeably looser than Instructor V. remembers.
Stress can be seen as neutral, good (also referred to as “eustress”), or bad (also referred to as “distress”) (McCarthy et al., 2018). Additionally, stress can be acute, chronic, or traumatic. In humans, acute stress is characterized by a direct danger that occurs within a short span of time and initiates the fight-or-flight response of the sympathetic nervous system. For example, one might experience acute stress after narrowly avoiding an accident. Chronic stress can result from persistent frustration or anxiety that a student encounters daily such as a chronic illness or an unpleasant job. Traumatic stress stems from a life-threatening situation that evokes fear and helplessness such as a tornado, fire, or war.
An evaluation of undergraduate nursing programs from 13 countries found academic stressors (which can be classified as bad or chronic stress) were mainly associated with academic environment, assignments, and examinations. Stressors identified in the clinical environment were related to student confidence in caring for patients and difficult relationships with clinical colleagues and educators (McCarthy et al., 2018). According to the American Institute of Stress (n.d.), typical signs of stress might include difficulty concentrating, racing thoughts, sudden attacks of life-threatening panic, chest pain, palpitations, rapid pulse, frequent urination, forgetfulness, disorganization, confusion, difficulty in making decisions, feeling overloaded or overwhelmed, and frequent crying spells or suicidal thoughts.
Example: Every time a particular student is called upon to administer medications to a patient or perform a certain skill, the student gets confused, starts crying, and has to use the restroom.
THERAPEUTIC COMMUNICATION STRATEGIES
With an understanding of the signs and symptoms of SANDS, educators can better acknowledge and accept the struggles that students experience. Therapeutic communication as an intervention may be one of the most beneficial tools a nurse possesses to reduce SANDS and establish rapport. This use of therapeutic communication is applicable and beneficial for patients and with students. Instructors can effectively support students by practicing basic therapeutic communication skills: providing empathy, encouragement, and information, actively listening, clarifying, questioning, confronting, and summarizing (See Sidebar: Case Study). These skills can be developed, modeled, and utilized with students experiencing SANDS. Practicing these skills with students may encourage healthy relationships between the student and instructor and promote positive academic outcomes. Without considering the use of therapeutic communication strategies, instructors may be less likely to effectively support students and minimize the negative impacts of unmanaged mental health behaviors. Therapeutic communication skills and sample statements are presented in Table 2.
Table 2. -
Skills and Sample Statements
|Student statement: I worked so hard to get into this program. I failed the first test, so I'm doomed. I'm never going to get this. All I do is study. I don't go anywhere, and I still failed. It's depressing. I'll never be happy again. I can't sleep...I forget to eat. I just don't get it, but everyone else does. If I'm having this much trouble, I should probably think about another major.
Therapeutic Communication Skill
Sample Instructor Statements
||I can see how difficult and upsetting this experience must be for you.
|Providing active listening
||I hear you saying that nursing school is challenging, and you don't think you're going to be successful.
|Providing information with permission
||Would you be interested in a list of resources that may help?
||This is only one performance evaluation. There will be other opportunities to improve. With tutoring, enhanced study techniques, and practice, it's likely that your performance will improve.
||Can you tell me how you studied for the test?
||Tell me what you mean by you're “doomed.”
||You said that you want to be a nurse, but you're giving up after failing the first test?
||It sounds like your confidence is shaken, even though you've worked hard to get to this point. You've given up a lot and you're disappointed and don't think you can do what is required to become a nurse. In addition, you're having trouble eating and sleeping. Did I understand you accurately?
Instructors can effectively support students by being transparent and demonstrating empathy. Having once been a nursing student, instructors can try to relate and acknowledge the demands of the educational program and its impact (Reeve et al., 2013). Validating the student's concerns may help the student to persist and push through adverse feelings and difficulties (Pralle, 2016). Validating may also allow instructors to help students adapt, learn from their experiences, and maintain perspective. Students can benefit from this and other adaptive coping opportunities (Reeve et al., 2013), and caring behaviors when modeled by instructors (Mills et al., 2017).
Actively listening to students might involve showing interest and engaging in student complaints and conversations and listening without passing judgment (Crowe, 2017; Hill, 2014; Kottler & Kottler, 2006). For example, if a student indicates that he or she is feeling inadequate, discouraged, or distressed, instead of drawing immediate conclusions (i.e., the student should not be in the program), instructors can listen objectively to the student's words and acknowledge what was heard. It is important to avoid stereotyping, making assumptions, or comparing the individual to other students or past situations. By refraining from these actions, the instructor may encourage the student to continue talking, allowing the instructor to offer useful information and resources to support the student.
Provide Information with Permission
Providing relevant information that educates and empowers a student to make decisions may help the student experience more confidence and fewer negative emotions. However, Miller and Rollnick (2012) suggest that instructors first establish a relationship with the student, then ask permission to give information. Asking for permission can empower students and reinforce the instructor's confidence in the student's abilities, autonomy, and strengths. Providing information also enables the instructor to play a significant role in helping students who lack appropriate coping strategies. However, instructors should not feel they need to know all the information or be a one-stop resource. It is important to acknowledge those facts of not knowing and be willing to give students information of which the instructor is aware, seek information to provide, and refer students to appropriate institutional or community resources.
“Worry weighs a person down; an encouraging word cheers a person up,” states Proverbs 12:25 (NLT). Instructors can utilize this biblical insight by speaking words of genuine encouragement to students without providing false hope. This is usually accomplished by courageously expressing concerns and providing honest feedback about his or her potential, strengths, and weaknesses.
As an instructor, be prompt and straightforward in communication efforts and avoid minimizing concerns that could lead to student confusion and misunderstanding (Cleary et al., 2012; Mills et al., 2017). Expressing empathy and speaking encouragement may help establish and demonstrate the instructor's trust and care. Appropriate encouragement can also foster hope and self-confidence. If instructors have trouble providing encouragement, they can initiate appropriate referrals and direct students to resources to further aid in the student's management of SANDS symptoms when necessary (Cleary et al., 2012; Pralle, 2016).
Questioning, Clarifying, and Confronting
Instructors do well to assess each situation individually and ask both open- and close-ended questions about the student's perception of his or her situation and needs. In addition, it is important to confirm that your understanding of what is being said is accurate (Crowe, 2017; Hill, 2014; Kottler & Kottler, 2006). This is done by clarifying what the student is saying and how he or she is feeling. Students should be gently challenged or confronted and made aware of inconsistencies in behaviors, beliefs, attitudes, and feelings. Challenging or confronting a student is done only after establishing trust, and then done gently (Crowe, 2017). Demonstrating these concepts of questioning, clarifying, and confronting also teaches appropriate professional and therapeutic communication for future implementation with patients, family members, and other professionals.
Summarizing is a communication skill in which one concisely reviews the key aspects of what has been said and done (Crowe, 2017). The summarized information can be written or shared verbally following face-to-face communications. Summarizing can provide focus and direction and clarify expectations moving forward with a student (Crowe, 2017). For instance, after meeting with an upset student, sending a written communication to the student summarizing the discussion and your expectations moving forward confirms that you were listening and affirms your support. This may also help hold the student accountable and leaves little room for miscommunication or future misunderstandings.
Modeling therapeutic communication shows students the heart of the instructor and the belief the instructor has in the students. Modeling therapeutic communication may not only help students identify, evaluate, and choose solutions that promote healthy and constructive outcomes, but may also foster hope, trust, faith, self-confidence, and empowerment. It is important to acknowledge that instructors may not have all the answers or be able to meet every student's need. However, recognizing possible signs and symptoms associated with SANDS, along with implementing therapeutic communication skills and staying abreast of available resources, will provide the instructor with a toolbox to help promote healthy relationships and retain students in nursing programs. God reminds us to avoid acting like the ostrich that forgets; instead we should act as the one who remembers. Proverbs 15:4 notes, “The soothing tongue is a tree of life, but a perverse tongue crushes the spirit” (NIV). “Join together in following my example, brothers and sisters, and just as you have us as a model, keep your eyes on those who live as we do” Philippians 3:17 (NIV).
Sidebar: Case Study
Cam∗ is a first-semester nursing student who feels defeated after failing two exams. Cam entered the program with a 3.8 GPA and had never failed an exam. Although Cam has three other courses and a clinical in which she is passing, she can't stop thinking about failing and being removed from the program. She loses sleep and sometimes cannot concentrate due to persistent negative thoughts and periods of sadness.
Like many of her peers, Cam has been defined by her academic success. Before nursing school, Cam had an active college life with many friends and extracurricular activities. Since beginning nursing school, Cam has seemingly disconnected. She experiences frequent depressive episodes and no longer socializes. She doesn't eat or sleep well and has not been to the gym in 2 months. Cam feels alone; she calls her mother daily, extremely anxious and stressed about her difficulties. Although her mother is supportive, she is unable to help. Most nights, Cam cries until she falls asleep.
After Cam appeared disheveled and had a panic attack in the lab, Dr. Neese∗ met privately with Cam. She said Cam was not in trouble. Instead, Dr. Neese expressed concern and reported her observations. She paused to allow Cam to reflect on what was said. Dr. Neese asked Cam to share (as much as she was comfortable) about what was going on. Cam reported why she was upset, what she had been experiencing, and what she thinks led to the panic attack. The instructor synopsized Cam's experience.
After wiping the tears and describing her experiences, Cam sat quietly. Dr. Neese stated, “You have shared a lot. Thank you for trusting me with this information [empathy]. I see how difficult and upsetting this experience has been [empathy]. It sounds like the stress and overwhelming nature of all this have taken a toll [active listening, summarizing]. Did I understand you correctly [clarifying, questioning]?
I'd like to connect you with someone who might be able to better support and help you overcome the challenges you said you are experiencing [active listening, providing information]. Are you open to receiving help and taking advantage of the support system available here [questioning]? I have a list of resources I've given to students with similar experiences [providing information]. You are not alone. I believe you can learn the skills you need to navigate this period and be successful [encouragement]. Stress and anxiety can be a normal part of school [providing information]. Learning to manage these issues will allow you to be successful now and in the future [providing information]. You said you want to be a nurse, right? [clarifying, questioning]. Are you willing to take care of yourself so you can take care of others?” [confronting, questioning].
Sometimes students don't feel comfortable speaking with instructors about personal issues. Thus, the student could have declined to meet with the instructor. In that case, the instructor could document the incident and follow departmental procedures for reporting students of concern. The instructor could also send an email to the student expressing concerns and offering resources. As the student agreed to meet, an email could be used to follow up with the student after meeting to document the situation. Some colleges have specific offices including Counseling and the Dean of Students where verbal and written reports can be filed. Concerns can also be reported anonymously if the instructor chooses not to contact the student. Furthermore, instructors don't always feel they have the time or are adequately qualified to explore student concerns. Then it would be important to report concerns to staff in the appropriate office.