What you’ll learn in this article…
- García et al (2025) found soft skills lack standardized definitions and assessment.
- Distrustful patients tried walking unassisted, raising fall risk, a 2015 study found.
- Validated rubrics and OSCE debriefs make trust-building as assessable as technique.
Relationship-based nursing skills are the behaviors that build patient trust: listening without rushing, explaining the plan, and noticing when someone stops asking questions. Most programs grade medication math and skills checklists with precision. Trust-building often gets one line on a clinical evaluation form.
Madeline Siefert's Nursing Times opinion piece, published 29 September 2026, argues there is nothing "soft" about these skills. She cites research linking low patient trust to unassisted ambulation and higher fall risk.
The obstacle for faculty is structural. A 2025 scoping review by García and colleagues found soft skills hard to define, teach, and assess because no standard exists. What goes unstandardized rarely gets graded.
What Are Relationship-Based Nursing Skills?
A student can deliver a flawless medication teaching and still leave a patient feeling unseen; another can say less and leave the same patient trusting them completely. That gap is where relationship-based nursing skills live. For a syllabus, use this working definition: observable behaviors that establish trust, convey understanding, and sustain a therapeutic nurse-patient relationship over the course of care.
How This Differs From General Communication
General communication skills aim at clear message exchange: the right information, delivered accurately, confirmed by teach-back. Relationship-based skills share that foundation but differ on three fronts. Purpose: the goal is a trusting alliance, not just comprehension. Continuity: the relationship develops across shifts and encounters, not in a single exchange. Power: the nurse holds structural authority over a vulnerable person, so the work includes managing that imbalance rather than ignoring it. Teaching communication without naming these dimensions produces technically correct nurses who still miss the human encounter central to Emotional Intelligence in Nursing.
The Core Skill Clusters
In plain language, the skill set breaks into five clusters you can teach and assess:
- Presence and active listening: attending fully, reflecting back, tolerating silence.
- Empathy expression: naming and validating what the patient is experiencing.
- Trust-building: reliability, honesty, and following through on small commitments.
- Boundary-setting: maintaining professional limits that keep the relationship therapeutic.
- Repair after rupture: acknowledging missteps and restoring the connection, a skill that benefits from Self-Compassion in Nursing Curriculum.
What makes these relational rather than transactional is that none resolves in a single interaction. A transaction ends when the task is done; a relationship accumulates. Trust built on Monday carries into Wednesday's difficult conversation, and a rupture left unrepaired follows the patient home. That accumulating quality is exactly what the next section's comparison helps you distinguish from adjacent frameworks.
Relationship-Based Care, Person-Centered Care, Caring Science, and Therapeutic Communication Compared
These four terms overlap, but they are not interchangeable, and using them loosely is one reason relational skill stays hard to define and assess. The core difference between relationship-based care and person-centered care is scope. Relationship-based care puts the nurse-person relationship at the center of nursing, while person-centered care, as AACN frames it, is broader and takes in family, significant others, context, prevention, health promotion, and the person's preferences. Use the table to decide which framework a given course is actually teaching, and to see what each one leaves you to specify yourself.
| Framework | Originator or standards body | Core focus | Where it typically sits in a curriculum | What it leaves unspecified |
|---|---|---|---|---|
| Relationship-based care | Educational framework drawing on Saracíbar-Razquin (2009), with related work by Rumeu-Casares et al. (2017) | The interpersonal relationship between nurse and person or family as the essence of nursing, within a humanistic approach | Threaded across undergraduate and graduate programs alongside service, preservation of life, and nursing leadership | Observable behaviors and scoring criteria for judging relational competence |
| Person-centered care | AACN (Essentials Domain 2); attributes described by Morgan and Yoder (2011) | The individual within complex contexts, including family and important others; care that is holistic, individualized, just, respectful, compassionate, coordinated, evidence-based, and developmentally appropriate | A defined learning domain preparing students to deliver person-centered care across diverse populations | How the nurse builds and sustains the relationship itself, moment to moment |
| Watson's caring science | Jean Watson's theory of human caring, introduced in the 1970s and developed over time | Caring as the essence of the nurse-patient connection and as a transpersonal process | Moral, theoretical, and philosophical foundation of the whole program, with practice evaluated through caring science | Standardized behavioral objectives or competency checklists, which it deliberately rejects |
| Therapeutic communication | Hildegard Peplau's theory of interpersonal relations, developed in the 1950s | Communication, empathy, and mutual understanding to build a therapeutic relationship, with the nurse as facilitator, resource, and counselor | Communication units and clinical courses teaching the orientation, working, and termination phases | How relational skill links to broader program outcomes beyond the individual encounter |
Why 'Soft Skills' Is the Wrong Label for Nurse Educators
Nursing education is rethinking a label it has used for decades, and that matters for anyone revising a nursing education curriculum this year.
The Argument Against "Soft"
In a September 2026 Nursing Times piece, Madeline Siefert, an assistant nurse manager in a surgical intensive care unit and a nursing PhD student, recalls learning as an undergraduate that building trust and forming therapeutic nurse-patient relationships counted as soft skills. She argues that the profession treats hard skills as quantifiable, tangible, and assessable for competency. Empathy and trust-building, by contrast, are not consistently standardized. She also points out that the thesaurus lists "soft as in weak" among the word's meanings. That connotation follows the content into the classroom.
What the Research Found
A 2025 scoping review by García and colleagues in Nurse Education in Practice (vol 89) supports her point. The team screened 1,182 records across six databases, including PubMed, CINAHL, and EMBASE. It included 11 studies of nursing students and practicing nurses.
- Hard skills: Broad consensus on which technical competencies nurses should master.
- Soft skills: No agreed definition of what even counts.
- Teaching: Varied strategies with no common instructional framework.
- Assessment: Different evaluation approaches but no unified system.
The authors call this a critical gap spanning education and clinical practice. They argue that nursing must balance technical competence with soft skills to deliver high-quality, humanized care.
Why the Label Shapes Your Curriculum
Whatever sits on the "hard" side of the binary gets a rubric, a skills checklist, and a remediation pathway. Whatever sits on the "soft" side gets a line in the course objectives. Students read grading schemes closely, and they conclude that what isn't measured doesn't matter.
Start by changing the vocabulary. Replace "soft skills" with "relational competencies" in syllabi, clinical evaluation tools, and simulation checklists, the core of a competency-based nursing curriculum. Then list each one as an observable behavior: establishing trust, eliciting patient concerns, responding to emotion, repairing a strained interaction. Calling something a competency commits you to defined criteria, a performance standard, and a consequence for falling short. Once you name it that way, you have to grade it.
In nursing, hard skills are quantifiable, tangible and assessable for competency, while soft skills such as demonstrating empathy and building trust are not consistently standardised.
The Evidence: What Relational Skill Changes for Patients and Nurses
What Professional and Peer-Reviewed Sources Say
The American Nurses Association (2023) holds that the nurse-patient relationship increases patient satisfaction and can reduce hospital length of stay. We found this position through Madeline Siefert's recent Nursing Times commentary and could not tie the length-of-stay claim to a quantitative analysis, so read it as a professional position, not a measured effect. Check the ANA's own publication before you cite it in course materials.
Siefert also points to a 2015 Western Journal of Nursing Research study on trust between Mexican American patients and nurses. As she describes it, patients who felt a lack of trust tried to ambulate unassisted, which raises fall risk. A 2024 study in Enfermería Intensiva on patient satisfaction named the nurse-patient relationship as a major theme. Both findings are qualitative and context-specific. They show what patients say and do, not how large the effect is.
Quantitative Signals on Safety and Retention
Three recent quantitative findings are worth knowing, each with caveats:
- Structured interaction and falls: Brosey and March (2015) reported inpatient falls dropping 57.7% on one medical/surgical unit, from 7.02 to 3.18 per 1,000 patient-days across two four-month periods a year apart (p=0.015). This was a single-unit pre/post design testing a structured interaction routine, not trust as a standalone variable.
- Workplace relationships and adverse events: A 2025 cross-sectional study found that collegial nurse-physician relationships were associated with fewer nurse-reported medication errors, healthcare-associated infections, and falls, with correlations in the medium negative range (falls r=-0.244). It measured colleague relationships, not nurse-patient ones, and everything was measured at the same time.
- Turnover and falls: A 2025 NDNQI analysis of 8,584 units found higher nurse turnover associated with more patient falls. The model explained about 10% of the variance, most satisfaction and practice-environment variables were nonsignificant, and trust was not measured directly.
A 2022 systematic review of nurse turnover adds a cautionary note: only 5 of 17 turnover and patient-outcome relationships were significant.
Reading the Evidence Honestly
Much of this literature is observational, qualitative, or tied to a single setting, and causation is hard to establish. Reviews of relational leadership and trust link them to satisfaction, safety climate, and intent to stay, but none gives a pooled effect estimate. For educators, the practical reading is that the case for explicit teaching rests on plausibility plus consistent associations across designs, much like the rationale for psychological safety in nursing education. That is enough to justify deliberate instruction and assessment. It is not enough to promise students or administrators a specific outcome gain, a caution that also applies to nursing student retention strategies.
Where U.S. Standards Already Ask for Relational Competence
Relational competence is not an optional add-on. The frameworks that shape U.S. nursing programs already name it, but they rarely say how to assess it, so faculty are left to define the observable behaviors, rubric criteria, and evaluation points themselves. QSEN is not included below because its exact patient-centered care wording could not be verified for this guide.
| Framework | Relevant Language or Domain | Gap or Opportunity for Faculty |
|---|---|---|
| AACN Essentials (2021) | Domain 2, Person-Centered Care, includes sub-competencies 2.1a "Demonstrate qualities of empathy," 2.1b "Demonstrate compassionate care," 2.1c "Establish mutual respect with the individual and family," 2.1d "Promote caring relationships to effect positive outcomes," and 2.1e "Foster caring relationships." Progression indicators include active listening, understanding, therapeutic communication, support, and trust. | The sub-competencies name the behaviors but not how to measure them. To make each one observable, map empathy, active listening, trust, mutual respect, and difficult-conversation skills to specific simulation scenarios, standardized-patient encounters, clinical evaluation tool items, and reflective debriefs. |
| NLN Competencies for Graduates of Nursing Programs | Apply across practical/vocational, diploma, associate, baccalaureate, master's, practice-doctorate, and research-doctorate programs. Core competencies include Human Flourishing and Nursing Judgment, intended to guide curricula for safe, quality care. | The competencies are broad and give no assessment method. NLN materials also describe caring attributes such as active listening, open dialogue, and understanding situations, which help educators, students, and staff "feel known, cared about, and valued." Treat relational skill as both a graduate outcome and a behavior faculty model in their own teaching. |
| NCSBN Clinical Judgment Measurement Model | A clinical-judgment application of the model links person-centered care to forming a therapeutic alliance, gathering and interpreting data through therapeutic communication, active listening, documenting client anxiety, determining preferences before procedures, and considering values and beliefs. | Grade the reasoning process, not only whether the learner chose the technically correct intervention. Ask whether the learner recognized cues through therapeutic communication, incorporated preferences and values, and documented psychosocial responses. |
| UK NMC Standards of Proficiency (comparison) | Nurses apply principles of therapeutic relationships and professional boundaries, build rapport through approachability and respect, keep interactions patient-centered, and maintain professional focus. | The UK emphasis pairs therapeutic relationships with explicit boundaries and role clarity. AACN is more granular about empathy and caring relationships. U.S. faculty can add a boundaries lens when writing relational rubric criteria. |
Related Articles
How to Thread Relational Skills Through Every Course
More programs are abandoning the standalone communication unit, and the reason is simple: a single module teaches students that relational skill is a topic to pass, not a practice to build. Threading it across the curriculum changes that message without adding a new course.
Build a Spiral, One Focus Per Course
Assign each course a single relational skill focus so the competency deepens over time instead of appearing once and disappearing:
- Foundations: establishing rapport and introducing yourself with your last name.
- Health assessment: eliciting the patient's story, not just the data points.
- Med-surg: sustaining trust under time pressure and competing tasks.
- Mental health: therapeutic presence and de-escalation.
- Leadership/capstone: modeling and coaching relational care in others.
This spiral lets you say precisely what you expect at each stage, which solves the definitional vagueness that makes relational content so hard to assess.
One Activity Per Learning Mode
Give students a concrete way to practice active learning strategies in every setting:
- Classroom: role-play a difficult admission, then swap roles.
- Simulation: use simulation-based learning in nursing education with a standardized patient who grows anxious if ignored.
- Clinical: a weekly log of one trust-building moment and what it changed.
- Online: recorded video of a mock patient interaction with structured peer feedback.
Embed, Don't Add
You do not need new assignments. Put relational criteria inside the work students already submit:
- Care plans: require a documented rapport-building intervention.
- Case studies: grade the proposed opening exchange, not just the clinical reasoning.
- Clinical reflections: prompt students to name one relational success and one miss.
Make It Visible on Paper
If a relational outcome never reaches the syllabus or the gradebook, students read it as optional. Map each course's relational focus to a stated course objective, weight it in the rubric, and name it in the gradebook. When relational competence carries points and language of its own, both faculty and students treat it as the measurable skill it is.
Validated Tools for Assessing Relational Competence
You do not need to build a relational competence rubric from scratch. Several published instruments already score communication with reported reliability or validity evidence, but they share one pattern: agreement between raters tends to drop on subjective items like empathy, so rater calibration is not optional. Match the tool to the setting and stakes, and treat any instrument validated in another language or profession as a starting point that needs local testing.
| Instrument | What It Assesses | Reliability / Validity Evidence | Best Use |
|---|---|---|---|
| Creighton Competency Evaluation Instrument (CCEI), communication component | Nursing students' communication performance and expected behaviors in clinical or simulated care, scored within a broader clinical competency framework | Content-validity ratings of 3.78 to 3.89 on a four-point scale; Cronbach's alpha above .90 when scoring three levels of simulation performance | Standardized grading of clinical competency, where clearly defined expected behaviors help faculty score consistently across sections |
| Spanish adaptation of the Creighton Simulation Evaluation Instrument (C-SEI) | Simulation performance across four categories: evaluation, communication, critical thinking, and clinical abilities | Average inter-rater agreement of 89.1% for communication, 84.4% for evaluation, 87.5% for critical thinking, and 78.1% for clinical abilities; Cohen's kappa above 0.80 for all items | Simulation scenarios that score communication alongside clinical skills; evidence applies to the Spanish version, so confirm which version your program uses |
| OSCE assessment rubrics for nursing students | Clinical competencies, including communication, in structured OSCE stations | Content-validity indices for rubric items ranged from .82 to .95 | Structured, station-based assessment of communication and clinical competencies |
| Communication-focused OSCE binary checklists (pre-registration nursing) | Communication and patient education, including verbal and empathy-related items | Excellent overall station agreement, ICC of 0.89 (95% CI 0.84 to 0.93); agreement was lower for subjective communication and empathy items than for technical skills | Pre-registration nursing OSCEs; calibrate raters carefully on empathy items before high-stakes use |
| Calgary-Cambridge Guides | Communication skills in undergraduate health-professions students; the psychometric study evaluated medical students, not nursing students | Good test-retest reliability and construct validity; item-level ICCs were moderate (0.05 to 0.57), with noted inter-rater reliability deficiencies | Structured communication feedback after thorough rater training; given the inter-rater limits and medical-student sample, better suited to feedback than high-stakes nursing grades |
Designing OSCE Stations and Debriefs That Surface Relational Skill
Build a Station That Challenges Trust, Not Just Technique
A relational OSCE station needs a scenario with emotional weight: a newly diagnosed patient who goes quiet, a family member questioning the plan, or someone who has stopped asking questions because they feel rushed. Give students 8 to 10 focused minutes with a standardized patient. The point is not to complete a task list but to notice distress, respond to it, and keep the relationship intact while the clinical work happens.
Score the encounter on relational criteria alongside any clinical content. Use behavioral anchors rather than a tally of completed steps, and have raters judge whether the student noticed the patient's cue, named or acknowledged it, and adjusted. Define in advance what adequate, borderline, and inadequate responsiveness look like so the station measures the relationship, not just the procedure.
Debrief With PEARLS and INACSL in Mind
The INACSL Healthcare Simulation Standards expect planned, purposeful debriefing for every simulation activity, and the PEARLS debriefing article gives you a workable structure: learner self-assessment, facilitated discussion, and directive feedback across its reactions, description, analysis, and summary phases. Ask prompts that pull for observation and reasoning, not performance of the "right" answer:
- What did you notice in the patient's words, face, or body language, and when did you first notice it?
- What did you do in response, and what were you hoping that would accomplish?
- Where did the patient's trust feel strongest or most fragile, and what shifted it?
- If you repeated this encounter, what would you do earlier or differently?
In assessment contexts, keep debriefing separate from scoring unless your blueprint explicitly defines remediation or a second attempt; debriefing should not retroactively change a scored performance.
Calibrate Raters and Avoid Scripted Scoring
Relational scoring carries judgment, so calibrate. Train raters on the construct, the rubric, and the standardized patient brief, then run joint scoring sessions using anchor videos of strong, borderline, and weak encounters. Have instructors score independently, compare, and rescore until they converge; repeat whenever you add a new station, patient, or rubric. For high-judgment stations, consider two evaluators.1
Finally, resist checklists that reward memorized phrases. A student who recites "I understand how you feel" without reading the patient should not outscore one who responds genuinely but off-script. Anchor your criteria to responsiveness, not vocabulary.
If a program claims to value trust and therapeutic presence, it has to measure them with the same rigor it applies to technical skills: defined criteria, validated tools, and repeated observation.
Remediating Students Who Struggle With Patient Interaction
Remediation has to be firm enough to protect patients and flexible enough to fit the reason a student is struggling. The published literature agrees on a general sequence of three to four parts: early identification, an individualized plan, deliberate practice with coaching, and reassessment. It is less settled on any single validated protocol, so treat what follows as a well-supported pattern, not a proven formula.
Diagnose Before You Prescribe
Start by naming the barrier. Anxiety, limited empathy, workload pressure, and a plain skill gap each call for a different response; language and cultural gaps need clinical communication strategies for ESL nursing students. A student who freezes needs a different plan than one who never asks open-ended questions. Use your relational rubric to pin down observable behaviors such as active listening, verbal empathy, and open-ended questioning.1
Build the Practice and Coaching Plan
Pair one-on-one coaching with varied methods, since remediation studies commonly combine them.2
- Repeated simulated encounters: Standardized patients and simulation are the most common platforms, and many communication interventions have shown improved patient-centered communication.3 Simulation alone may not cover the full skill set, though.4
- Video review with a rubric: Student and coach score the same recording, then compare.
- Paired coaching: Add structured feedback in a supportive, listening-first setting.
- Reflective prompts: Guided reflection and emotional regulation are linked to restored competence in recent program-theory work.5
Set Re-Assessment Terms Up Front
Write the plan down before practice begins. Recent conceptual work recommends documenting observable concerns, required standards, support strategies, and timelines. Reassess with the same rubric, using clear thresholds and a firm date, and draw on more than one method: direct observation, checklists, global-rating scales, 360-degree evaluations, or patient surveys. A single test is a weak basis for a progression decision.
One caution: evidence on long-term outcomes such as retention and readiness for the Next Generation NCLEX is still thin, and students should enter remediation willingly, with feedback that is timely and specific. Track those outcomes in your own program so your data can fill the gap.
Putting It Into Practice: A First-Semester Action Plan for Faculty
Where does a faculty team actually start if relational competence has never been named in your evaluation tools? You do not overhaul nursing curriculum development in one term. You pick one tool, revise it, calibrate on it, and pilot it. Then you measure whether it worked.
A Semester Timeline
- Weeks 1-4 (audit): One faculty lead pulls every clinical evaluation form, simulation checklist, and course rubric and marks which criteria name relational behavior (trust building, eliciting patient concerns, responding to emotion) versus auditable tasks. Deliverable: a one-page gap list.
- Weeks 5-10 (revise and calibrate): The course coordinator rewrites a single rubric to add 2-3 observable relational criteria with behavioral anchors, grounded in evidence-based teaching strategies for nursing educators. The full teaching team then watches one shared video of a nurse-patient interaction and scores it independently, discussing where ratings diverge until anchors are clear.
- Weeks 11-15 (pilot): The course lead runs the revised rubric in one course or one OSCE station, collecting data without high-stakes grading consequences this first cycle.
Three Low-Cost Metrics
- Rater agreement: Compare faculty scores on the calibration video and on live pilots; target shrinking the spread.
- Student self-ratings: Have students rate their own relational confidence before and after the course.
- Standardized-patient feedback: Capture a short structured comment from the patient actor after each encounter.
None of this requires new funding, only shared attention. The argument Madeline Siefert makes in Nursing Times lands here: a program broadcasts its values through its scoring sheets. What gets assessed gets taught. Name relational skill on the rubric, and faculty will start teaching it on purpose.
