Nurses’ views of fundamental relational skills used in clinical practice: a cross-sectional pilot study


 
 
 Effective communication skills are one of the core competencies of nursing curricula internationally. Nurses are generally regarded as proficient. Despite our complete trust in the profession, deficiencies and gaps exist. However, it is not clear to which extent nurses use key communication skills in practice, and whether or not confident in using these skills compounds environmental issues that occur. This study explored nurse's confidence and application of relational skills competencies in nursing practice.
 
 
 
 A 13-item online survey was used to collect data.
 
 
 
 Being self-aware on key areas where there was more uncertainty. Nurses also lacked confidence in exploring the impact of their personal feelings and values on their interactions. Nurses were also less confident on responding appropriately to instances of unsafe or unprofessional practice and using information and communication systems and technology.
 
 
 
 Given the potential impact of poor relational skills on quality client care, an increased emphasis on caring and compassion, and the ever-expanding use of communication technologies, there is a need to explore the need for reflective practice to enhance continuous professional development for nurses to enhance their relational skills.


Nurses' views of fundamental relational skills used in clinical practice: a cross-sectional pilot study health care and technological support. Health care staff are increasingly struggling to adapt to complex health care environments that are all too demanding. 14 A hiatus has grown between the burdens being placed on nurses and their capacity to deliver this care. 14 Nurses often experience burnout, and thus have limited capacity to care for others; this is especially prominent when there are low staffing levels. 13,15 This is also the case in the People's Republic of China where a high level of emotional distress is reported among nurses (compared with the average citizen) and there also appears to be a high intention to leave. 16 It is perhaps very beneficial if the initiatives are put in place to strengthen fundamental aspects of care in these fast-paced challenging health care environments.
Surely, there is a growing awareness that sometimes there is inattention to fundamental human needs, including communication and relational care. 17 Additionally, fundamental care is often understood as "common sense" and so not always highly valued or explicitly taught or assessed within nursing curricula, 17 and quickly forgotten when there are more pressing deadlines. 13,18 To address this, nurses are now being encouraged to remember and place value on these fundamentals of care. 19 The Journal of Clinical Nursing 20 for example recently presented two special issues on this topic. 21 Fundamental care has been conceptualized as comprising physical, psychosocial, or relational care. 22 Thus the importance of good relational and communication skills form a key component of this fundamental care movement. While working on an agreed definition of fundamental care is continuing by this group, their working definition clearly prioritizes relational care: 17 "Fundamental care involves actions on the part of the nurse that respect and focus on a person's essential needs to ensure their physical and psychosocial wellbeing. These needs are met by developing a positive and trusting relationship with the person being cared for as well as their family/carers" (emphasis not original). 22 Certainly, there is evidence internationally for an increased emphasis on improving nurse-patient communication. [23][24][25] Developing increased skills of compassion is another topical area. 26 In UK, a national campaign for example (completed in 2016) emphasized "compassion in practice" within the context of a leadership framework that encouraged care, compassion, competence, communication, courage, and commitment (the "six c's") to become "embedded" in nursing practice. 27 Similarly in the Republic of Ireland (ROI), a national position paper was developed in 2016 by the Office of the Chief Nursing Officer, reaffirming nurse's values as with information patients and families received about health care conditions. Dissatisfaction around the communication of prognosis was identified as a particular concern. 4 This fact is surprising given the advancements in health care, but also the widely acknowledged fact that communication and relational skills are the core skills required within professional health care standards and competencies internationally. 2 Patients and their family's reactions to health care inadequacies can have a consequential effect on a nurse who is at the receiving end of their emotional reactions. 3 Thus it is useful for the nursing profession to reflect on communication competencies and how they can improve to reduce or address patient complaints and improve the overall quality of care.
Indeed patients are becoming increasingly vocal and outspoken regarding their concerns about health care communication. 2 Many patients and relatives complaints about health care are related directly to poor communication and interpersonal relationships. 5 Analysis of these complaints reveals that many complainants perceived a lack of person-centered, personalized care that recognizes each human being as an individual. 5 A key emerging message from patient advocacy groups and associations, such as Patient Voices, is "look at me," "see me," and "treat me as human." 6 Technological advancements have also reshaped modern communication. 7 As such there is also a tendency to over-rely on technological skills as a replacement for good communication and relational skills, with recent concerns emerging about the risks associated with the modern technological communication environment. 8,9 Indeed gaps in health care communication could be magnified rather than reduced by the use of technology. [7][8][9] For example, electronic health care records have extenuated errors at the cost of millions in the USA. 8 Therefore, requirements for good health care communication are more pertinent now than ever before.
Indeed when problems arise, concerns about nurses' communication and relational care receive consistent attention in both policy and media. 10,11 Compassionate care deficits, for example, currently being addressed at multiple levels in the UK, point to potential deficits in nurses' communication skills, driven in part by environmental factors. 10 International missed care research too finds that providing education and information to patients, key relational competencies, are often forfeited when nurses need to prioritize. 12,13 This is likely because health care settings are now faster-paced, with increasing short-term admissions, an aging patient profile and more emphasis on care in the community. At the same time, those patients requiring longer-term health generally have complex care needs and require intensive "compassion, care, and commitment." 28 There are also some commendable efforts being made to support UK nursing staff to attend leadership programs offered at NHS Leadership Academy. 29 An example of one such initiative is by Dewar et al. 14 and Dewar and Christley 30 who were responsible for a major action research project in Scotland that sought to imbed compassionate care within the NHS culture.
Importantly in the People's Republic of China, improving aspects of nurses' caring within the nursing practice are emphasized in recent years for both scholars and practicing nurses alike. 31,32 There is a great emphasis on developing a caring response within the health professions for example with greater emphasis on the inclusion of humanities content in the nursing curriculum to strengthen caring consciousness. 33 Increasingly, Chinese nursing scholars have been engaging in research in the field of caring and also the implementation and development of practical approaches in the profession on nursing so that nursing is based on values and philosophies of caring. 34 In keeping with Leininger's approach, these scholars believe that implementing nursing that has a strong basis in caring theory and philosophy can have a positive influence on health and the human condition. They describe caring as an "interactive process that usually occurs during moments of shared vulnerability between nurse and patient." 35,36 However overall little is known about nurses' communication and relational skills in practice, and how contemporary requirements for skills of caring, compassion, and advocacy are operationalized and developed in relation to these skills. In a technological age, little is also known about whether or not technological advancement is bringing about improvements in nurses' communication or hindering it. Overall it is unclear whether the basic educational preparation provided to nurses continues to be appropriate for the purpose once qualified, particularly in the light of the recent emphasis on fundamental caring skills. The success or otherwise of national and local values improvement campaigns is unclear. To address some of these issues, and as only a little research has been performed examining nurses' communication skills in the ROI, this study aimed to explore Irish nurses' application of core relational skills' competencies in practice. This study is aimed to find out about these nurses' use and views of these skills, particularly the core competencies required by the national nursing professional body (Nursing and Midwifery Board of Ireland). 37 This survey also aimed to find out nurses' perceptions of important elements of nurse/patient communication to determine the consistency between these and contemporary requirements.

Aim
This study aimed to explore nurse's confidence with required communication skills competencies.

Design
A cross-sectional pilot study using an online survey (SurveyMonkey TM ) was administered via a web link provided in an email to the nursing alumni of one nursing school in Ireland in 2015. A gatekeeper based at the local Alumni Office sent the link. A follow-up/reminder email was sent reminding participants to complete the survey after 2 weeks.

Sample
Determining a robust data collection method for qualified nurses within the ROI was problematic. Probability sampling, which is the favored method of approach in quantitative research, 38 proves difficult as the main national nursing database, the national register of nurses in ROI yields notoriously low response rates, often <10%. 39,40 Internationally, incredibly high responses from national nurse databases (up to 70%) are received when compared with ROI. 41 Additionally while there are many professional nurse associations internationally, there is no such organization in the ROI that could be utilized to seek nurses' views. The Irish Nurses Organisation is a national trade union. 42 However sampling from this cohort leads to a conflict of interest. Researchers are therefore confined mostly to convenience sampling or retrieving responses from localized specialized nursing organizations (e.g., cardiac or cancer care). To combat this, and to gain information from a wider group of qualified nurses for this study, this team accessed the Alumni database (n = 5000) of one national university. Fifty-two responses were received. As it is impossible to determine how many of the 5000 alumni truly responded in determining the sampling framework and hence become very difficult. As such the 52 respondents were considered for this purposive pilot sample, and as such included in a small case study for the research purposes.

Measure
The research team developed a 13-item questionnaire based exclusively on the existed current national professional regulatory standards for nurses' competence in communication. 37 In this tool 15 individual statements derived from the core national nursing competencies requirements within the domain of communication were included. 37 These statements were derived from expanding beyond the 2 central competencies to include a reference to the 5 indicators of these competencies within the prescribed syllabus content outlined by the National Nursing and Midwifery Board of Ireland (NMBI) for nursing schools. These 15 items were then presented to the respondents who were invited to reply in terms of their level of confidence with each item. A 5-point Likert scale (not at all confident, somewhat confident, unsure, confident very confident) was provided for these responses. Nurses were then presented with these 15 items again and were asked to provide what their views were in terms of their level of importance for providing quality nursing care. Using the stem question: What is your view do nurses need to know about communication to equip them to provide qualitynursing care?, participants were permitted to select any number of items from these 15 options. As these items were nationally validated (by the regulatory body) 37 and in use for competence assessment and entry to the nursing register, (at the time of the survey), criterion-related validity had already been established for these items. 43 Two open-ended items were also included that asked: response to the most essential communication skill required for nursing and the communication skill most used in nursing practice. These were later analyzed and coded. Demographic data were also collected.

Data analysis
Data were analyzed using descriptive statistics. Data were exported to excel from SurveyMonkey TM and frequencies and distributions in the data were outlined.

Results
Fifty-two respondents completed the survey and all of them were registered nurses. Most (98%, n = 51) were employed as nurses. There was a good distribution of ages among the group. Most respondents were under the age of 40 (56%, n = 30). The majority of them were under the age of 30 (30.8%, n = 16). A quarter of the cohort was aged between 40 and 49 (25%, n = 13) and 9 (17.3%) nurses were over 50. Most had received education and training in communication skills (88.5%, n = 46), although 1 (1.9%) had not, and a further 5 were unsure (9.6%). Many (55.8%, n = 29) received this during pre-registration education, although 34.6% (n = 18) of the sample received education during a postregistration nurse/midwife education/training programme and many (26.9%, n = 14) received education during another course of study.
Most nurses expressed confidence in using the required communication and relational skills competencies 37 in practice (Table 1). Nurses appeared most confident in communicating nursing information both verbally and writing (92.3%, n = 48). Areas where less certainty arose related to being self-aware and exploring the impact of personal feelings and values on interactions with clients, where 37 expressed confidence (71.1%). Similarly, only 37 nurses (71.1%) expressed confidence in communicating/interacting with different cultural and ethnic groups, people with disability/impairment, and different age groups. Only 75% were confident in reflecting the usefulness of their personal communication techniques. Thirty-six (69.2%) were confident with responding appropriately to instances of unsafe or unprofessional practice and using information and communication systems and technology.
Participants agreed that communication and relational skills competencies 37 are needed in providing quality-nursing care. Specifically, they were asked "what is your view do nurses need to know about communication to equip them to provide quality nursing care?" The top 5 communication skills identified are outlined in Table 2. The top-ranking communication skill was "communicating nursing information verbally and in writing" ( Table 2). All except two items scored >65% approval and these low scoring items are outlined in Table 3. Interestingly few respondents rated the items: "integrating accurate and comprehensive knowledge of ethical principles, the code of professional conduct and within the scope of professional nursing practice in the delivery of nursing practice" and "using information and communication systems and technology" highly (Table 3).
Two open-ended items asked respondents to state the most essential communication skill for nursing (Table 4) and the communication skill that is mostly used in your nursing practice (Table 5). Listening and empathy emerged as key skills.

Discussion
Effective communication skills are core competencies of nursing curricula internationally. Nurses are generally regarded as proficient. However, when problems arise, concerns about nurses' communication and relational care receive consistent attention in terms of policies and by the media. 10 Compassionate care deficits, for example, currently being addressed at multiple levels in the UK, points to potential deficits in nurses' communication skills, driven in part by environmental factors. 11 International missed care research too finds that providinginformation, a key role in practice, is often forfeited when nurses need to prioritize. 13 the profession, it is not clear to which extent nurses use key communication skills in practice, and whether or not it is environmental issues or confidence that affects their application.
However, this study confirms that personal nursepatient communication remains a fundamental relational nursing skill that is important to nurses, 44 with listening and empathy emerging as most important. This is an important finding as there is some evidence to suggest that what undergraduate students learn about communication does not transfer into practice. 45 Additionally relational and communication aspects infiltrate and influence all other aspects of fundamental care and thus affect the patient's holistic experience of health care. 46 National policy requirements for improvements in nurses' communication and caring values may have also limited effect, as they are not accompanied by any substantive educational input for nurses in practice, nor are there any related outcome measures. Certainly, the increased awareness of the need for improvements in communication and relational skills in health care translates across local and national quality measurements, with gaps in this area receiving increasing scrutiny. 47 Strengthening approaches to communication and relational skills locally might serve to support a commitment to these fundamental skills. Liu et al. 34 demonstrated a straightforward yet powerful approach adopted within a model of caring at Wuhan Union Hospital, in the People's Republic of China, whereby nurses are encouraged to communicate on a personal level with patients each day for at least 5 min asking key questions such as "Do you have any discomfort?" and "Do you have any needs that I need to address?" Recent international deliberations in terms of the development of spiritual care competencies for nurses recommend a similar two-step approach: "What is important to you right now?" and "How can we help?" 48 Additionally what is greatly lacking internationally is funding resources to support robust research and measurement within fundamental care activity 46 although arguably some countries are more active than others in this regard. 49,50 However to note within the study is that one-third of respondents lacked confidence using information and communication systems and technology, and respondents did not rate this particular aspect of communication competency highly. It is also interesting that when asked to express important communication skills, technology did not feature in it. Rather there was a reliance on the traditional, fundamental skills of listening, observation and empathy. This may be due lack of familiarity with technology as other studies have demonstrated that nurses often have not received any training but rather rely on their own experience to navigate  Assisting clients and groups to communicate needs and to make informed decisions 76.9% (n = 40) Developing interpersonal and communication skills that are essential to the nurse 78.8% (n = 41) Ensuring confidentiality in respect to records and interactions 75.0% (n = 39) Table 2. What is your view do nurses need to know about communication to equip them to provide quality nursing care-top 5.

Items
Percentage respondents (number) Ability to listen/active Listening 23% (12) Recognizing nonverbal cues 11.5% (6) Empathy 9.6% (5)  the equipment. 51,52 There might be a recognition that good communication skills are still required, in terms of supporting the accuracy and safety of the technology. 9 However at the same time there is an acknowledged lack of confidence in using the communication technology among nurses 52,53 and a lack of preparation among undergraduates. 51 Furthermore some studies indicate that technology use impedes communication, although this could be due to a lack of confidence or unfamiliarity. 50 Additional support is therefore likely required to enhance technology use among nurses for technological record keeping as well as for utilizing electronic tools which are ever expanding in health care. 54,55 The emergent role of digital health advocacy and social media in patient education and support is likely to mean that nurses will require additional skills in this field for the future. 56 One-third of respondents were not confident with responding appropriately to instances of unsafe and unprofessional practice. Of interest too is that only a few rated knowledge of ethical principles highly. Although small in number, it is of concern because patient advocacy is emerging within international codes of conduct as a key required skill of the nursing profession. 1 Advocacy is important because nurses are expected to promptly report if they witness substandard patient care. 57,58 Nurses need to be taught these skills as highlighted in one recent UK report entitled Freedom to Speak up that suggested that mechanisms for speaking out need to be embedded in practice. 25 Equipping nurses with the necessary skills to speak out by targeted training is recommended urgently by this latter report and has recently also been emphasized internationally. 58,59 Although reflection and self-awareness are key components of contemporary nurse education programs in the ROI, many nurses in this study were not confident with these areas and they did not rank them highly in terms of importance. This is interesting as it is generally accepted that reflective learning by nurses in health care needs to be increased 3,60 and that reflective practice education, and supervision for reflective practice needs to be encouraged. 61 Reflection has been found to be a useful way of reframing incidents of poor communication and developing new insights that can improve personal practice. 3 Spending time in short reflection or contemplation is also an important component of selfcare when formulating caring frameworks in clinical practice. 62 It is possible for example to determine that more could be done in personal practice with regard to personal communication skills and having the capacity to reflect and learn from this reflection is crucial. 63 Communication competency requirements upon entry to the discipline become transient and are not necessarily updated with new knowledge nor would it be feasible or possible to do so. Rather nurses need to continuously reflect on their own completence 3,63 and address gaps in learning through personal and professional development. Although many nurses in this study demonstrated skills of self-awareness, few only reflected on their communication skills, something which could be improved and encouraged across the discipline internationally.
Making a realistic long-lasting impact and improvements in communication and fundamental relational skills in practice requires a strategic approach and strong leadership. While there is evidence of international strategic approaches to strengthening fundamental care delivery, 19.22 strengthening caring actions, 34 and strengthening leadership 14,27,30 , more needs to be done at a clinical level by nurse managers locally. 34 Relational leadership styles for example can improve the clinical atmosphere and moral of nurses, and by caring for the nurses, this can be transferred to caring for patients. Indeed, in the People's Republic of China, satisfaction and intention to leave have also been directly linked to work environments outside of simply the nurse-patient ratio. 64 Shao et al. 64 examined cross-sectional data that were derived from the Chinese Nurses' Environment of Work Status study (C-NEWS study, 2016-2017). The C-NEWS study is nationwide research that aims to measure the work status of registered nurses. Shao et al. 64 revealed that the work environment had a direct effect on nurses' job satisfaction. Poor work environments were linked to burnout and emotional exhaustion. Wang et al. 65 recently found a positive relationship between inclusive leadership style and leaders' innovative behaviors and work engagement. Other studies similarly found links between positive work environments and satisfaction, suggesting that improving the work environment has a positive influence on nursing staffs' attitudes, 66 and ultimately performance, so giving attention to environmental issues is an important component to strategically address the deficits in communication and relational care.

Conclusions
Overall, despite evidence of a profession that is competent in communication and relational skills, in relation to their educational preparation, it is not clear to which extent nurses use key communication skills in practice. Additionally, when deficiencies in the quality arise, it is not clear whether this is due to a direct result of environmental issues or due to nurses' skills and confidence. But, it is reassuring that nurses in this study mostly expressed confidence with specific communication competencies and skill requirements in relation to interdisciplinary, nurse/patient communication, and record keeping. However, participants were less confident with technology usage, reflecting on their practice and their own self-awareness and responding appropriately to instances of unsafe or unprofessional practice. Although there have been many advances in communication, technology, and the use of social media in nursing, nurses still lack confidence in some fundamental areas. It is important that these gaps are addressed through continuous professional development, and the communication skills for nurses should remain high on the agenda and are prioritized in terms of active educational input and research, which may help to achieve what is stated here regarding the health care and nursing: "[The] human touch is and always will be the imprimatur of nursing. We must not lose touch". 7

Limitations
This pilot study had a low response rate and so the results ought to be interpreted with caution. However, this work is done with the knowledge of other ROI surveys 40,67 and UK online surveys. 68 This pilot study provides some interesting results that serve as a factfinding exercise to inform the discipline about possible patterns and trends, and certainly these preliminary findings resonate with the literature on the topic. Replication of the survey with larger cohorts internationally would be useful.

Impact statement
Nurses appear confident with specific communication and relational competencies and skill requirements in relation to interdisciplinary, nurse/patient communication, and record keeping. However, nurses are less confident in using technology, reflecting on their practice/self-awareness, and responding appropriately to instances of unsafe or unprofessional practice. Highlighting these issues has important implications for contemporary nursing practice, insofar as using technology, reflection on practice, and responding to issues of unsafe practice are high on policy makers' agendas and require even greater attention within the discipline. These are crucial skills for contemporary nursing practice, but the relational aspects of care receiving unprecedented public scrutiny quality mechanisms still report important gaps in nurses' behaviors.

Ethical approval
Ethical approval was obtained from the Local Research Ethics Committee. Taking part was optional for the participants, and their consent gleamed during the completion of an online survey.

Conflicts of interest
All contributing authors declare no conflicts of interest.