Writing Therapeutic Letters in Undergraduate Nursing Education: Promoting Relational Skill Development

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2010 20: 707 originally published online 25 November 2009Qual Health ResLee SmithBattle, Sheila Leander, Nina Westhus, Patricia E. Freed and Dorcas E. McLaughlin

DevelopmentWriting Therapeutic Letters in Undergraduate Nursing Education: Promoting Relational Skill

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Teaching Matters

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Writing Therapeutic Letters in Undergraduate Nursing Education: Promoting Relational Skill Development

Lee SmithBattle,1 Sheila Leander,1 Nina Westhus,1

Patricia E. Freed,1 and Dorcas E. McLaughlin1

Abstract

Although therapeutic letters (TLs) have been included in graduate nursing programs, studies have not examined the impact of TLs on the clinical learning of undergraduate students. This qualitative study was part of a larger project that introduced TLs into already established undergraduate clinical courses. Instructors prepared students for writing TLs by discussing their purpose and by providing a relevant article and examples. In all, 74 students participated in 12 focus group interviews. Interviews were audiotaped, professionally transcribed, and analyzed using qualitative description. Results suggest that TLs cultivate rapport building and the development of students’ relational skills. Although the assignment promoted clinical learning and reflection on helping relationships for the vast majority of students, a few students treated TLs as an instrumental activity. Implications for educating health professionals are described.

Keywords

education, health professional; nursing education; relationships, health care; support; trust; writing

Health professional education focuses heavily on the scientific basis for the prevention and management of dis-ease and the promotion of health. Scientific knowledge, however, must always be melded with clinical judgment and ethical reasoning that is attentive to patients’ con-cerns and understandings of health and illness (Benner & Leonard, 2005; Svenaeus, 2000). As Benner (2001) stated, “Learning to be a good practitioner requires not only technical expertise, but also the ability to form helping relationships and engage in practical, ethical, and clinical reasoning” (p. 60). In undergraduate nursing education, supervised clinical experience provides the opportunity for students to meld scientific reasoning with the needs and concerns of patients in concrete situations (Benner et al., 2007). In this research, we introduced therapeu-tic letter writing (TLW) into already developed clinical courses and examined the impact of the assignment on students’ development of relational skills and their reflec-tion on helping relationships.

Developing Relational Skills in Nursing EducationClinical experiences in undergraduate nursing education provide important opportunities for students to apply what is learned in the classroom, to refine communication skills,

to learn from patients, and to respond to their concerns, priorities, and emotions (Benner et al., 2007; Kotecki, 2002; Orland-Barak & Wilhelem, 2005). The trends toward shortened inpatient lengths of stay and impersonal care settings severely limit the opportunity for students to develop relational skills that permit what Tanner, Benner, Chesla, and Gordon (1993) refer to as knowing the patient as a person. Because many community settings allow stu-dents to work with patients over a full semester, they provide an ideal setting for students to develop their rela-tional skills and to gain a fuller understanding of patients’ needs, concerns, strengths, and challenges.

Because good nurse–patient relationships are crucial to effective and compassionate care, nursing faculty need to be mindful of how students learn to connect with patients and to give the same priority to learning relational skills as is given to performing technical skills (Benner et al., 2007; Ironside, Diekelmann, & Hirschmann, 2005). Learning to connect with patients facilitates students’ understand-ing of patients’ concerns and perspectives (Scheckel &

1Saint Louis University, Saint Louis, Missouri, USA

Corresponding Author:Lee SmithBattle, 3525 Caroline Mall, Saint Louis, MO 63104, USAEmail: [email protected]

at Monash University on December 5, 2014qhr.sagepub.comDownloaded from


708 Qualitative Health Research 20(5)

Ironside, 2006). Understanding the patients’ experience also guides clinical judgment and encourages students to think about clinical situations from multiple perspec-tives, to reflect on their interactions with patients, and to explore the meaning and significance of relationships for achieving positive clinical outcomes.

In a review of the literature from 1984 to 1998 on student nurse–patient relationships, Suikkala and Leino-Kilpi (2001) found that the nature of such relationships is complex, including aspects of caring and aspects of learn-ing. An inductive approach was used to identify unique features of the student–patient relationship. Of the studies reviewed (N = 104), the vast majority sampled students rather than patients. The authors found that relationships with patients were “connected with students’ personal and professional growth, confidence and self-esteem” (p. 48).

Three types of relationships emerged in a subsequent qualitative study of 30 students and 30 patients: mechanis-tic, authoritative, and facilitative (Suikkala & Leino-Kilpi, 2005). Students who exclusively focused on their learn-ing needs treated patients mechanistically. Authoritative relationships were directed by what the students assumed patients needed. Facilitative relationships were more reciprocal and addressed the learning needs of students and the care needs and preferences of patients. In a more recent study, differences were found in the way students and patients evaluated their relationships (Suikkala, Leino-Kilpi, & Katajisto, 2008). Students were more likely to evaluate their relationships with patients as authoritative and facilitative, although patients viewed the relationships as authoritative or mechanistic at least often as facilitative. Little is known, however, about educational strategies that promote the development of facilitative relationships and students’ reflection on the helping relationship.

Use of TLs in Practice and EducationTLs, composed by the clinician and mailed to the patient or family between clinical encounters, have been used by nurses and therapists in their professional practice for many years (Moules, 2002; Rombach, 2003; White & Epston, 1990). TLs differ from social and administrative letters in intent, content, and effect (Pyle, 2006). They are a vehicle for supporting individual and family strengths, for building trust, and for reinforcing ideas discussed in previous clinical encounters (Marshall & Harper-Jacques, 2008; Moules, 2002). Although empirical data on the therapeutic value of TLs are limited, studies suggest that TLs have a powerful impact on the people who receive them, perhaps in part because they can be read repeatedly (Moules, 2002; Pyle, 2006; Rombach, 2003). Moules (2002) reported that writing TLs with supervision allowed graduate-level nursing students to strengthen the nurse–patient relationship and to validate patients’ suffering,

their courage in coping with illness or life transitions, and individual and family strengths.

Despite the importance for nurses to learn relational skills and develop patient-centered care, there is limited empirical research on this topic in undergraduate nursing education (Ironside et al., 2005; Suikkala & Leino-Kilpi, 2001). To our knowledge, TLs have not been used with undergraduate students, and research on the impact of TLs is rare. In this article, we report on the results of a study that was part of a larger project that introduced TLs into undergraduate clinical courses. The aim of the study was twofold: The primary goal was to examine nursing stu-dents’ perspectives on the impact of writing TLs on their clinical learning and development of relational skills. A second goal was to describe patients’ views on receiving a TL from nursing students. This article presents students’ perspectives.

The TL Writing AssignmentAfter a small pilot project by the first author demonstrated the feasibility of including TLs in an undergraduate clini-cal course, faculty members introduced the TL assignment into psych-mental health nursing (PMHN) and public health nursing (PHN) clinical courses in a school of nurs-ing in a private, Jesuit university located in a midwestern state in the United States. In 2008, 91 students graduated with a baccalaureate degree in nursing from the traditional 4-year undergraduate program and 65 students completed the accelerated option designed for students with previous degrees. In both programs, clinical courses involve a total of 84 hours over a full semester and are typically offered in the second semester of the junior year or in the fall of the senior year. Accelerated-option students enroll in the courses in the fall or spring semesters of the 11-month program and are also considered junior- or senior-level students.

Students enrolled in either clinical course are assigned to care for and visit one or two individuals or families in the patients’ homes or community agencies over the full semester. Patients assigned to students are often socially isolated and disadvantaged and include adults with chronic mental illness, elderly residents in public housing, disabled adults in a residential care facility, families attending neighborhood clinics, and women enrolled in programs for domestic violence. Clinical instructors supervise a maxi-mum of eight students in a clinical group and meet with students in pre- and postconferences to help them plan, review, and reflect on their clinical experiences.

During the orientation to the clinical course, students learned of the required assignments, including care plans and clinical journals. Clinical journals required students to reflect on practice and to apply theoretical concepts or research findings to their clinical experience. Students had



SmithBattle et al. 709

the option of writing two TLs to their assigned patient in lieu of writing two clinical journals. To prepare students for writing TLs, we discussed their purpose and provided a packet that included examples and a relevant article. Instructors made it clear that the content of a TL would be unique to each patient’s situation; examples of letters were provided to illustrate the tone and content of letters. In reviewing students’ letters prior to mailing, instructors focused on developing each student’s capacity to listen to the autobiographical; to deepen student understanding of the person’s concerns, strengths, and difficulties; to strengthen therapeutic relationships; to clarify practical or ethical issues; to correct misunderstandings of clinical situations or the helping relationship; and to prepare stu-dents and patients for termination. TLs were not graded, but students were expected to revise their TLs based on faculty feedback. In most cases, students sent a TL at the midpoint of the clinical course and at termination. Occa-sionally, students sent a TL if they missed a week of clinical group or if a patient was not home for a scheduled visit.

Study DesignThe study was approved by the university’s human research committee. Students were informed of the study by a flyer placed in their mailbox. The flyer stated that student participation was voluntary and would not affect their grade or academic progress. Consent was implied by students who showed up for the interview. Of the 74 participants, 61 students were enrolled in the PMHN course and 13 students were enrolled in the PHN course. Twelve focus groups were conducted at the end of the fall 2006 or spring 2007 semesters. Focus groups were chosen because they are considered a useful tool for gathering qualitative data when group participants have experienced a similar situ-ation (Stewart, Shamdasania, & Rooks, 2007). Focus groups can also be more cost-effective than individual interviews, and they allow participants to react to and build on the contributions of other group members (Morgan, 1988; Stewart et al., 2007). Although other researchers have described alternate methods for fixing focus group data, the focus group sessions in our study were audiotaped (Scott et al., 2009).

Students participated in one interview with their clini-cal group; they were therefore familiar with the clinical site and the patients assigned to their student peers. Focus groups ranged from three to eight students per clinical group, lasted a maximum of 90 minutes, and were con-ducted by one of the research team members within a week after students had terminated with their patients. A semi-structured interview guide was used to facilitate students’ description of the process of writing TLs and the impact of letter writing on their clinical learning and develop-ment of helping relationships. The interview began with

the following broad prompt: “Tell me about the thera-peutic letters you wrote for your client.” Other questions included the following: “What did you learn, if any-thing, from writing TLs to your client?” “Did your client acknowledge receiving the letter?” “What are your thoughts about writing TLs instead of the assignment it replaced?” “Do you have suggestions for faculty in continuing the project?” Probes helped students to elaborate on their thoughts, to respond to each other’s comments, and to share differences as well as similarities in responding to the assignment. Interviews were tape-recorded, profes-sionally transcribed, and reviewed for accuracy by the interviewer. Data also included copies of the 140 TLs that were written by students. TLs were deidentified before analysis.

Data for this study consisted of 12 transcripts and 140 TLs. Data were analyzed using qualitative descrip-tion (Sandelowski, 2000). This approach is the “least encumbered by preexisting theoretical and philosophi-cal commitments” (Sandelowski, 2000, p. 337) and was therefore well suited to our goal of allowing students’ views on the assignment to instruct us, to discover issues we had not anticipated, and to describe patterns and variations in students’ experiences. In the first stage of analysis, the research team independently read all 12 interview transcripts to identify potential codes or descriptive labels. Codes and decisions for applying them were discussed during team meetings until consensus was reached. Codes were then applied to the text using a qualitative computer software program, to ease retrieval of data and writing. As team members reread interview transcripts to apply the codes, broader themes were identified and discussed. TLs were read by two mem-bers of the team and validated students’ comments about the content of their letters. No additional codes were identified.

FindingsWe present three broad themes that address students’ perspectives on the assignment: the process and content of letter writing, the impact of the assignment on clini-cal learning, and the perceived benefits for patients of receiving a letter. We also discovered that a few stu-dents approached the assignment as an instrumental activity. We refer to these students as disengaged and describe how their comments differed from the majority of participating students.

The Process and Content of Letter WritingMany students described their initial reaction to the TL assignment as “intimidating” and “scary.” Although the ori-entation materials were considered “helpful” in providing




broad guidelines, students were anxious and uncertain about what to include in their first letter and how it might be received by the patient. The anxiety of some students was somewhat tempered when classmates’ letters were warmly received by their patients. Writing the second letter was deemed less intimidating than the first letter but introduced the challenge of terminating with patients.

In addition to asking students about the process of writ-ing TLs, we asked them to describe what they included in their letters. Students identified patients’ strengths, achievements, emotions, and challenges in TLs. They often reviewed what they had learned from patients about their daily routines, preferences, and what mattered to them. The TLs provided an opportunity to validate these aspects of patients’ lives and to reinforce their goals, achieve-ments, and new health care practices. Termination letters summarized what had been accomplished over the semes-ter and what the student had learned from the patient. The following statements illustrate students’ intentions in writing TLs to patients:

My particular client has a huge amount of issues going along with her postpartum period and so I was able to reinforce a lot of the teaching and remind her . . . of the things that she’s doing that are good and that people are out there rooting for her.

[My letters] were written according to what phase we were in. So for the first letter, we were moving from the orientation phase to the working phase and so the letter was based on what we were doing at that time. The last letter was a review of what we had worked on and encouragement to continue what we’ve been working on.

[My client] had been through some hardships and abusive relationships so I wanted to make sure that I gave her some positive encouragement and how I’ve seen her progress in her nutrition and social interaction. . . . You don’t want it too lengthy but make her aware that I appreciated the time that she spent with me and I have seen growth in her.

As the last comment suggests, termination letters acknowl-edged that patients contributed to student learning. One student said, “I think that’s another important thing—to let your client know that they actually do something for you. It’s not just [that] you’re there for them.”

We provide two examples of student TLs. Appendix A presents a first letter written by a PHN student to a preg-nant teenager. A termination letter written by a PMHN student to a patient in a rehabilitation setting is found in Appendix B.

The Impact of TLs on Clinical Learning

We asked students to describe what they learned from writing TLs to patients. Their comments highlighted their inexperience and struggles in developing relational skills. Although students had previously taken a required commu-nication course, theory learned in the classroom needed to be fleshed out with real patients. Students described a delicate line in developing professional caregiving rela-tionships that were neither “too formal” nor “too casual,” neither “too close” nor “too distant.” Students chose their words carefully so the letter would not be misconstrued by patients and “fine-tuned” the letter so that it would be meaningful for their patient. Writing the first letter often involved significant amounts of time as students reviewed their interactions with the patient. Further editing some-times occurred based on the instructor’s review of the letter, which for one student provided a safeguard for her inexperience: “I know there was a lot I wanted to say but with a limited amount of training, I was still unsure what was appropriate, so I wanted my letters to be reviewed.” The following comments revealed how the assignment focused students’ attention on learning a therapeutic rela-tional stance:

I appreciated practicing dancing that line between the personal and therapeutic. . . . My first draft took like 2.5 hours because I’d write something and then I’d look at it and then I’d try to figure out if that was appropriate. So it gave me the time to try and dance that line a little better.

I think [the hardest part of writing a TL] was putting the professional aspect into the letter. That was always what was on my mind. Okay, is this sentence that I just wrote therapeutic or could it be more ther-apeutic or is it just more small talk? I think that was the hardest thing.

The clinical experience in general, and writing letters in particular, encouraged relational skills and knowing the patient as a person (see Tanner et al., 1993). One student said,

Overall in this clinical experience we’re trying to practice our skills as nurses to open up to people . . . and I think the letters definitely enhanced my awareness of what I was trying to accomplish and what the client was trying to accomplish and kind of combine it.

Getting to know the patient as a person required that students gain skills in developing patients’ trust and their




own openness to patients’ perspectives and experi-ences. Openness required overcoming social embarrass-ment, gaining confidence in asking sensitive questions, broaching intimate subjects, and becoming attuned to the patient’s perspective. Here is what students volun-teered when asked what they would advise future students in writing TLs:

My advice would be get in there and ask personal questions. Try your best to word it in a way that’s friendly and that you’re a trusting person, you’re there to talk about that kind of thing. Just go for it.

I’d say listen to what matters, listen to what they say and what matters and is important in their life. It might not be important in your life whether or not you play bingo, but that might be the only thing that keeps them going every day and then to bring it up in the letter, bring up the things that matter to them, watch their facial expressions and what they get excited about and add those to your letter.

Gaining an understanding of patients’ perspectives enabled students to cultivate patients’ strengths and accom-plishments. Although letters fostered this skill, identify-ing patients’ strengths often proved difficult for students, perhaps because, as the following student suggests, nurs-ing education and research give far more attention to patients’ deficits and problems than to their strengths and accomplishments: “The letters help us focus on what their greatest strengths are. I think a lot of times we talk about criteria of what makes them sick and this is like a reversal of that—like what makes them strong.” A fellow student agreed: “At first I really didn’t care for the TLs but it made me think of [their strengths] that I probably wouldn’t have thought of if we had just had the clinical journals.” Some students learned that validating patient strengths in a letter promoted rapport and provided the reciprocity and direction for working with patients over time:

The next time I went to visit her after I wrote the letter it kind of made me focus in on different things she does that are positive.

It gave us a springboard. I talked about positive things in the letter and then when she read it, that made it easier for us to talk about it more in depth and go from there.

I think by focusing on the positive, it just really made them trust you more, they were able to open up a little easier. I think it was a really good exer-cise just for us to learn how to communicate and

get people to trust us and to encourage people to talk to us in a more in-depth kind of way.

Some students believed that the first TL contributed to a “turning point” that moved the student–patient relation-ship from the introductory to the working phase, as patients and students became more “invested” and engaged:

I think from that point on, our relationship took a different turn, it added more comfort, it provided more ease for her to talk to me. . . . The next week she was more comfortable in talking to me more because I think the letter showed her that I had another level of concern for her and I was interested in how she was doing that week.

At least for me, the letter made my client more important to me . . . because it reminded me of the things that she was going through. . . . I don’t know, it just made me think about her more as a person and appreciate her.

As the above comments suggest, TLW prompted students to reflect more deeply on the relationship with their client and to review, as one student said, “what we’re working towards, what we’ve accomplished. It’s nice for myself as a student and for our relationship to have that.” Students learned the important lesson that clinical goals need to be patient centered and collaboratively identified:

I think putting it into words also reinforces whatever you’re trying to achieve with the relationship. . . . I had asked him what his goals were. I’ve got these objectives that I’d like him to meet but are his goals going to be the same? One of my goals was to have him reduce his smoking, and we talked about it. He decided he was fine where he was and so I thought if I was going to push my objectives on him, it would not have helped our relationship.

I was asking her what she would like to do with our time together and if there was anything that she spe-cifically wanted to work on. . . . For some reason, her getting that in writing just sort of jump-started it. And then every week, she would talk about how she was doing with that goal. I don’t know what it was about it that triggered that . . . maybe just the writing made it more concrete for her to be able to look at it and say okay, this is what I’m going to be able to do. . . . I definitely saw a change in her reaction.

One student asked her patient in a letter to develop a list of goals for them to work on over their remaining visits.




She was surprised to find that her patient presented such a list at the next visit. She recalled the patient’s remarks:

“I did what you said in the letter, I’ve got a list of things that I want to work on, let me show you my list.” She really took it seriously . . . and used it as a stepping stone for our work together.

The final letter provided another opportunity for stu-dents to reflect on the significance of relationships and their emotional ambivalence in terminating with patients:

I thought the second [letter] one was more difficult because I found myself wanting to say something about seeing them again in the future. . . . It seemed kind of abrupt, because there’s no looking forward.

The one disadvantage I can identify is feeling more emotionally involved with the client as a result of writing the letter and feeling guilty for not being able to continue the relationship. I think the letter makes my client view me as a more stable presence in her life and she may not be able to rely on contin-ued relationships like that in the future, so feeling more invested in the client.

Some students considered letters to be more “mean-ingful” and “less academic” than the clinical journal assignment. Here is how one group of students compared the two assignments:

S1: A journal you just kind of reviewed what you did in a clinical day, which is nice, because you can see what objectives you met but the letter was more. . .

S2: Individualized so you can really bring out things of the people that you are seeing.

S3: And you’re also communicating with your patient as opposed to the journal where you’re not. There’s no communication. You don’t get any feedback from them as far as how you’re doing or how they’re doing.

S4: The journals just seemed more academic. We had to apply public health nursing theories to what we did.

PMH students similarly applied scientific knowledge to their patients in clinical journals. The following remark suggests that students recognized and appreciated assign-ments which fostered different kinds of knowledge and skill:

I was not going [to describe the disease process] in my letter. The focus was just different, so both

[assignments] promoted learning, it was just a dif-ferent kind.

Perceived Benefits for Patients of Receiving a LetterIn many clinical settings, students might not receive direct feedback from patients. Students were therefore surprised when patients responded enthusiastically to their letters. As one student reported, “My patient pulled me aside. She’s really never done that before and she thanked me and I gave her a hug and told her thank you for letting me visit with her over the semester.” Another student shared a similar experience:

I got a lot of positive feedback from my letter. My client liked it; his caseworker liked it, and today I was talking to my client and somebody else who I’d never met walked by me and said, “Hey great letter.” . . . So it made me feel kind of good.

A PHN student was surprised when family members of her client arrived at the next scheduled visit to meet the author of the letter. This positive feedback validated the power of letters to strengthen the nurse–client relationship and encouraged students to reflect on the importance of relationships in fostering trust, openness, and disclosure:

Prior to sending my letter, my client was very with-drawn and difficult to talk to. I tried to compliment her or express interest in her life but she seemed very skeptical of the desire I had to show her attention. She actually read the letter in front of me and while she read it, she kind of hid the text, and she read it very slowly. And at the end she just looked down and the only thing she said was, “I like it.” After that, she was much more open with me and was more appreciative of my relationship with her. She said thank you often and she told me that she would miss me. I just think the experience was positive for her.

She really enjoyed getting the letter. It was the first thing she brought up the next Friday and she told me that she showed it to all of her friends. She was really surprised that I would say those things, she really liked it.

After receiving a letter, we went into real depth about her life. It was almost like okay, you’re not going to judge me. You’re going to think good things about me no matter what I tell you, so here it is.

My person was paranoid schizophrenic and had a lot of issues like remembering things and everything




was kind of transposed but she got the gist of the letter. She knew it was positive. She was kind of shy about it but she was all smiles and she carried it in a bag that she carried everywhere. She put it in there so I knew she appreciated it.

I had to read mine to my patient because she has eye problems. She hugged me and told me she loved me. So it was a little awkward because I thought to myself, “Well that’s not therapeutic.” . . . She obvi-ously had a pretty good response, but I felt a little awkward.

Not all students received direct feedback about their let-ters, but as the above quotes suggest, students sometimes noted changes in the patient’s receptivity after receiving a letter. Some students received a note from their patient in response. Lack of feedback prompted some students to wonder if patients never received the letter or were unable to read. Although some students had anticipated these issues, for example, by using a larger font, by reading their letter to the patient, or by providing a copy when patients denied receiving a letter by mail, not all students had done so.

That some patients carried TLs with them or placed them on their wall or in their Bible led students to con-sider the potentially lasting impact of letters:

I think that the letter also gave them something to hang on to, something to remember the relation-ship, something to bring them comfort. They can take it out and look at it and know that somebody really cared about them.

Validating patients’ contributions to students’ learning in letters was also perceived as beneficial for patients. As one student stated, “I think she liked the opportunity to feel like she was helping me as well . . . to feel like it was a reciprocal relationship as opposed to me just working with her. She helped me, too.” Others were surprised that “something so little can be so appreciated,” a sentiment that prompted another student to reflect more broadly on nurses’ proximity to patients and the engagement that supports personhood and well-being:

I think I learned that even though I might not be able to see the implications of my actions on other individuals, small acts of kindness can affect people and I think that says something about nursing in general regarding the tasks that we engage in on a daily basis. We may not be able to see how they affect our clients immediately but I think that it does do things for their feelings of self-worth and their emotional and psychological well-being.

Disengaged Students

The tone and content of two focus group interviews dif-fered from the other 10 interviews. These students described TLW as “easy” rather than difficult. They endorsed the assignment not because it enriched their learning or furthered the nurse–patient relationship but because TLs took them less time to complete than clinical journals. These students offered little reflection on the process of writing or editing a letter or setting the right tone. They offered few comments on getting to know their patient or the impact of their interactions on patients. One student described “writing this letter to get the best grade I can” (even though TLs were not graded). A few students in one clinical group seemed to subtly mock the patients assigned to them. When asked if they would consider writ-ing letters in their future nursing practice, they responded with a resounding, “No!” Expediency, getting good grades, and learning technical skills appeared to matter most to these students. The instructors of these clinical groups later identified each group as “difficult.” One instructor related that all but one or two students in her group needed to be “pushed” to engage with their patients each week.

DiscussionThere is a growing appreciation for educational strate-gies that develop students’ understanding of patients’ experiences, concerns, and meanings of health and ill-ness (Lorenz, Steckart, & Rosenfeld, 2004; Rosenbaum, Ferguson, & Herwaldt, 2005; Scheckel & Ironside, 2006). Writing TLs is consistent with this development, and our findings provide beginning evidence that TLs cultivate nursing students’ relational skills and their understanding of patient’s perspectives.

There was a broad consensus among participating students that TLW promoted clinical learning and the development of therapeutic relationships. The assignment contributed to patient-focused habits of care as they listened for patients’ strengths, likes and dislikes, and concerns. Students also noticed that letters promoted comfort and personalized care, validated patients’ difficult experiences, and prepared patients for termination. In some cases, letters honed students’ skills at accommodating patients’ literacy, poor vision, or other issues. These findings are consistent with Moules’s (2002) conclusion that TLW enhanced the clinical learning and understanding of grad-uate family nursing students.

Students are inexperienced in thinking and acting like a nurse; they lack the relational skills and experien-tial knowledge to respond to patients’ clinical trajectories and their concerns, strengths, and personhood. Develop-ing these skills was a central concern for the majority of students as they grappled with developing relationships




that were neither “too formal” nor “too casual,” neither “too close” nor “too distant.” As Kotecki (2002) also discovered, students worried about appropriate profes-sional boundaries and saying (or writing) the right thing. Because the assignment promoted rapport building, stu-dents were prompted to reflect on their relationships with patients and the importance of knowing the patient as a person. Their comments attested to the engagement and openness that are central to knowing the patient as a person and the development of facilitative relationships. The assignment strengthened connections as students negotiated professional boundaries, including issues related to termination.

Other researchers have suggested that nursing stu-dents move from a mechanistic relationship that is task oriented to a more facilitative, patient-centered relation-ship as they gain experience (Suikkala & Leino-Kilpi, 2005). Our data suggest that the assignment supported a facilitative relationship for most but not all students, regardless of students’ prior clinical experience. Stu-dents’ responses did not seem to differ if they were junior- or senior-level students in either the traditional or the accelerated options, and this finding suggests that the length of clinical experience might be less crucial in developing facilitative relationships than other factors, such as the nature of clinical and classroom assignments, clinical sites, patient acuity, and the extent to which the curriculum promotes students’ relational skills and patient-centered care. Patient-centered care is not a new concept in nursing (Mitchell, 2008), but little is known about educational strategies that promote facilitative relation-ships and patient-centered care. TLs promoted facilitative relationships by helping students identify and validate patients’ strengths, concerns, goals, and struggles. From the students’ perspectives, letters also conveyed to patients their important contribution to the formation of nursing students. Because students’ and patients’ views of their relationships might differ (Suikkala et al., 2008), we are examining patients’ perspectives on receiving TLs for the larger project.

The comments of disengaged students offered a strong contrast to the engaged and open stance of the majority of students. These students described mechanistic relation-ships with patients (Suikkala & Leino-Kilpi, 2005) and an instrumental approach to clinical learning that focused on actions rather than interactions (Orland-Barak & Wilhelem, 2005). Students might have dismissed the assignment, and the understanding fostered by TLW, because they had learned that scientific knowledge is rewarded (e.g., via care plans and exams) over the devel-opment of relational skills and that clinical situations are primarily a test of their scientific and technical knowl-edge. These data raise difficult questions about how students become disengaged and the conundrum of how

to engage or reengage students lest they become techni-cally skilled but detached from patients’ plight and suffering (see Benner et al., 2007). This issue is crucial in light of the press for undergraduate faculty to teach to the National Council Licensure Examination and for students to learn enormous amounts of scientific–technical knowledge.

Many years ago, Tanner and colleagues (1993) cau-tioned that knowing the patient is underdeveloped in nursing education, even though it is crucial to clinical judgment. Since then, the proliferation of nursing taxono-mies and the call for evidence-based practice have further legitimated scientific–technical knowledge at the expense of relational skills and experiential knowledge (Benner et al., 2007). Although participants in this study per-ceived relational skills and knowing the patient as less “academic” and more “personal” than scientific–technical skills, they believed that these skills were no less impor-tant to becoming a good nurse. Students appreciated different forms of knowledge and supported diverse edu-cational strategies. Introducing relational skills early in the curriculum and supporting the development of these skills with clinical and classroom experiences might help students to meld scientific–technical reasoning with the relational and ethical, even though the latter skills cannot be formalized in rules and procedures (Benner & Leonard, 2005; Tanner et al., 1993).

Strengths and Limitations of the StudyStudents were junior- or senior-level students enrolled in either a traditional or an accelerated undergraduate nurs-ing program. Although students were diverse, the findings of this study are limited to one nursing school. In addi-tion, the assignment was added to clinical courses that permitted long-term relationships. Other settings, such as neonatal intensive care and long-term care units, might also be appropriate for writing TLs to patients or family members. Further studies are warranted to determine the feasibility of expanding TLs into additional clinical set-tings and their use in educating other health professionals. Future studies would also benefit from interviewing clinical instructors about their strategies in helping stu-dents develop relationships and negotiate professional boundaries. Although the focus groups we conducted generated a lively discussion about the assignment among student peers, some students might have felt pressured by group dynamics to respond negatively (in the groups we described as disengaged) or positively in groups describ-ing the benefits of TLs. More reserved students might also have been reluctant to share their perspectives in a group setting. These limitations of focus groups (Carey & Smith, 1994; Morgan, 1988; Stewart et al., 2007) could be offset in future studies by offering students the option of participating in individual or focus group interviews.




Conclusion

Multiple forces conspire to emphasize scientific–technical knowledge in health care settings at the expense of the nontechnical skills that cannot be formalized into proto-cols and clinical pathways (Benner & Leonard, 2005). Although students might equate what is “academic” with scientific–technical knowledge, the vast majority of stu-dents in this study viewed relational skills as essential to becoming a good nurse. Writing TLs cultivated these skills and promoted student reflection on developing helping relationships. Students also identified benefits for patients who received letters. The comments of disengaged stu-dents validate the need to strengthen relational skills in undergraduate nursing curricula, lest students assume that nursing involves a set of instrumental tasks directed solely by scientific evidence.

Appendix AExample of a First Therapeutic Letter Written by a Public Health Nursing Student to a Pregnant Teenager

DearI wanted to just take a moment and share some thoughts

with you about how well you are progressing through your pregnancy. First of all, I want to thank you for allowing me the opportunity to visit you each week. I know that lately, you have been tired when you get home from school but you always greet me warmly. I can’t thank you enough for that and I truly appreciate you letting me work with you.

I am very impressed with you for many different reasons. You have taken great care of yourself and baby these past months. You are always thinking of many excellent questions to ask which shows you have taken the time to think about many aspects of your preg-nancy. I am proud that you have kept going to school even though it might not be the easiest thing to do and I am so excited that you will be going to your senior prom! That will be a great night for you after your baby is born!

I always look forward to my home visits with you each week. It is so nice to see that you have an amazing support group of family members and your boyfriend. I think that you and your loved ones will make a wonder-ful home for your new baby! You are so close to welcoming your baby into the world and I can’t wait to see what she looks like! I hope that everything goes well these next couple of weeks and I look forward to seeing you again. Take care and know that I am thinking about you while I am gone for semester break.

Appendix BExample of a Final Therapeutic Letter by a Psych-Mental Health Nursing Student to a Patient in a Psychiatric Rehab Setting

DearThis is our last week together and I wanted to take a

moment to say thank you for working with me. It has been extremely helpful in my education and I will carry what I have learned from this experience with me into my future career. I really appreciate your willingness to work with me, your openness about why you are here, and your helpfulness with the activities I asked you to complete. For everything, I want to say thank you!

While our time working together has been short, I do feel like I have seen you grow. You have good insight about what you need to work on and how to make it better. Listening to you in the anger management group shows me that you have good ways to handle your anger, and watching you interact with the other men on the ward proves that you can carry out those strategies. It is obvi-ous that the other men on the ward appreciate your friendship, and enjoy being around you.

I wish you the best of luck in your treatment. I truly hope you are able to move into a group home soon. Your ability to control your anger is what will make this a suc-cess. I know being in the hospital is hard, and at times discouraging but you have an inner strength and deep faith that will help you stay positive. I wish you happiness, joy, and peace in your life.

There are many things you have taught me during our time together. I feel very confident in my abilities to interact with others. I am not nervous or anxious when I enter the ward, and I have you to thank for that. If it weren’t for your support and helpfulness, I would not feel as secure in my abilities as I do now. I always looked forward to seeing you greet me at the door and knew that our time would be productive and fun. Plus I got a chance to learn some new card games. Playing games and talking might not seem that important, but to me it was very help-ful. I learned many things, but most of all I learned not to be judgmental. I hope you enjoyed our time together as much as I did. Thank you for letting me work with you. Best of luck in your future.

Acknowledgments

We thank Sithokozile Maposa for her research assistance and the nursing students who participated in the study.

Declaration of Conflicting Interests

The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.




Funding

The authors disclosed receipt of the following financial sup-port for the research and/or authorship of this article: Funding for this study was provided by the Voices Project of Saint Louis University.

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Bios

Lee SmithBattle, RN, DNSc, is a professor at the School of Nursing, Saint Louis University, in Saint Louis, Missouri, USA.

Sheila Leander, RN, MSN, is an assistant professor at the School of Nursing, Saint Louis University, in Saint Louis, Missouri, USA.

Nina Westhus, RN, PhD, is an associate professor at the School of Nursing, Saint Louis University, in Saint Louis, Missouri, USA

Patricia E. Freed, RN, MSN, EdD, CNE, is an associate pro-fessor at the School of Nursing, Saint Louis University, in Saint Louis, Missouri, USA.

Dorcas E. McLaughlin, RN, PhD, PMHCNS, BC, is an associ-ate professor at the School of Nursing, Saint Louis University, and an advanced practice nurse in private practice in Saint Louis, Missouri, USA.



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Writing Therapeutic Letters in Undergraduate Nursing Education: Promoting Relational Skill Development