The American Association of Colleges of Nursing's Essentials of Baccalaureate Education for Professional Nursing Practice outlines expectations for the graduate nurse regarding clinical judgment and psychomotor and communication skills. The process of professional socialization includes internalization of the norms and values of the profession, as well as attitudes, behaviors, professional skills, and roles. Communication skills are fundamental to demonstrating internalization of professional skills and core values, but nursing students and new graduates continue to report difficulty in initiating and engaging in conversations on difficult topics with their patients. Practice in communication skills may decrease student unease with a discussion about dying, a poor prognosis, or an unexpected diagnosis. We are advocating a two-pronged approach to addressing this issue: a more deliberative inclusion of therapeutic communication practice in the clinical setting as well as in simulation scenarios.

Clinical judgment and psychomotor skills are emphasized throughout nursing curricula, too frequently at the expense of communication skills. New graduate nurses are expected to possess excellent communication skills and intuitively recognize the need to engage in difficult conversations. They are also expected to be able to communicate with the interdisciplinary team, patients, and family members. But the opportunity to practice these conversations is usually dependent on clinical assignments, clinical experiences, and the clinical faculty and/or preceptor comfort level with communication, especially with the dying patient. Simply because of lack of exposure, new graduates often do not recognize the need to address, or how to address, the patient's concern.

In addition, a more recent threat to developing essential skills in establishing a therapeutic relationship with patients is the preference of today's students for electronic communication. Texts, e-mail, voice mail, and social media platforms like Instagram have all contributed to the decline of face-to-face interactions. Habitual lack of eye contact, use of short phrases and abbreviations, and use of small digital images to express emotions are all part of a new normal in communication.

Clinical faculty and preceptors are valuable as role models and are essential for nursing students' integration of professional behaviors. Their role in assisting students in recognizing situations requiring therapeutic communication techniques such as active listening, silence, and using open-ended questions cannot be overstated. If students don't have significant practice with communication skills, they are likely to have difficulty as new graduates.

Clinical faculty have an obligation to assess their students' comfort levels about speaking to patients and utilizing therapeutic communication techniques. They should remind students that providing holistic care includes addressing the patient's psychosocial needs and encourage students to initiate difficult conversations. These conversations begin with establishing rapport, including asking patient-specific questions-which some students may perceive as inappropriate-and not necessarily waiting for cues from the patient. Finally, clinical faculty should require students to reflect on their interactions with patients and recognize that communication skills require as much practice as clinical reasoning and psychomotor skills.

Since simulation scenarios are now often used to fill didactic and practice gaps, faculty should ensure therapeutic communication is included in the scenario as well as part of the debriefing. Students would benefit from simulation scenarios that extend beyond interactions using the SBAR (situation, background, assessment, recommendation) format and include initiation of conversations with patients and/or family members. These conversations may focus on end-of-life care, but they may also include such topics as surviving a life-altering but not necessarily life-threatening illness or injury, giving birth to a "not perfect" child, or decisions about treatment options.

To ensure students are socialized into the profession, they need proficiency in all of the professional skills. The ability to communicate effectively, initiate difficult conversations, and provide emotional support is a necessary skill, and like any other skill along the novice-to-expert continuum, it needs practice.