INTRODUCTION
As of 2025, Korea has become a “ super-aged” society, with individuals aged 65 years or older comprising 20.3% of its total population [1]. Additionally, the prevalence of dementia, a geriatric disease, has been increasing dramatically [2]. In 2022, the prevalence of dementia among those aged 65 years or older was approximately 10.2% and is expected to rise to approximately 16.6% by 2050, with the figure reaching approximately 3.15 million [3]. With this geo-metric increase in numbers, the social demand for dementia nursing care is also considerably elevated [4].
Patients with dementia experience various symptoms, such as impairments in cognitive functions and a decline in abilities to perform daily activities, and can exhibit complex BPSD (behavioral and psychological symptoms of dementia). Furthermore, these patients are usually more dependent on caregivers compared to those with other diseases, and require nursing and care for a long term [5,6]. Thus, it is vital for nurses, as professional caregivers, to establish relationships with these patients based not only on knowledge of dementia but also on psychological and emotional understanding [7,8]. Likewise, nursing students as future healthcare professionals must be prepared for nursing competency specific to patients with dementia [8].
The interaction between the nurse and patient is an important theme in clinical settings [9] and an essential element contributing to the patient's recovery and health [10]. A therapeutic relationship is one that focuses on the needs, experiences, emotions, and thoughts of the patient. Thus, nurses require communication skills and an understanding of human behavior to effectively interact with their patients [10]. That is, it is desirable for nurses, as professional caregivers, to establish therapeutic relationships based on their knowledge and skills and geared towards finding solutions to patients’ problems [11,12]. Nurses can form therapeutic relationships with patients with dementia through actions such as active listening, empathy, and providing an appropriate environment. Indeed, a well-established therapeutic relationship can delay the progression of dementia [13].
However, older adults with dementia face certain challenges related to forming social or therapeutic relationships with their nursing staff, owing to impaired cognitive functions and difficulties in communicating with others [14]. Prior studies have reported that although nurses often feel empathy for older patients with dementia, they focus on providing physical care and safety management, thereby restricting their relationship to be task-oriented and objective [15].
Nursing students can also experience therapeutic relationships and communication with various patients through clinical practice [16]. However, evidence indicates that nursing students tend to show more negative perceptions and attitudes toward older patients with dementia than toward patients with other conditions [17]. Further, they often feel scared and intimidated, and experience a decline in self-confidence when caring for these patients, despite having an academic knowledge of dementia [4].
In this era of a super-aged society, healthcare professionals are expected to maintain therapeutic relationships with patients with dementia and contribute to the establishment of supportive environments for dementia care. Accordingly, this aspect should be incorporated into the education of nursing students as future healthcare providers [18]. Therefore, it is necessary to explore the experiences of nursing students in forming therapeutic relationships with dementia patients in clinical practice and practical training, evaluate their readiness to care for dementia patients, and identify their shortcomings. It is also necessary to identify their areas for improvement and implement follow-up actions within the nursing curriculum.
Most previous studies on providing care to such patients have examined nursing students’ perceptions [17] or the educational effects of a dementia care program [19]. A few qualitative studies have been conducted on their experiences caring for patients exhibiting BPSD [4,20], and their volunteer experiences with older adults with dementia [18,21]. However, these studies have been insufficient in capturing the meaning of nursing students’ experiences in forming therapeutic relationships with older patients with dementia who suffer from cognitive decline and exhibit various behavioral and psychological symptoms.
To overcome these limitations, phenomenological research methods can be used; these aim to uncover the universal essence and meaning of experiences as lived by individuals [22]. In particular, Colaizzi's descriptive phenomenological approach allows for the extraction and synthesis of common themes from participants’ narratives, thereby providing a deep and holistic understanding of their experiences [22]. This approach is therefore well-suited for the present study, which seeks to explore how nursing students experience and interpret their relationships with older patients with dementia.
This study involved a comprehensive exploration of nursing students’ experiences of forming a therapeutic relationship with older patients with dementia during clinical practice at long-term care hospitals and aimed to provide foundational data for developing programs to help nursing students enhance their therapeutic communication skills and dementia nursing competencies.
METHODS
1. Design
Colaizzi's [22] phenomenological approach was employed for an in-depth description of nursing students’ experiences of forming therapeutic relationships with older patients with dementia.
2. Participants and Setting
Nursing students from two universities located in B Metropolitan City were recruited. The inclusion criteria were as follows: (a) nursing students who completed a gerontological nursing clinical practicum; (b) students who had experience with older patients with dementia for at least five days (≥45 hours) at long-term care hospitals. Ten nursing students participated (eight females and two males; mean age: 23.3 years; all seniors grade). Seven had personal experience with older adults who suffered from dementia in the past (Table 1).
Table 1.
General Characteristics of the Participants
| No | Gender | Age (year) | Year in program | Practicum site† | Personal dementia experience |
|---|---|---|---|---|---|
| 1 | Man | 25 | Senior | A | Yes |
| 2 | Woman | 22 | Senior | A | Yes |
| 3 | Man | 24 | Senior | A | Yes |
| 4 | Woman | 27 | Senior | A | No |
| 5 | Woman | 22 | Senior | B | Yes |
| 6 | Woman | 22 | Senior | A | Yes |
| 7 | Woman | 22 | Senior | A | Yes |
| 8 | Woman | 24 | Senior | A | No |
| 9 | Woman | 23 | Senior | B | Yes |
| 10 | Woman | 22 | Senior | B | No |
3. Data Collection and Procedure
Data were collected using in-depth interviews for each participant from September 1 to October 1, 2024. The researchers explained the study's purpose and procedures to the deans of the participants’ nursing colleges and requested their cooperation for data collection. Next, a participant recruitment notice was posted in the online group chat from August 19 to 30, 2024 for senior students who had completed the geriatric-nursing clinical practicum. A total of 12 individuals expressed interest in participating after reviewing the recruitment notice. However, two with-drew their participation by phone prior to the interviews.
Interview appointments were made at the participants’ convenience, and interviews, lasting approximately 50∼70 minutes, were conducted in an empty seminar room. To ensure consistency in data collection, a single experienced qualitative researcher conducted all the interviews. For three participants who were unfamiliar with the interviewer, each session began with casual conversation in order to build sufficient rapport before addressing the research questions. After the first round, additional questions were deemed necessary for two of the participants, as the interpretation of their statements during the data analysis process was unclear. Therefore, a follow-up interview lasting approximately 15 minutes was conducted via mobile phone with each of them.
The interview started with the question: “ Could you share your experience in your forming a therapeutic relationship with older patients with dementia while participating in clinical practice at a long-term care hospital?”. Additional questions were asked to obtain data on various concepts and themes: (a) What were your thoughts about meeting older patients with dementia before you began clinical practice? (b) What were some of the most notable moments when you were building a relationship with the patient? (c) What were the challenges you faced in forming a relationship with the patient? (d) What efforts did you make for building a therapeutic relationship with the patient? (e) What feelings/emotions did you have at the end of the clinical practice?
To ensure accuracy of data collection and analysis, interviews were recorded with the participants’ consent. Interviewers took notes on participants’ non-verbal expressions, including their facial expressions, body gestures, and reactions during the interviews. The recorded files were first transcribed using CLOVA Note, an AI-based recording management service. Data collection and analysis were performed in a circular manner, and participants’ statements were consistently compared and analyzed. While interviewing, when no new ideas emerged from participants’ statements on their therapeutic relationship with older patients with dementia, data saturation was reached, and the researchers ceased data collection.
4. Data Analysis
The interview data were analyzed by two researchers using the analysis framework proposed by Colaizzi [22]. First, raw transcribed data were read to derive a holistic understanding of the participants’ experiences. Second, from transcripts, each researcher derived significant statements directly related to the experience of building a therapeutic relationship with these patients and deleted over-lapping statements. Third, derived sentences and phrases were described in generalized forms and repeatedly reviewed to avoid misunderstandings or deviations from the participants’ intended meaning. Fourth, similar and repeatedly stated constructed meanings were grouped into themes, and then into theme clusters, and organized into categories based on the four phases of the therapeutic nurse-patient relationship [11]. Fifth, researchers repeatedly compared the transcripts to ensure consistency between the inductively interpreted data and the participants’ expressed experiences, and revised the derived theme clusters accordingly. Sixth, all outputs were collected and comprehensively synthesized to produce an exhaustive description. Seventh, three of the participants reviewed the findings and offered feedback for validity.
5. Researcher Preparation
Researchers have regularly participated in relevant conferences to improve competencies for qualitative research and published several qualitative research articles applying phenomenological methods in various academic journals. One researcher teaches geriatric nursing and lectures at a graduate school on qualitative research methodology. The other researcher teaches psychiatric nursing, particularly the aspects of a therapeutic relationship and communication skills, at a university. Their competencies played a vital role in deriving the research findings from the interview data.
6. Rigor
Study quality was ensured using the evaluative criteria for qualitative research proposed by Lincoln and Guba [23]. For credibility, they transcribed the recorded data verbatim within 3 days. Moreover, three of the participants reviewed the analysis results to confirm whether they accurately conveyed their intentions. For transfer-ability, the researchers asked two non-participating nursing students to externally validate the derived concepts and statements. For dependability, we thoroughly followed Colaizzi's [22] method and went through the member check for the derived meanings. To ensure confirm-ability, the three criteria mentioned above were rigorously followed, and the derived themes were validated by a nursing professor with experience in conducting qualitative research.
To ensure neutrality, the researchers minimized bias during interviews by listening openly to participants’ statements. In the analysis phase, assumptions were brack-eted to prevent personal perspectives from influencing the findings.
7. Ethical Considerations
This study was approved by the institutional board of Catholic University of Pusan (Approval No. CUPIRB-2024-015). Before data collection, researchers provided participants with information on the study's purpose, interview procedures, recording and transcribing, and storage of research data. Before the in-depth interviews, the participants were informed about the privacy protection terms, guarantee of anonymity, and cessation and withdrawal from the study. Pre interview, participants provided informed consent and, post interview, received a small reward of appreciation.
RESULTS
A total of 235 significant statements were extracted from the raw data. These were organized into 54 themes and 17 theme clusters based on similarities and repetitions. The theme clusters were ultimately grouped into five categories (Table 2).
Table 2.
Nursing Students' Experiences of Forming a Therapeutic Relationship with Older Patients with Dementia
Category 1. Preparing for Scheduled Encounters with Unfamiliar People
1) Evoking images of older patients with dementia
Before beginning clinical practice at long-term care hospitals, most participants had assumed that these patients had difficulties in having everyday conversations, were gradually losing their memory, and consistently needed assistance and support from their family members or others. Additionally, they also had strong negative perceptions-specifically, that it was unlikely for these patients to recover from the disease.
2) Various emotions before the first encounter
Before beginning clinical practice, participants expressed positive feelings-curiosity regarding meeting new patients, and expectations for checking and applying what they had learned at school. Simultaneously, they stated having negative feelings (vague fears) regarding these patients and a sense of burden in relation to participating in clinical practice. Such negative emotions were consistently reported by participants who had not previously encountered older adults with dementia.
Category 2. Embarking Upon the Exploration to Build a Relationship
1) Making attempts to approach the patient
On the first day of clinical practice, participants attempted to get closer to the patients by observing their environment, introducing themselves, and inquiring about them.
2) Failing to communicate with patients as intended
Most of the participants reported that although they tried to communicate, the patients usually did not react, or gave unrelated answers, while helplessly lying on their beds. In some cases, they had difficulties in communicating with the patients as they did not understand what the patients were saying.
Category 3. Making Various Efforts to Maintain a Therapeutic Relationship
1) Providing daily care services
Participants provided basic nursing services, such as measuring vital signs, assisting patients while eating meals or moving, or supporting patients to prevent accidents, including falling off the bed.
2) Making efforts to identify the patients’ needs
Although participants reported having more difficulties in communicating with patients with dementia compared to those with other diseases, they tried to understand the patients’ preferences by considering various factors, such as their personality, past jobs, family relations, and back-ground. Moreover, when they could not understand what patients said, they asked the patient to repeat it and tried to better understand their needs.
On the first day, a patient yelled and was unusually aggressive… (omitted)… Later, I found out he hated rainy days. He was usually calm, but his mood changed whenever he saw rain outside the window. It rained four of the five days I was there. After realizing this, I kept him from looking outside and talked with him about why he disliked the rain. (Participant 9)
3) Approaching patients with a respectful attitude
Participants maintained a respectful attitude even when the patients shared out-of-context stories, carefully listening to them and waiting for them to finish. They also used non-verbal communication skills during conversations, such as nodding, looking into patients’ eyes, and holding their hands.
4) Implementing various cognitive stimulation strategies
Participants repeatedly asked disoriented patients simple questions regarding their name, the weather, the season, or talked about things that the patients were interested in. They also tried to maintain and improve the patients’ cognition using various methods, such as controlling the lighting and noise levels.
5) Receiving help from others
While forming a relationship with these patients, participants received some guidance from care workers who had provided care to them for a long time, or sometimes asked experienced nurses for advice. They also shared and discussed examples of communicating with these patients at a conference.
Category 4. Facing Obstacles in Maintaining a Relationship
1) Unchanging patient conditions despite continuous efforts
Participants faced challenges when, despite trying to persuade patients to participate in cognitive rehabilitation programs, they refused or showed a passive attitude toward participation. Moreover, participants experienced difficulties when patients consistently showed negative reactions even after they used therapeutic communication skills, or when they could not see any improvements in the health of patients, who spent most of their time lying in bed.
2) Persistent BPSD
Participants identified BPSD as one of the most significant obstacles to maintaining therapeutic relationships with patients during clinical practice. They reported that although they attempted to respond to patients’ BPSD based on what they had learned in theoretical classes, it was challenging because the patients’ behaviors persisted despite their efforts.
The patient got very upset, saying he couldn’ t find his dentures… He said a guy stole it, but there was no such person. As I had learned (in class), I tried to distract the patient by asking who had bought him the dentures, but there was a difference between theory and reality. It did not work well.(Participant 8)
3) Difficulty regulating personal emotions
Participants reported factors that posed significant challenges in sustaining therapeutic relationships with the patients. These included the death of the patient, feelings of sympathy for those gradually losing their memories, and anger toward families who abandoned their relatives in care facilities.
Category 5. Witnessing Myself Growing in a Therapeutic Relationship
1) Feeling a sense of accomplishment
Participants experienced feeling a sense of accomplishment when patients appeared more at ease or showed progress, attributing it to the attentive care they provided through communication and sincere attention. They also stated that they were proud of themselves when nurses praised them for their behaviors or attitudes.
During a conversation, the patient said it was hard to reach out his hands and grab a spoon as his muscles were weak. So, I massaged his hands and taught him how he can do exercises for the hand on the bed … On the last day, when I visited him to say goodbye, I saw him doing those exercises by himself… I felt so great. (Participant 7)
2) Engaging in emotional sharing
On the last day of clinical practice, participants ended their therapeutic relationship by sharing their feelings. They expressed gratitude for the time spent together during clinical practice, as well as the sorrow of parting.
3) Gaining broadened perspectives
At the end of clinical practice, when their therapeutic relationship with the patients ended, some participants expressed sympathy for patients’ family members who took them to the hospital instead of providing care themselves. Others questioned themselves on what a dignified life meant. Additionally, they realized their need for more professional knowledge and skills to care for these patients. Concurrently, they surmised the importance of providing integrated care to these patients not only by nurses, but also by diverse types of professionals.
DISCUSSION
After examining the nursing students’ experience of forming a therapeutic relationship with older patients with dementia, the structure of the participants’ experiences was outlined based on five categories. Its first stage “ Preparing for scheduled encounters with unfamiliar people” corresponds to the pre-interaction phase, wherein participants recognized their own thoughts before meeting the patients. As nursing students, they experienced anxiety regarding new experiences, uncertainties regarding their ability to provide help, and lack of self-confidence [12].
In fact, most of the participants mentioned negative pre-conceptions about these patients before meeting them at the long-term care hospitals during clinical practice. They reported that while they felt somewhat interested and excited to meet new people, they also felt negative emotions, including worry and anxiety. Such biases have been consistently reported in previous studies conducted with nursing students [4,18,20]. Previous findings report that nursing students become less biased after completing the geriatric nursing clinical practice [24], and participating in volunteering work [21]. These results also confirm that among this study's nursing students, those with previous experience of personally meeting or caring for these patients showed a relatively lower level of prejudice against them. Accordingly, first-or second-year nursing college students should be provided with opportunities for adequate direct or indirect experiences with these patients, before clinical practice, by participating in volunteering activities or extracurricular programs, as this would contribute to lowering their levels of prejudice.
In this study, participants prepared in their own ways before meeting older patients with dementia, a finding that has not been previously reported in studies involving nursing students. Based on participants’ experiences in the pre-interaction phase identified in the first category, nursing professors should present guidelines on the details of clinical practice, what students should prepare for, as well as answer students’ questions to help relieve their anxiety about interacting with patients.
The second phase “ Beginning exploration to build a relationship” corresponds to the orientation, wherein the participants reported meeting the patients for the first time. Although participants made attempts to build relationships with patients, they encountered “ confronting unexpected situations” including “ failing to communicate with patients as intended”, unexpected physical contact, BPSD, and unstable emotional states. These results are consistent with previous research that reported participants feeling “ an invisible barrier” from patients who were unfriendly and showed resistance at the first meeting [25]. Another study [4] revealed themes such as “ closed communication” and “ difficulties in forming a relationship” in nursing students’ experiences with patients during the early stage of voluntary work [21].
The orientation phase typically involves forming a co-operative relationship, identifying patient issues, and exploring mutual emotions [11]. A previous study reported that, during this phase, dementia patients expressed their health concerns and emotions while observing nurses’ responses [26]. However, such emotional exploration was not observed during participants’ initial encounters with older patients with dementia in this study.
In the orientation phase, the participants build trust with the patients. If this phase does not go as planned, it is difficult to successfully form a therapeutic relationship [11]. Appropriate communication by nurses who care for these patients directly impacts patients’ health outcomes and is an essential element in performing their role as medical professionals [25]. Therefore, nursing education should focus on specific details and field cases covering both the verbal and non-verbal communication skills needed for patients whose cognitive functions are impaired, and who have difficulties communicating with others.
The third stage “ Making various efforts to maintain a therapeutic relationship” corresponds to the working phase, wherein most tasks for forming a therapeutic relationship are performed. It is a core phase where a relationship with the patient is further developed [11]. As nursing students providing daily care to patients, the participants tried to understand the needs of their individual patients. Moreover, they formed and maintained relationships with older patients with dementia by actively listening, being patient, utilizing non-verbal communication, and demon-strating a respectful attitude. They also applied various approaches to support the patients’ cognitive enhancement. These findings corroborate the results of qualitative research on nurses at long-term care facilities [27], in which participants placed emphasis on the demands of the patients, while making efforts to establish relationships based on non-verbal exchanges and favorable attention to their care.
Participants also listed a few “ obstacles to maintaining a relationship” with older patients with dementia. Specifically, patients’ never-changing state despite nursing students’ efforts, and the consistently reappearing BPSD negatively influenced the formation of a therapeutic relationship. These results are consistent with those of a previous study which showed that these obstacles create a “ psychological distance” between nurses and patients with dementia [27]. The results also align with another study that revealed the theme of “ confronting limitations” from nursing students’ experiences in caring for older patients with dementia [4]. Research has reported that nursing students showed stress symptoms due to the BPSD observed among older patients and experienced both moral conflicts and conflicts between their professional role as nurses and their individual personalities [20].
BPSD are unpredictable, destructive, and uncontrol-lable, and nursing care providers feel burdened by these symptoms [28]. Participants’ statements revealed that when faced with patients’ BPSD, they tried to respond based on what they had been taught in their classes. However, applying these approaches was challenging in a real medical setting. Thus, it is necessary to preemptively teach communication skills that could be used when providing care for older patients with dementia, as well as provide simulation-based training based on virtual scenarios that include patients with various types of BPSD. Previous studies have reported that providing simulation-based education on dementia to nursing students has a significant effect in developing their knowledge of dementia, related skills, as well as their communication with these patients [29]. To enhance nursing students’ dementia-related competencies, developing and implementing curriculum in cooperation with health professionals working at long-term care hospitals, would be beneficial.
Moreover, participants reported challenges in managing emotions such as shock at patient death, pity for patients’ conditions, and anger toward neglectful family members. Similar emotional responses have been documented in previous studies on nursing students’ experiences in dementia care [4,8]. These reactions are indicative of countertransference, which is distinct from empathy and, if unaddressed, may impede the development of therapeutic relationships [12]. To mitigate this, nursing students should cultivate self-awareness, enabling them to objectively examine their emotions, biases, and sources of stress during clinical practice [12]. Self-awareness has been shown to facilitate therapeutic engagement and aid novice caregivers in processing emotional experiences [30,31]. Therefore, providing structured opportunities-such as case discussions or reflective journaling-can support the development of self-awareness. In such settings, faculty feedback plays a critical role in helping students establish and maintain appropriate professional boundaries in their relationships with patients.
“ Witnessing myself growing in a therapeutic relationship” could be summarized into the experience of the termination phase. Even if only for a short period, participants felt a sense of accomplishment in forming a relationship with the patients and had time to mutually share their feelings and thoughts with them. Moreover, participants reported changes in their overall perspectives of dementia as a disease, as well as of the patients, after clinical practice. Previous studies on the experiences of caring for these patients have reported similar themes: “ witnessing myself changing” [27] and “ experiences of reflection and growth” [32].
Participants stated that in the termination phase, they reflected on patients’ family members’ stances, the meaning of life, and realized what they lacked as future nurses. As such, if professors and field instructors present students with such topics for thought, it would have a positive impact on their competencies in forming a therapeutic relationship with these patients, as well as encourage them to take part more actively in clinical practice in a self-directed manner.
Considering the increased prevalence of dementia with population aging, this study explored the process of forming a therapeutic relationship among nursing students working with older patients with dementia. Based on its key research findings, it expands the current understanding of the process of how nursing students develop a therapeutic relationship with these patients, who have difficulties in communication due to impairments in cognitive functions and other related symptoms. Further, it presents guidelines on practical measures applicable in the field of nursing education to reinforce nursing students’ therapeutic communication skills, and other related competencies. However, since data were collected from a limited number of nursing students from two universities with a short 5-day practicum experience, there are limitations in generalizing the research results.
CONCLUSION
Through an in-depth exploration of nursing students’ experiences in forming therapeutic relationships with older patients with dementia during in long-term care hospitals, it was found that the participants began their practice with individual preparation for scheduled encounters with unfamiliar person. In the early phase, they explored to build a relationship with patients and made various efforts to maintain therapeutic relationships. Despite encountering obstacles, by the end of the practicum, they recognized their growth within these relationships.
Based on this study's findings, diverse practical training programs-such as virtual reality programs that include patients with dementia and scenario-based simulations that consider the progression of this disease should be developed and integrated into nursing education to enhance the competencies of students. To achieve this goal, continuous program development, implementation, and feedback in collaboration with clinical sites should be systematically supported through financial assistance from government bodies such as the Ministry of Health and Welfare and the Ministry of Education. Finally, this study looked at the experiences of nursing students who interacted with elderly individuals with dementia through clinical practice via in-depth interviews. However, as this study relied solely on participants’ accounts of their five-days experience, it is suggested that future studies incorporate qualitative methods such as interviews with field supervisors, observational visits, and in-depth case studies.
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