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Introduction
Nursing competence comprise knowledge, abilities, attitudes, and behaviors integrated into and aimed at holistic care 1. This competence is not innate but developed in a complex process to which the environment and internal motivations contribute. Nursing competence is a multidimensional concept; its attributes include professional values, critical judgment, leadership, and effective interpersonal relationships 1,2, the latter being the most relevant considering the growing need for human care in the world.
Developing behaviors aimed at establishing optimum interpersonal relationships do not always occupy essential places in institutional or educational nursing programs 3, in addition to the fact that nursing professionals with little experience find it difficult to put into practice effective methods to build up relationships with care recipients 3. Therefore, the need for interpersonally competent nurses is explicit.
Then, care as affection and interpersonal relationship 4 shows that these aspects are the most important for interpersonal skills in nursing. Care as affection reflects the emotional commitment to the other, and care as an interpersonal relationship is the essence of caring; it is the means through which the other is reached, which requires a genuine interest in the welfare of the other 5,6. In other words, the interpersonal dimension of care establishes the ontological and epistemological aspects of the relationships with the subjects of care, the interpersonal nursing skills being necessary.
When inquiring about this topic within the literature and practice, concepts such as social skills, communicative aptitudes, communicative skills, relational knowledge, among others, are commonly used. However, the term "skill" is not fully grasped, and, as it is not clearly defined, a conceptual void is left. Therefore, a concept analysis of interpersonal skills in nursing is required.
For clarity purposes, concept analysis is a theoretical development strategy of the discipline, even being considered a form of theoretical research in nursing 7. It is a strategy that allows examining the attributes or characteristics of a term; it is a formal linguistic exercise that must be rigorous and precise to approach a definition, focusing on the potential and actual uses of words that convey the meanings of a concept 8. In this case, the term interpersonal skills in nursing arises from an attempt to narrow down the diversity of concepts on relational function in nursing found in the literature that are unclear to be used in research and applied in practice. This article aims to provide a broad definition of interpersonal skills in nursing as a theoretical approach that contributes to nursing research, practice, and education.
Materials and methods
A concept analysis was carried out as the most suitable and rigorous method to define the concept of interpersonal skills in nursing.
Comparing the different forms of analysis, Walker and Avant's 8 methodology has fewer steps to follow than Wilson's 8, which allows to exemplify what the concept is and is not; in contrast to Rodger 9, which only includes the model case and it does not require explicit assumptions as proposed by Meleis 7. Walker and Avant's steps were followed for concept analysis: 1) Select a concept; 2) Determine the aim and purpose of the analysis; 3) Identify all uses of the concept; 4) Identify the defining attributes of the concept; 5) Construct a model case; 6) Construct borderline, related, and contrary cases; 7) Identify antecedents and consequences; 8) Define empirical referents.
Two strategies were employed to gather information on the concept and perform the analysis: literature search and consultation with an expert in the field. Both strategies are described below:
Literature search: It was conducted in Science Direct, Pubmed, Medline, Academic Search Complete, PsycARTICLES, BVS, and Scopus databases. We narrowed down the search to articles written in English, Spanish, and Portuguese and published between 2009 and 2019. This time range is adequate to cover the theoretical-conceptual evolution and the current state of the topic because the initial search yielded results per year, with a marked increase in articles related to professional competence and interpersonal skills in nursing since 2009. DeCS and MeSH terms 'nursing research,' 'nursing education research,' 'nursing practice,' 'professional competence,' and 'interpersonal skills' were searched using the Boolean operators AND and OR.
The literature review only included research articles, dissertations, thesis, and books addressing interpersonal aspects in nursing. Critical appraisal of manuscripts that presented research results was conducted using CASPe tools 10. The search and selection strategy of manuscripts is described in Figure 1.
Source: Adapted from PRISMA Flow diagram for Scoping Review 11
Figure 1 Literature search and selection diagram
Subject experts: Although the concept analysis methodology does not explicitly consider nurses' experiences regarding the conception and uses of the concept, we decided to include two nurses. They were part of the main study of the dissertation in which this analysis is immersed and were interested (voluntarily) in talking about the subject. Thus, from their experience, they fed what was found in the literature. Given the scope and uses of the concept, knowing the nurses' definition of interpersonal skills was considered relevant. With their prior consent, these nurses with graduate degrees in nursing and education were invited to participate in a semi-structured interview. They have researched into professional competence and communication skills; both have extensive practical experience, and nowadays, they work as lectures in nursing schools and departments in Spain and Colombia. They were asked about their knowledge, perception, and definition of competence and interpersonal skills; the main questions asked were the following: "When talking about the concept of interpersonal skills in nursing, what is the first thing that comes to your mind? How do you define it? What aspects make it up? Answers were audio-recorded, transcribed, and analyzed according to relevant themes and attributes using Atlas ti.
Data analysis: The analysis of the information collected aims to follow the steps proposed in the concept analysis methodology, the literature review, and the consultation of subject experts. However, the review process is described according to Whittemore and Knafl 12, and the interviews with the experts were subjected to thematic analysis 13, as presented in Table 1. They were then compared with each other to define the critical attributes of the concept, as shown in the results.
Table 1 Analysis of the information collected
| Integrative review of the literature | Thematic analysis of the interviews |
| 1. Problem identification: The concept of interest arises when conducting a limited search for the dissertation in which the concept analysis is included. | Phase 1. Getting familiar with the data/information: The interviews are read during the transcriptions. |
| 2. Literature search: As presented in Figure 1 | Phase 2. Generation of categories or initial codes: In a detailed reading, the general topics are highlighted. |
| 3. Data assessment: Critical reading is performed as presented in Figure 1. | Phase 3. Search for topics: The emerging codes related to the concept of interpersonal skills are gathered. |
| 4. Data analysis: The information is organized by common characteristics, in this case, by the attributes that represent the concept. | Phase 4. Topic review: Codes are merged and described from the data and part of the literature. |
| 5. Presentation of results: The antecedents, consequences, and characteristics of the concept are speciied. | Phase 5. Topic definition and naming: The topics are named and defined according to the concept concerned. |
| Phase 6. Production of the final report: The concept analysis is carried out, and the findings from the interviews and the literature review are contrasted. |
Source: Own elaboration
In analyzing the information from the literature and interviews, attributes and concepts emerged repetitively, showing strength in the data and characterizing the concept with aspects such as empathy, confidence, emotional intelligence, and negotiated decision making. These aspects are expanded in the uses of the concept and the critical attributes.
Finally, to follow the ethical principles of research, this concept analysis is embedded within a dissertation endorsed by the Ethics Committee of the Nursing School, Universidad Nacional de Colombia. Additionally, the participating experts signed informed consents for the interviews. This information is in possession of the first author, which will be retained and kept confidential for five years and then eliminated.
Results
Following the steps of concept analysis, the results are described below.
Concept selection and aim of the analysis
Multiple definitions of this term were found during the literature search on different nursing skills. However, when approaching the interpersonal aspects, we determined that the concept of interpersonal skills in nursing had not been clearly defined within the discipline since this concept tends to be confused with others, such as social skills, communication skills, empathy, or emotional intelligence, which, although linked, convey different meanings. Then, it is essential to clarify the meaning of interpersonal skills in nursing by offering a constitutive and operating definition.
Uses of the concept
The literature on the discipline and the experts in nursing skills were consulted to verify the uses of the concept. In this way, we could determine that the concept of interpersonal skills has been addressed mainly by nursing education research, clinical practice, and some nursing theories focused on interaction as a form of care. This section describes some aspects found in the literature review that can be divided into topics, as presented in Table 2.
Table 2 Integrated evidence from the literature
| Topic | Characteristics |
|---|---|
| Beginnings and origin of the concept | Conceptually, interpersonal skills in nursing began to be addressed by the Tuning Project 14. It defined it as individual abilities to express one's feelings and to be critical and self-critical, social skills related to interpersonal skills, ability to work in a team or to express social and ethical commitment, and abilities that tend to facilitate social interaction processes in nursing 15. |
| Communication skills in nursing | The most outstanding nurses' skills, strategies, and gestures to communicate effectively include empathy, negotiation skills; use of socio-culturally appropriate information; good intonation, volume, and rhythm of the voice, body language, and facial expression. According to these authors, all these aspects may be trainable 16-18. Regarding nursing education, some studies started from the positive teacher-student experience; that is, when they understand each other, students' anxiety levels are reduced in practice settings 19,20. Then, the relationship modifies the student's behavior 21. |
| Empathy and emotional intelligence | Interpersonal skills in nursing comprises emotional skills (emotion expression and control, anxiety management, among others) 22 and cognitive skills (interpreting the situation, perceiving others correctly), which enable nurses to observe, interpret, and integrate a situation, and take an empathic position 5. Sociodemographic, labor, and academic variables seem to be related to emotional intelligence and empathy 23. For senior nursing students, proper empathy, respect, and assertiveness levels are associated with good performance during clinical practices 24,25. Then, student's education requires not only instrumental skills, but also affective skills 26,27. |
| Negotiated decision-making in nursing care | Some authors determined in their studies that situational aspects for both patient and nurse may condition the quality of the established relationship, participation in care, and communication 28-30. Research on end-of-life care found that nurses seek consensus and emotional support during decision-making, which gives peace of mind to the person, the family, and the nurse 29. |
| Concept from nursing theories | Peplau affirms that nursing care is an interpersonal therapeutic process carried out through a relationship between the individual and the nurse 31,32. For Paterson and Zderad, nursing is an intersubjective-transactional relationship between a nurse and a patient, where they share experiences that lead to intersubjectivity, characterized by real presence and authentic sharing 33,34. Then, humane practice becomes the purpose of interpersonal skills in nursing. |
Source: Own elaboration
Finally, the literature review shows no clearly defined concept of interpersonal skills in nursing to work with for research and practice. What is clear is that interpersonal skills delimit knowledge, abilities, attitudes, and values applied to interpersonal relationships that nurses establish with care recipients and integrated into practical situations of care to ensure human care provision.
Concept attributes
The concept attributes allow us to approach a definition and recognize its characteristics. Interpersonal skills in nursing are made up of the knowledge, abilities, attitudes, and values expressed by nurses in recognition of the other person, in an authentic encounter that provides the interaction with therapeutic properties and positive effects for mutual growth 35 and favors the development of negotiation capacity and shared decision-making 36.
The development of interpersonal skills in nursing is mediated by attributes of interpersonal relationship such as trust, empathy, emotional intelligence, assertive communication, respect, openness towards others experiences, flexibility, social maturity, being in touch with one's and others' feelings, understanding, and negotiated decision-making 37. Interpersonal skills are also influenced by the nurse's experience and other interpersonal relationships, such as those involved in teamwork and work settings 36,38.
Findings from the literature are supported by the experts' opinions about the subject. They consider interpersonal skills related to the formation of the self in nursing, the ability to reflect on interactions, nurses' previous and personal experiences, and communication as the cross-cutting factors of interpersonal relationships. Voices of the experts and topics discussed are shown in Table 3.
Table 3 Topics and voices of the experts interviewed
| Topics | Voices of the experts |
|---|---|
| Formation of the self in nursing: That "self" includes professional and personal values, ethical principles, emotion management, and comprehension of the other person's experience and meaning of health. | "If I don't work on all these aspects of the self, not just what has to do with values, but also, for example, what has to do with self-assurance, how will I tune up confidence and sureness in a student who is going to lead health care teams and decision-making processes in nursing care?" (Expert 02) |
| Communication as a basis for interpersonal relationships: Conveying an idea in which verbal and non-verbal expressions bear meanings for both parties to understand and help each other grow. | "[Interpersonal skills comprise] verbal language, non-verbal language, contact, empathy, and communication. I think that dialogue and communication are essential. These skills are just as crucial between teacher and student as among nurses and between doctor and nurse." (Expert 01) |
Source: Data obtained from the analysis carried out by the authors in Atlas ti
For clarity purposes, critical attributes of the concept are presented in Table 4. These attributes represent what we found in the literature review, complemented and validated by the interviews carried out.
Table 4 Critical attributes and surrogate terms of the concept
| Critical attributes | Definition |
|---|---|
| Expression of the self of nursing and its bioethical values, in which the relationship has a therapeutic or pedagogical aim (according to the role of nursing) that produces positive results. | The self of nursing is abstract; however, it essentially provides care as an interpersonal relationship 4, in which the connection and interest in others' needs and vulnerable situations make nurses use their sensitivity, trust, active listening, and respect as a means of understanding and benefiting other people. |
| Ability to negotiate and make decisions together with the other person. Communicating needs | Negotiated and jointly made care decisions foster horizontal relationships and give value and importance to what other people think about a situation. Other people may be students, patients, families, communities, and work teams. |
| Identification and self-control of emotions derived from shared experiences | Nurses should reflect on their own emotions, which are often difficult to identify and control due to nurses' multiple adverse situations. So, emotional intelligence is part of interpersonal skills in nursing. |
| Understanding the context where other interpersonal relationships established by nurses take place | It means that part of the nurses' attitude may depend on other relationships, such as those with colleagues and other professionals in the health team. Literature shows that a good work environment fosters good interpersonal relationships. |
Source: Own elaboration
The self of nursing identifies with the essence of care that is the interpersonal relationship, which allows understanding the human health experience; in this dynamic, the need to identify and control emotions emerges, especially because experiences such as pain or death are difficult to handle when caring behaviors are marked by empathy and ethical principles of caring 39,40. Consequently, the critical and reflective analysis of these situations helps the nurse understand the conceptions of health and care of people and the contexts in which care occurs, actively participating in decision-making. These characteristics enable us to recognize interpersonal skills in nursing.
In summary, interpersonal skills describe nurses' abilities to be open to others and their own experiences in the caring process. It involves knowing how to listen and communicate assertively, regulate emotions, be empathetic, respect and understand situations, help make negotiated decisions, and show a humane practice 41,42. Besides, there are settings for teamwork that also affect the way interpersonal relationships are established.
Case construction
Subsequently, once exclusive characteristics of the concept are evident, the next step is taken, which is, at first sight, something simple but requires analytical thinking: case construction. The cases are constructed to illustrate what the concept is and is not, as follows:
Model case
An emergency nurse is caring for an older adult dying on a gurney in the hall, accompanied by his relative. The nurse decides to approach them because when she started her shift, she noted the patient's condition and the sad expression of his relative, so she greets them amicably and warmly, introduces herself, and asks them what they need. The patient's relative breaks into tears, and the nurse comforts him with a purposeful touch. The patient's relative tells her that he does not understand what is going on with his father and does not know if he is suffering exposed to the sight of everyone. The nurse listens to the patient's relative, answers his questions, and helps him say goodbye to his father. Then, understanding the situation and noting that there are no beds available in the inpatient unit, the nurse moves the patient to a more private area with an exclusive space for him and the relatives who wish to be there with him. The nurse informs the psychologist about the situation, and they together support the process of death and mourning, giving peacefulness to the family and dignity to the father's death.
Borderline case
An emergency nurse is caring for an older adult going through the dying process in the hall, accompanied by his relative. The nurse decides to approach them as she does with all her patients on each shift, greeting them and asking them what they need. The patients' relative breaks into tears, and she keeps silent and leaves for a moment. Then, she returns and informs the patient's relative that as there are no beds available in the inpatient unit, she will locate the patient in a more private place so that his family can say goodbye to him. Then, understanding the situation, the nurse informs the psychologist about the situation and, they together support the process of death and mourning.
Related case
An emergency nurse is caring for an older adult going through the dying process in the hall, accompanied by his relative. The nurse decides to approach them because she feels empathy, as she had liveda similar situation with her grandfather. She greets and asks them what they need, the patient's relative breaks into tears, and the nurse begins to talk to them about how important it is to say goodbye and be grateful for everything they shared and lived together. The nurse then informs the patient's relative that there are no beds available in the inpatient unit, but she will locate the patient in a more private place. There, the patient's relative expresses his feelings; the nurse listens to him and asks for support from the psychologist to support the process of death and mourning.
Contrary case
An emergency nurse is caring for an older adult going through the dying process in the hall, accompanied by his relative. The nurse approaches to give the patient the medications and notes that the patient's relative is sad; so, she decides to avoid the situation and only informs them that she is giving medications that relieve pain.
The patient's relative asks her to please relocate them. She moves the patient to a more private area and tells them again that there are no beds available. She informs the treating physician and says that it is his job to support them in this process of death and mourning.
Comparing the model case versus the contrary case, Table 5 presents a specific analysis that makes explicit the differences between them.
Table 5 Comparison between cases
| Critical attributes | Model case | Contrary case |
|---|---|---|
| Expression of the self of nursing and bioethical values | The ethical principle of beneficence, approaching others, and authentic presence | Minimum interest and responsibility for the person's situation |
| Ability to negotiate and make decisions together/ communication | Control of situations and decision-making considering the family | Superficial management of the problem, unable to mediate care decisions. |
| Identification and self-control of emotions | She manages to empathize with the situation without being affected emotionally | Little control of emotions during attention, runs away from the situation. |
| Understanding the context of others interpersonal relationships | Good communication and relationship with the team and focuses attention on the patient | There is no relationship with the patient care team |
Source: Own elaboration
Identification of antecedents and consequences
Antecedents are those aspects present before competence achievement, and consequences are those aspects that result from such competence.
As antecedents, nurses ought to have theoretical knowledge of interpersonal relationships, which is acquired during their professional training and from previous experiences such as the school and family education they received, especially values, morals, and ethics. Additionally, self-criticism and reflection on practical action should be strengthened to think and rethink the experiences derived from established relationships 43,44.
Regarding the consequences of developing interpersonal skills, nurses will follow a humane practice, be genuinely present in the care they provide, be guided by bioethical principles, and efficiently work in teams 45,46.
Empirical referents: Methods and measurement instruments
Few validated instruments are available to measure interpersonal skills in English and Spanish versions. Some scales that may measure specific attributes or address interpersonal aspects are shown in Table 6. Research perspectives to approach this phenomenon show that experiences and the process of developing interpersonal skills in nursing have been researched from the qualitative point of view. Quantitatively, researchers have come close to describing the characteristics and relating each attribute to this concept.
Table 6 Measurement instruments related to the concept
| Concept | Instrument | Validity and Reliability |
| Caring Behavior | Caring Behaviors Assessment (CBA) 47. It is based on Watson's Theory. | Cronbach's alpha: 0.96 Content Validity (CVI): 0.93 (high) Factor analysis with Varimax rotation of 72 % explained variance |
| Caring Interpersonal Relationships | Assessment of nurse-patient interpersonal relationship VRIEP-ICU 48. It is based on the HANC model (humanism, patient assistance, met need, and quality of care). | Content Validity with Kappa index of agreement of 0.86 (high) It needs tests for construct validity and reliability. |
| Caring Interpersonal Relationships | Nursing Care Interpersonal Relationship Questionnaire 49. It is based on Imogene King's Conceptual Model. | Cronbach's alpha: 0.90 Content Validity: > 0.78 (high) One factor explains 31.5 °% variance. |
| Attributes of Care Subjectivity | Caring Assessment Scale Tool (CAT-V). It is based on the Theory of Transpersonal Human Caring. | Cronbach's alpha: 0.95 Three factors explain 59.3 % variance. |
Source: Own elaboration
Implications for research, practice, and education
Having conceptual clarity of the term interpersonal skills in nursing guides both the being and the duties of nursing professionals. Evidence shows a growing need to include it within the training practices of students since interpersonal skills has become essential to provide care recipients with authentic and humane care. Despite being often intangible, interpersonal skills are perceptible to those who are receiving care.
However, approaching more factual knowledge, it is expected that the attributes derived from this analysis will guide future translational research through interventions that favor the development of these skills in nursing professionals and psychometric research to create specific scales for its measurement. The real impact will be on the patient cared for and their families by having nurses that make them visible and participants in their care.
Conclusions
After the literature review and the consultations with subject experts, we can affirm that interpersonal skills in nursing are the knowledge, abilities, attitudes, and values that nurses can express comprehensively during the interpersonal relationships they es tablish with others, whether care recipients, family members, communities, colleagues, or other professionals. These skills are characterized by respect, openness to others' experiences, emotion management, commitment to others, empathy, negotiated and shared decision making, teamwork, and application of bioethical principles. Their purpose is to develop a humane nursing practice in which positive results are obtained therapeutically or pedagogically depending on the role played by the nursing profession.
Hopefully, this concept analysis will guide future research on measurement and assessment of interpersonal skills and the effect of educational programs that include interpersonal skills. Despite the different global settings in which nurses work today, interpersonal skills concern each country and each role nurses play.
