ht. J. h’ur.s. Srud., Vol. 28, No. I, pp. 3-11, Printed in Great Britain.
1991. 0
00207489/91 13.00+0.00 1991 Pergamon Press plc
Nurses’ interpersonal behaviours and the development of helping skills KENNETH
J. SELLICK,
Ph.D.,
M.Psychol.,
R.N.
Senior Lecturer, Department of Nursing, LaTrobe University, Melbourne, Victoria, Australia
Abstract-This study investigates the interpersonal behaviours of general nurses and evaluates the effectiveness of a nine-week program in developing helping skills. Ninety-nine nurses undertaking tertiary studies were administered the FIRO-B Scale, which assesses six dimensions of interpersonal behaviours, before and after the skills program. Changes in interpersonal behaviours were examined for the total sample and for six clinical subgroups based on the nurse’s area of clinical practice. Nurses’ FIRO-B scores at pre-test were also compared with results from a sample of occupational therapy students. The results of this study showed that nurses, when compared with occupational therapists, had less desire to belong and a stronger need to influence or control interpersonal relationships. When clinical subgroups of nurses were contrasted, significant differences in the need for inclusion and affection were identified. Evaluation of the communication skills program demonstrated some significant improvements in helping attitudes for the sample as a whole, but no differences when specific nursing subgroups were examined. Findings from this study are discussed in relation to the helping role of nurses, methodological limitations, and directions for future investigation.
Introduction
It has long been acknowledged that interpersonal communication, helping, and counselling skills are a fundamental component of the nurse’s role and essential prerequisites for quality nursing care (Anderson and Gerrard, 1984; Clark, 1981; Sellick and Bolton, 1989). In performing their every-day functions nurses are confronted with a wide range of situations that require effective interpersonal skills. Such situations include providing patients with information and reassurance about procedures and treatments, helping them cope with the stressful impact of illness and hospitalization, and working with other nurses and health professionals in planning and implementing quality patient care. However, while most 3
4
K. J. SELLICK
countries agree on the importance of helping skills by including them as one of the standards of nursing practice (Murray and Zentner, 1979), it is only in the last decade that an interpersonal communications component has been introduced into nursing curricula. However, despite some developments in this area, most nursing programs cover the topic at a conceptual rather than skill development level (Hills and Knowles, 1983). The interpersonal qualities and communication skills of nurses have received scant research attention. Further, findings from the few studies that have been published are disappointing, suggesting that nurses’ level of empathy, warmth, and genuineness, as well as basic communication skills are often below the minimum needed to be effective helpers (Daniels et al., 1988; Hills and Knowles, 1983; Anderson and Gerrard, 1984). Many of these deficiencies, found to apply across a wide range of clinical settings, have been attributed to the absence of formal communication skills training within the nursing program. However, not all studies present such a pessimistic view. Forsyth’s (1979) study of the relationship between empathy and therapeutic effectiveness found nurses had moderate to high empathy, and that scores were higher for baccalaureate nurses when compared with diploma level nurses. Similarly, Iwasiw and Olson (1985), in their pilot study of acute care nurses, found it was baccalaureate prepared nurses who were more empathic and had greater skill in identifying and responding to patients’ feelings. The results from both these studies suggest that helping attitudes can also vary as a function of age, years of experience, and field of nursing practice. Investigation of the effectiveness of interpersonal communication skills training for nurses, while limited to a few studies, has provided some encouraging results. In the study by Anderson and Gerrard (1984) first year student nurses who participated in a comprehensive interpersonal skills course were assessed relative to a control group. Responses to interactions with simulated patients showed nurses who completed the skills program were more empathic than students who received no training. More recently Daniels et al., (1988) demonstrated the efficacy of a microcounselling program for teaching therapeutic communication skills to nurses. In this well-controlled study 53 second year nurses were’randomly assigned to treatment (microcounselling) and control (non-attention) groups and compared on generic communication skills. Nurses undertaking the microcounselling program performed better overall and specifically on measures of empathy, reflection of feelings, summarizing, and questioning technique. When the two groups were assessed at nine months follow-up there were no significant differences between groups: a finding the authors attribute to the lack of further training or the opportunity for students to practice the skills developed during the program. However, the results do show the microcounselling group recorded higher post-test scores on all measures. It is evident from a review of the literature that more research is needed to establish the interpersonal qualities and communication skills of nurses, identify possible differences in interpersonal effectiveness between nursing levels and specialist areas of nursing practice, and to evaluate the efficacy of communication skills training programs. The purpose of the present study was to investigate the interpersonal behaviours of a group of qualified general nurses undertaking tertiary studies. Specifically, the aims of the study were (i) to compare the interpersonal behaviours of nurses with the reported behaviours of a group of occupational therapists, (ii) to establish whether the interpersonal behaviours of nurses differ as a function of their chosen area of clinical practice and (iii) to establish the extent to which an interpersonal communication skills program can facilitate the development of effective helping behaviours.
NURSES’ INTERPERSONAL
BEHAVIOURS
AND THE DEVELOPMENT
OF HELPING
SKILLS
5
Method
Sample The initial sample consisted of 99 nurses commencing either a one year Diploma or a two year Bachelor degree course which included a core interpersonal communication skills program. All students were registered nurses with at least two years post-registration nursing experience. Students were enrolled in one of five major streams of study: maternal and child health nursing (diploma), advanced clinical nursing, community health nursing, midwifery, nursing education, and nursing administration (degree courses). The sample was predominantly female (95%) with an age range from 22 to 50 years (M= 31.34 years). A breakdown of the sample by stream of study, group size, and age is presented in Table 1. Comparison of groups showed students enrolled in the midwifery stream were significantly younger than the other groups [F(5.93) = 4.86, P < O.OOl].Of the 99 students, 66 (67%) were available for follow-up on completion of the interpersonal communication skills training program.
Table 1. Sample characteristics Study stream
N M
Maternal and child health nursing Clinical nursing Community nursing Midwifery Nursing education Nursing administration
25 18 16 15 16 9
32.60 32.22 31.56 25.07 34.94 36.22
Age SD 6.70 7.30 7.14 4.08 6.42 6.57
Measures Interpersonal behaviours were assessed using the Fundamental Interpersonal OrientationBehaviour (FIRO-B) Test. The FIRO-B is a 54-item self-report instrument developed by Schulz (1978) to measure three dimensions of interpersonal behaviour: inclusion, control and affection. The inclusion dimension assesses behaviours that reflect a person’s need to associate with others; the control dimension the degree to which a person wishes to influence relationships; and the affection dimension relates to a person’s need for emotional involvement, warmth, or intimacy in interpersonal relationships. Each dimension is measured in terms of the characteristic behaviours the individual displays towards others (expressed) and the behaviours the person desires from others (wanted). Thus the FIRO-B test comprises six primary scales with nine items for each scale. Higher scores on the scales indicate a greater need to express or receive inclusion, control, and affection in interpersonal relationships. The FIRO-B scales have been shown to have high stability, validity and test-retest reliability (see Schulz, 1978). Scores on the FIRO-B have been established as good predictors of interpersonal effectiveness and a useful measure of the interpersonal behaviour of nurses, medical students (Schulz, 1978), occupational therapists (Patterson et al., 1970), and physician assistants (Buhmeyer and Johnson, 1977). The Scales have also been used as an indicator of the effectiveness of human relations workshops (see Schulz, 1978). Normative
6
K. J. SELLICK
data for a variety of occupational groups are provided in the FIRO-B Manual (Schulz, 1978). In addition to completing the six FIRO-B scales participants were asked to specify their age, sex and stream of study. Interpersonal communication skills program All students who participated in the study completed a nine week interpersonal communication skills training program. This program is based on Carkhuff’s (1969) model of helping and had as its major objectives the development of self-awareness and effective interpersonal skills. The program commenced with a three day residential self-awareness workshop followed by nine two-hour skill development sessions. Prior to the start of the program students were allocated to small groups of five to seven members. The groups, which remained the same throughout the program, were conducted by experienced group leaders who focused on the development of self-awareness, helping attitudes, and basic interpersonal skills (e.g. attending, listening, questioning, reflecting) using group techniques and role-play and video process-recall strategies. Procedure The FIRO-B test was administered to students by the group leaders during the first week of the Interpersonal Communication Skills course and again during the last week of the program. Prior to the first administration students were informed of the general purpose of the study and given assurance that participation was voluntary. In order to retain anonymity subjects were asked to assign themselves a code name to be used to identify pre- and post-test responses. Both administrations of the FIRO-B were given in a group setting. Ninety-nine students completed the pre-test assessment and 66 (67%) the post-test. Results
Comparison of nurses with occupational therapy students Means and standard deviations for FIRO-B scale scores were calculated for the sample of post-registration nurses and contrasted with mean level data reported for occupational therapy students (Patterson et al., 1970). The occupational therapy student sample (N= 114) consisted of 107 females and 7 males attending Colorado State University. The median age of the sample was 20 years with an age range of 18 to 7 1. Table 2. Comparison of interpersonal behaviours of nurses and occupational therapy students Nurses (N= 99)
Scale
Occupational therapists (N= 114) Mean SD
t
Mean
SD
4.45 3.41
3.04
5.86 5.33
1.88 3.30
-5.59*** -3.79***
2.03 3.05
2.00 2.09
2.09 4.67
1.80
1.99
NS -5.77***
2.86 4.24
1.44 2.51
4.25 5.04
2.30 2.39
-5.36*** -2.37+
Inclusion
Expressed Wanted
1.80
Control
Expressed Wanted Affection
Expressed Wanted *p < 0.05. ***p < 0.001.
NURSES’ INTERPERSONAL
BEHAVIOURS
AND THE DEVELOPMENT
OF HELPING
SKILLS
I
Analysis of group differences using the t-test for independent samples showed nurses scored significantly lower than occupational therapy students on most FIRO-B scales (see Table 2 for a summary of test results). The only area of interpersonal behaviour where the two groups did not differ was on the measure of expressed control. Comparison
of interpersonal
behaviours by stream of study
To investigate the extent to which categories of nursing students differed on measures of interpersonal behaviours, study stream groups (maternal and child health nursing, clinical nursing, community health nursing, midwifery, nursing education, nursing administration) were contrasted on scores on each of the six FIRO-B scales. Because of the significant age difference noted between groups, analysis of covariance (ANCOVA) was employed separately for each measure, with age entered as the covariate. Where a significant group effect was found the Newman-Keul’s Student range test was used to establish the source of group difference. Results are presented separately for Inclusion, Control and Affection measures. Inclusion. Comparative means and standard deviations for Expressed and Wanted Inclusion scores for the six nursing stream groups are presented in Table 3. ANCOVA resulted in a significant group difference on the Wanted Inclusion measure [F(5,92) = 2.80, p < 0.051. Follow-up Newman-Keul’s analysis showed midwives scored significantly higher than all groups except maternal and child health nurses, and that maternal and child health and community health nurses had scores significantly higher than clinical nurses, nurse administrators, and nurse educators. There were no significant differences between nurse administrators, nurse educators and clinical nurses, or between community health and maternal and child health nurses. Table 3. Means and standard deviations for Inclusion measures by stream of study Study stream Maternal and child health nursing Clinical nursing Community health nursing Midwifery Nursing education Nursing administration
Expressed inclusion Mean SD 4.84 4.39 5.06 5.00 4.56 4.00
1.49 1.34 1.61 2.24 1.63 2.24
Wanted inclusion Mean SD 4.68 2.44 4.06 5.33 2.00 1.33
2.12 2.96 3.68 3.18 2.85 2.69
Control. Analysis of group differences on Control measures showed no significant differences on Expressed or Wanted Control scores. Comparative mean level statistics are presented in Table 4. Affection. Comparison of the six groups on the Affection scales resulted in a significant difference on Wanted Affection scores only [F(5,92) = 2.72,~ < 0.021. Post-hoc analysis of Wanted Affection scores indicate the source of group difference was associated with significantly higher scores for midwives relative to all other groups except community health nurses and higher scores for community health nurses, clinical nurses, and nurse educators compared with nurse administrators and maternal and child health nurses. Differences between maternal and child health nurses and nurse administrators, and between educators, clinical nurses and community health nurses were non-significant. Comparative means and standard deviations on affection measures are presented in Table 5.
8
K. J. SELLICK
Table 4. Means and standard deviations for Control measures by stream of study Study stream
Expressed control Mean SD
Maternal and child health nursing Clinical nursing Community health nursing Midwifery Nursing education Nursing administration
1.36 2.00 1.50 1.93 2.56 2.11
Wanted control Mean SD
1.44 2.30 1.51 2.25 1.71 2.03
3.00 3.22 2.75 3.47 3.31 2.67
2.40 1.93 1.73 2.03 2.39 1.94
Table 5. Means and standard deviations for Affection measures by stream of study Wanted affection SD Mean
Expressed affection Mean SD
Study stream Maternal and child health nursing Clinical nursing Community health nursing Midwifery Nursing education Nursing administration
3.28 2.67 3.50 3.93 2.31 2.22
1.57 1.33 2.16 1.98 1.74 1.48
3.00 4.50 5.06 5.47 4.25 3.33
3.35 1.72 1.77 1.89 1.65 1.80
Effects of communication skills training on interpersonal behaviours Pre- and post-scores on the six FIRO-B scales for the total sample and for the six study stream nursing groups were compared to establish the impact of communication skills training. Results of repeated measures ANOVA applied separately for the total sample for each measure showed nurses’ level of expressed affection increased significantly over the time span of the study [F(1,66)= 5.59,~ < 0.0251. Changes in mean scores on the remaining five measures were non-significant. Means, standard deviations and test of significance results for the total sample are presented in Table 6. A series of ANOVAs were used to compare study stream groups on pre- and post-FIROB scores. Results showed no significant group effects or group x time interactions, thus indicating that nursing stream groups did not differ in the pattern of change in interpersonal behaviours in response to a program of interpersonal communications training. Table 6. Mean FIRO-B scores for pre- and post-tests for total sample (N=66) Scale
Pre-test Mean
SD
Mean
SD
4.45 3.41
1.80 3.04
4.45 3.32
1.94 3.36
0.00 0.57
2.03 3.05
2.00 2.09
1.91 2.80
2.04 2.09
0.62 1.12
2.86 4.24
1.44 2.51
3.33 4.58
1.77 1.97
2.34** 1.06
Post-test
F
Inclusion
Expressed Wanted
Control Expressed Wanted Affection
Expressed Wanted **p < 0.025.
NURSES’
INTERPERSONAL
BEHAVIOURS
AND
THE DEVELOPMENT
OF HELPING
SKILLS
Discussion The aims of this study were to investigate the interpersonal behavioural profile of nurses and evaluate the effectiveness of a communication skills program in developing behaviours conducive to effective helping. The results showed the interpersonal qualities of nurses differed significantly to those reported for occupational therapy students and that some differences were evident when nursing subgroups were compared. Evaluation of the effectiveness of a nine-week communication skills training program found only a few changes in interpersonal behaviours as assessed by the FIRO-B scales. Comparison of nursing and occupational therapy students indicate dissimilar patterns of interpersonal behaviours. It appears that nurses express less need to belong and have a stronger desire for influence and control in social situations than occupational therapy students. A similar tendency for occupational therapy students was reported by Patterson et al. (1970) in their study, with occupational therapy students concerned less with exerting control than psychology majors and teachers. The question is whether the pattern of results for nurses can be attributed to occupational differences. According to Schulz (1978) the FIRO-B scales consistently differentiate between a variety of occupational groups. However, because of differences in the characteristics of the two samples used in the present study, the possible influence of age, educational level, and cultural factors cannot be excluded. For example, comparison of the two groups shows nurses were older than the occupational therapy students. Clearly further research is needed to examine differences in the interpersonal behaviours of health professional groups, taking into account the influence of other factors. Of particular interest to the study of the helping role of nurses is the comparison of interpersonal behaviours across specialist clinical nursing groups. When responses on the FIRO-B scales for the six course streams were contrasted, notable differences on inclusion and affection measures were identified. Nurses enrolled in the midwifery and maternal and child health streams had a greater need to be included in interpersonal relationships than nurses in the nursing administration, nursing education, clinical nursing, and community health nursing groups. Interestingly, the differences between the midwifery and maternal and child health nursing groups were non-significant: a result that may be due to the fact that midwifery is also a prerequisite for the maternal and child health course. A different pattern of results emerged when nursing subgroups were compared on the wanted affection measure. Again, midwives recorded the highest mean score which achieved statistical significance for all group comparisons except in the case of the community health nursing group. Nurse educators, clinical nurses, and maternal and child health nurses also had a greater need for affection from others compared with nurse administrators. Unlike inclusion scores, these findings are not easily explained in terms of area of practice. One possible explanation for these findings is that midwifery and community health nurses were younger than other clinical groups: a finding consistent with results reported by Forsyth (1979). In this study younger nurses scored higher on the Hogan Empathy Scale (Hogan, 1969), although the difference between age groups was not statistically significant. However, in the present study the possible influence of age was controlled for using analysis of covariance. The Forsyth (1979) study also compared nurses’ empathy scores across five areas of clinical practice (medical, surgical, psychiatric, orthopaedic and rehabilitation). Although differences were not statistically significant, the mean scores for the rehabilitation group were considerably higher. Coupled with the present study, these results suggest comparison of different areas of nursing practice to be a fruitful area for future investigation.
9
10
K. J. SELLICK
The other question addressed by this study was the extent to which a nine-week communication skills training program facilitated the development of nurses’ interpersonal behaviours. While results demonstated few changes in FIRO-B scale scores, a significant increase in the level of expressed affection for the total sample does suggest some improvement in interpersonal effectiveness. That nurses had a greater need to express more affection in their interpersonal relationships could result in greater empathy, warmth, and willingness to focus on the feelings of others: a possible outcome consistent with the emphasis of the training program on self-awareness and the affective domain of therapeutic communication, but one that would need to be established through follow-up study. Several explanations can be offered for the lack of effect on other domains. One is the appropriateness of the FIRO-B scales as a measure of interpersonal skill development. While these scales have been found to be effective in differentiating between groups they may not have the specificity to detect changes as a consequence of a communication skills training program. This study has a number of methodological limitations which influence the interpretation of results. For example, the sample consisted of a group of qualified nurses, with varying clinical experience and expertise, who were undertaking post-graduate studies. As such their interpersonal profile may be quite different from nurses in general and from student nurses in particular. Secondly, because of the context of the study, it was not feasible to use a control group to evaluate the effectiveness of the interpersonal skills program: a design requirement necessary to exclude the possibility that changes in behaviour could have occurred independently to the program. Fin&y, the measure used in this study, while having established reliability and validity, may not have been sensitive enough to detect changes in interpersonal behaviour. It is also of note that FIRO-B measures are based on the self-’ report of respondents rather than an independent assessment by others. For future studies it may be more appropriate to employ measures that assess specific helping attitudes and skills, such as the empathy scales developed by Carkhuff (1969) and Hogan (1969) or the technique for assessing microskills used by Daniels et al. (1988). Despite the constraints in research design, this study does provide some evidence of the effectiveness of an interpersonal communication skills program and points to the value of comparing nurses with other health professional groups. In particular, this study emphasizes the helping role of the nurse and the need to evaluate the efficacy of skill development programs, taking into account the influence of age, level of experience, and area of clinical practice. Future studies should also examine the relative effectiveness of different methods of teaching helping skills and the impact of such programs on the quality of patient care. References Anderson, M. and Gerrard, B. (1984). A comprehensive interpersonal skills program for nurses. J. Nurs. Ed. 23, 353-355. Buhmeyer, K. J. and Johnson, A. H. (1977). Personality profiles of physician extenders. Psycholog. Rep. 40, 655462. Carkhuff, R. R. (1969). Helping and Human Relations: A Primerfor Lay and Professional Helpers. Rinehart and Winston, Montreal. Clark, J. M. (1981). Communication in nursing. Nurs. Times 77, (l), 12-18. Daniels, T. G., Denny, A. and Andrews, D. (1988). Using microcounselling to teach RN nursing students skills of therapeutic communication. J. Nurs. Ed. 27, 246-252. Forsyth, C. L. (1979). Exploration of empathy in nurse-client interactions. Ad. in Nu. Sci. 1,53-61. Hills, M. D. and Knowles, D. (1983). Nurses’ level of empathy and respect in simulated interactions with patients. ht. J. Nurs. Stud. 20, 83-87.
NURSES’ INTERPERSONAL
BEHAVIOURS
AND THE DEVELOPMENT
OF HELPING
SKILLS
11
Hogan, R. (1969). Development of an empathy scale. J. Consult. Clin. Psychol. 33, 307-316. Iwasiw, C. and Olson, J. (1985). A comparison of the communication skills of practicing diploma and baccalaurete staff nurses. Nurs. Papers 17, 38-48. Murray, R. B. and Zentner, J. P. (1979). Nursing Conceptsfor Health Promotion. Prentice-Hall, Engeiwood Cliffs. Patterson, T. W., Marron, J. P. and Patterson, N. B. (1970). Behavioral patterns of occupational therapy students on the FIRO-B. Am. J. Occupat. Ther. 24, 269-271. Schulz, W. (1978). FIR0 Awareness Scales Manual. Consulting Psychologists Press, Palo Alto. Seliick, K. and Bolton, B. (1989). Counselling. In Psychology for the Health Sciences. N. J. King and A. G. Remenyi (Eds), pp. 171-183. Nelson, Melbourne.
1991. 0
00207489/91 13.00+0.00 1991 Pergamon Press plc
Nurses’ interpersonal behaviours and the development of helping skills KENNETH
J. SELLICK,
Ph.D.,
M.Psychol.,
R.N.
Senior Lecturer, Department of Nursing, LaTrobe University, Melbourne, Victoria, Australia
Abstract-This study investigates the interpersonal behaviours of general nurses and evaluates the effectiveness of a nine-week program in developing helping skills. Ninety-nine nurses undertaking tertiary studies were administered the FIRO-B Scale, which assesses six dimensions of interpersonal behaviours, before and after the skills program. Changes in interpersonal behaviours were examined for the total sample and for six clinical subgroups based on the nurse’s area of clinical practice. Nurses’ FIRO-B scores at pre-test were also compared with results from a sample of occupational therapy students. The results of this study showed that nurses, when compared with occupational therapists, had less desire to belong and a stronger need to influence or control interpersonal relationships. When clinical subgroups of nurses were contrasted, significant differences in the need for inclusion and affection were identified. Evaluation of the communication skills program demonstrated some significant improvements in helping attitudes for the sample as a whole, but no differences when specific nursing subgroups were examined. Findings from this study are discussed in relation to the helping role of nurses, methodological limitations, and directions for future investigation.
Introduction
It has long been acknowledged that interpersonal communication, helping, and counselling skills are a fundamental component of the nurse’s role and essential prerequisites for quality nursing care (Anderson and Gerrard, 1984; Clark, 1981; Sellick and Bolton, 1989). In performing their every-day functions nurses are confronted with a wide range of situations that require effective interpersonal skills. Such situations include providing patients with information and reassurance about procedures and treatments, helping them cope with the stressful impact of illness and hospitalization, and working with other nurses and health professionals in planning and implementing quality patient care. However, while most 3
4
K. J. SELLICK
countries agree on the importance of helping skills by including them as one of the standards of nursing practice (Murray and Zentner, 1979), it is only in the last decade that an interpersonal communications component has been introduced into nursing curricula. However, despite some developments in this area, most nursing programs cover the topic at a conceptual rather than skill development level (Hills and Knowles, 1983). The interpersonal qualities and communication skills of nurses have received scant research attention. Further, findings from the few studies that have been published are disappointing, suggesting that nurses’ level of empathy, warmth, and genuineness, as well as basic communication skills are often below the minimum needed to be effective helpers (Daniels et al., 1988; Hills and Knowles, 1983; Anderson and Gerrard, 1984). Many of these deficiencies, found to apply across a wide range of clinical settings, have been attributed to the absence of formal communication skills training within the nursing program. However, not all studies present such a pessimistic view. Forsyth’s (1979) study of the relationship between empathy and therapeutic effectiveness found nurses had moderate to high empathy, and that scores were higher for baccalaureate nurses when compared with diploma level nurses. Similarly, Iwasiw and Olson (1985), in their pilot study of acute care nurses, found it was baccalaureate prepared nurses who were more empathic and had greater skill in identifying and responding to patients’ feelings. The results from both these studies suggest that helping attitudes can also vary as a function of age, years of experience, and field of nursing practice. Investigation of the effectiveness of interpersonal communication skills training for nurses, while limited to a few studies, has provided some encouraging results. In the study by Anderson and Gerrard (1984) first year student nurses who participated in a comprehensive interpersonal skills course were assessed relative to a control group. Responses to interactions with simulated patients showed nurses who completed the skills program were more empathic than students who received no training. More recently Daniels et al., (1988) demonstrated the efficacy of a microcounselling program for teaching therapeutic communication skills to nurses. In this well-controlled study 53 second year nurses were’randomly assigned to treatment (microcounselling) and control (non-attention) groups and compared on generic communication skills. Nurses undertaking the microcounselling program performed better overall and specifically on measures of empathy, reflection of feelings, summarizing, and questioning technique. When the two groups were assessed at nine months follow-up there were no significant differences between groups: a finding the authors attribute to the lack of further training or the opportunity for students to practice the skills developed during the program. However, the results do show the microcounselling group recorded higher post-test scores on all measures. It is evident from a review of the literature that more research is needed to establish the interpersonal qualities and communication skills of nurses, identify possible differences in interpersonal effectiveness between nursing levels and specialist areas of nursing practice, and to evaluate the efficacy of communication skills training programs. The purpose of the present study was to investigate the interpersonal behaviours of a group of qualified general nurses undertaking tertiary studies. Specifically, the aims of the study were (i) to compare the interpersonal behaviours of nurses with the reported behaviours of a group of occupational therapists, (ii) to establish whether the interpersonal behaviours of nurses differ as a function of their chosen area of clinical practice and (iii) to establish the extent to which an interpersonal communication skills program can facilitate the development of effective helping behaviours.
NURSES’ INTERPERSONAL
BEHAVIOURS
AND THE DEVELOPMENT
OF HELPING
SKILLS
5
Method
Sample The initial sample consisted of 99 nurses commencing either a one year Diploma or a two year Bachelor degree course which included a core interpersonal communication skills program. All students were registered nurses with at least two years post-registration nursing experience. Students were enrolled in one of five major streams of study: maternal and child health nursing (diploma), advanced clinical nursing, community health nursing, midwifery, nursing education, and nursing administration (degree courses). The sample was predominantly female (95%) with an age range from 22 to 50 years (M= 31.34 years). A breakdown of the sample by stream of study, group size, and age is presented in Table 1. Comparison of groups showed students enrolled in the midwifery stream were significantly younger than the other groups [F(5.93) = 4.86, P < O.OOl].Of the 99 students, 66 (67%) were available for follow-up on completion of the interpersonal communication skills training program.
Table 1. Sample characteristics Study stream
N M
Maternal and child health nursing Clinical nursing Community nursing Midwifery Nursing education Nursing administration
25 18 16 15 16 9
32.60 32.22 31.56 25.07 34.94 36.22
Age SD 6.70 7.30 7.14 4.08 6.42 6.57
Measures Interpersonal behaviours were assessed using the Fundamental Interpersonal OrientationBehaviour (FIRO-B) Test. The FIRO-B is a 54-item self-report instrument developed by Schulz (1978) to measure three dimensions of interpersonal behaviour: inclusion, control and affection. The inclusion dimension assesses behaviours that reflect a person’s need to associate with others; the control dimension the degree to which a person wishes to influence relationships; and the affection dimension relates to a person’s need for emotional involvement, warmth, or intimacy in interpersonal relationships. Each dimension is measured in terms of the characteristic behaviours the individual displays towards others (expressed) and the behaviours the person desires from others (wanted). Thus the FIRO-B test comprises six primary scales with nine items for each scale. Higher scores on the scales indicate a greater need to express or receive inclusion, control, and affection in interpersonal relationships. The FIRO-B scales have been shown to have high stability, validity and test-retest reliability (see Schulz, 1978). Scores on the FIRO-B have been established as good predictors of interpersonal effectiveness and a useful measure of the interpersonal behaviour of nurses, medical students (Schulz, 1978), occupational therapists (Patterson et al., 1970), and physician assistants (Buhmeyer and Johnson, 1977). The Scales have also been used as an indicator of the effectiveness of human relations workshops (see Schulz, 1978). Normative
6
K. J. SELLICK
data for a variety of occupational groups are provided in the FIRO-B Manual (Schulz, 1978). In addition to completing the six FIRO-B scales participants were asked to specify their age, sex and stream of study. Interpersonal communication skills program All students who participated in the study completed a nine week interpersonal communication skills training program. This program is based on Carkhuff’s (1969) model of helping and had as its major objectives the development of self-awareness and effective interpersonal skills. The program commenced with a three day residential self-awareness workshop followed by nine two-hour skill development sessions. Prior to the start of the program students were allocated to small groups of five to seven members. The groups, which remained the same throughout the program, were conducted by experienced group leaders who focused on the development of self-awareness, helping attitudes, and basic interpersonal skills (e.g. attending, listening, questioning, reflecting) using group techniques and role-play and video process-recall strategies. Procedure The FIRO-B test was administered to students by the group leaders during the first week of the Interpersonal Communication Skills course and again during the last week of the program. Prior to the first administration students were informed of the general purpose of the study and given assurance that participation was voluntary. In order to retain anonymity subjects were asked to assign themselves a code name to be used to identify pre- and post-test responses. Both administrations of the FIRO-B were given in a group setting. Ninety-nine students completed the pre-test assessment and 66 (67%) the post-test. Results
Comparison of nurses with occupational therapy students Means and standard deviations for FIRO-B scale scores were calculated for the sample of post-registration nurses and contrasted with mean level data reported for occupational therapy students (Patterson et al., 1970). The occupational therapy student sample (N= 114) consisted of 107 females and 7 males attending Colorado State University. The median age of the sample was 20 years with an age range of 18 to 7 1. Table 2. Comparison of interpersonal behaviours of nurses and occupational therapy students Nurses (N= 99)
Scale
Occupational therapists (N= 114) Mean SD
t
Mean
SD
4.45 3.41
3.04
5.86 5.33
1.88 3.30
-5.59*** -3.79***
2.03 3.05
2.00 2.09
2.09 4.67
1.80
1.99
NS -5.77***
2.86 4.24
1.44 2.51
4.25 5.04
2.30 2.39
-5.36*** -2.37+
Inclusion
Expressed Wanted
1.80
Control
Expressed Wanted Affection
Expressed Wanted *p < 0.05. ***p < 0.001.
NURSES’ INTERPERSONAL
BEHAVIOURS
AND THE DEVELOPMENT
OF HELPING
SKILLS
I
Analysis of group differences using the t-test for independent samples showed nurses scored significantly lower than occupational therapy students on most FIRO-B scales (see Table 2 for a summary of test results). The only area of interpersonal behaviour where the two groups did not differ was on the measure of expressed control. Comparison
of interpersonal
behaviours by stream of study
To investigate the extent to which categories of nursing students differed on measures of interpersonal behaviours, study stream groups (maternal and child health nursing, clinical nursing, community health nursing, midwifery, nursing education, nursing administration) were contrasted on scores on each of the six FIRO-B scales. Because of the significant age difference noted between groups, analysis of covariance (ANCOVA) was employed separately for each measure, with age entered as the covariate. Where a significant group effect was found the Newman-Keul’s Student range test was used to establish the source of group difference. Results are presented separately for Inclusion, Control and Affection measures. Inclusion. Comparative means and standard deviations for Expressed and Wanted Inclusion scores for the six nursing stream groups are presented in Table 3. ANCOVA resulted in a significant group difference on the Wanted Inclusion measure [F(5,92) = 2.80, p < 0.051. Follow-up Newman-Keul’s analysis showed midwives scored significantly higher than all groups except maternal and child health nurses, and that maternal and child health and community health nurses had scores significantly higher than clinical nurses, nurse administrators, and nurse educators. There were no significant differences between nurse administrators, nurse educators and clinical nurses, or between community health and maternal and child health nurses. Table 3. Means and standard deviations for Inclusion measures by stream of study Study stream Maternal and child health nursing Clinical nursing Community health nursing Midwifery Nursing education Nursing administration
Expressed inclusion Mean SD 4.84 4.39 5.06 5.00 4.56 4.00
1.49 1.34 1.61 2.24 1.63 2.24
Wanted inclusion Mean SD 4.68 2.44 4.06 5.33 2.00 1.33
2.12 2.96 3.68 3.18 2.85 2.69
Control. Analysis of group differences on Control measures showed no significant differences on Expressed or Wanted Control scores. Comparative mean level statistics are presented in Table 4. Affection. Comparison of the six groups on the Affection scales resulted in a significant difference on Wanted Affection scores only [F(5,92) = 2.72,~ < 0.021. Post-hoc analysis of Wanted Affection scores indicate the source of group difference was associated with significantly higher scores for midwives relative to all other groups except community health nurses and higher scores for community health nurses, clinical nurses, and nurse educators compared with nurse administrators and maternal and child health nurses. Differences between maternal and child health nurses and nurse administrators, and between educators, clinical nurses and community health nurses were non-significant. Comparative means and standard deviations on affection measures are presented in Table 5.
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K. J. SELLICK
Table 4. Means and standard deviations for Control measures by stream of study Study stream
Expressed control Mean SD
Maternal and child health nursing Clinical nursing Community health nursing Midwifery Nursing education Nursing administration
1.36 2.00 1.50 1.93 2.56 2.11
Wanted control Mean SD
1.44 2.30 1.51 2.25 1.71 2.03
3.00 3.22 2.75 3.47 3.31 2.67
2.40 1.93 1.73 2.03 2.39 1.94
Table 5. Means and standard deviations for Affection measures by stream of study Wanted affection SD Mean
Expressed affection Mean SD
Study stream Maternal and child health nursing Clinical nursing Community health nursing Midwifery Nursing education Nursing administration
3.28 2.67 3.50 3.93 2.31 2.22
1.57 1.33 2.16 1.98 1.74 1.48
3.00 4.50 5.06 5.47 4.25 3.33
3.35 1.72 1.77 1.89 1.65 1.80
Effects of communication skills training on interpersonal behaviours Pre- and post-scores on the six FIRO-B scales for the total sample and for the six study stream nursing groups were compared to establish the impact of communication skills training. Results of repeated measures ANOVA applied separately for the total sample for each measure showed nurses’ level of expressed affection increased significantly over the time span of the study [F(1,66)= 5.59,~ < 0.0251. Changes in mean scores on the remaining five measures were non-significant. Means, standard deviations and test of significance results for the total sample are presented in Table 6. A series of ANOVAs were used to compare study stream groups on pre- and post-FIROB scores. Results showed no significant group effects or group x time interactions, thus indicating that nursing stream groups did not differ in the pattern of change in interpersonal behaviours in response to a program of interpersonal communications training. Table 6. Mean FIRO-B scores for pre- and post-tests for total sample (N=66) Scale
Pre-test Mean
SD
Mean
SD
4.45 3.41
1.80 3.04
4.45 3.32
1.94 3.36
0.00 0.57
2.03 3.05
2.00 2.09
1.91 2.80
2.04 2.09
0.62 1.12
2.86 4.24
1.44 2.51
3.33 4.58
1.77 1.97
2.34** 1.06
Post-test
F
Inclusion
Expressed Wanted
Control Expressed Wanted Affection
Expressed Wanted **p < 0.025.
NURSES’
INTERPERSONAL
BEHAVIOURS
AND
THE DEVELOPMENT
OF HELPING
SKILLS
Discussion The aims of this study were to investigate the interpersonal behavioural profile of nurses and evaluate the effectiveness of a communication skills program in developing behaviours conducive to effective helping. The results showed the interpersonal qualities of nurses differed significantly to those reported for occupational therapy students and that some differences were evident when nursing subgroups were compared. Evaluation of the effectiveness of a nine-week communication skills training program found only a few changes in interpersonal behaviours as assessed by the FIRO-B scales. Comparison of nursing and occupational therapy students indicate dissimilar patterns of interpersonal behaviours. It appears that nurses express less need to belong and have a stronger desire for influence and control in social situations than occupational therapy students. A similar tendency for occupational therapy students was reported by Patterson et al. (1970) in their study, with occupational therapy students concerned less with exerting control than psychology majors and teachers. The question is whether the pattern of results for nurses can be attributed to occupational differences. According to Schulz (1978) the FIRO-B scales consistently differentiate between a variety of occupational groups. However, because of differences in the characteristics of the two samples used in the present study, the possible influence of age, educational level, and cultural factors cannot be excluded. For example, comparison of the two groups shows nurses were older than the occupational therapy students. Clearly further research is needed to examine differences in the interpersonal behaviours of health professional groups, taking into account the influence of other factors. Of particular interest to the study of the helping role of nurses is the comparison of interpersonal behaviours across specialist clinical nursing groups. When responses on the FIRO-B scales for the six course streams were contrasted, notable differences on inclusion and affection measures were identified. Nurses enrolled in the midwifery and maternal and child health streams had a greater need to be included in interpersonal relationships than nurses in the nursing administration, nursing education, clinical nursing, and community health nursing groups. Interestingly, the differences between the midwifery and maternal and child health nursing groups were non-significant: a result that may be due to the fact that midwifery is also a prerequisite for the maternal and child health course. A different pattern of results emerged when nursing subgroups were compared on the wanted affection measure. Again, midwives recorded the highest mean score which achieved statistical significance for all group comparisons except in the case of the community health nursing group. Nurse educators, clinical nurses, and maternal and child health nurses also had a greater need for affection from others compared with nurse administrators. Unlike inclusion scores, these findings are not easily explained in terms of area of practice. One possible explanation for these findings is that midwifery and community health nurses were younger than other clinical groups: a finding consistent with results reported by Forsyth (1979). In this study younger nurses scored higher on the Hogan Empathy Scale (Hogan, 1969), although the difference between age groups was not statistically significant. However, in the present study the possible influence of age was controlled for using analysis of covariance. The Forsyth (1979) study also compared nurses’ empathy scores across five areas of clinical practice (medical, surgical, psychiatric, orthopaedic and rehabilitation). Although differences were not statistically significant, the mean scores for the rehabilitation group were considerably higher. Coupled with the present study, these results suggest comparison of different areas of nursing practice to be a fruitful area for future investigation.
9
10
K. J. SELLICK
The other question addressed by this study was the extent to which a nine-week communication skills training program facilitated the development of nurses’ interpersonal behaviours. While results demonstated few changes in FIRO-B scale scores, a significant increase in the level of expressed affection for the total sample does suggest some improvement in interpersonal effectiveness. That nurses had a greater need to express more affection in their interpersonal relationships could result in greater empathy, warmth, and willingness to focus on the feelings of others: a possible outcome consistent with the emphasis of the training program on self-awareness and the affective domain of therapeutic communication, but one that would need to be established through follow-up study. Several explanations can be offered for the lack of effect on other domains. One is the appropriateness of the FIRO-B scales as a measure of interpersonal skill development. While these scales have been found to be effective in differentiating between groups they may not have the specificity to detect changes as a consequence of a communication skills training program. This study has a number of methodological limitations which influence the interpretation of results. For example, the sample consisted of a group of qualified nurses, with varying clinical experience and expertise, who were undertaking post-graduate studies. As such their interpersonal profile may be quite different from nurses in general and from student nurses in particular. Secondly, because of the context of the study, it was not feasible to use a control group to evaluate the effectiveness of the interpersonal skills program: a design requirement necessary to exclude the possibility that changes in behaviour could have occurred independently to the program. Fin&y, the measure used in this study, while having established reliability and validity, may not have been sensitive enough to detect changes in interpersonal behaviour. It is also of note that FIRO-B measures are based on the self-’ report of respondents rather than an independent assessment by others. For future studies it may be more appropriate to employ measures that assess specific helping attitudes and skills, such as the empathy scales developed by Carkhuff (1969) and Hogan (1969) or the technique for assessing microskills used by Daniels et al. (1988). Despite the constraints in research design, this study does provide some evidence of the effectiveness of an interpersonal communication skills program and points to the value of comparing nurses with other health professional groups. In particular, this study emphasizes the helping role of the nurse and the need to evaluate the efficacy of skill development programs, taking into account the influence of age, level of experience, and area of clinical practice. Future studies should also examine the relative effectiveness of different methods of teaching helping skills and the impact of such programs on the quality of patient care. References Anderson, M. and Gerrard, B. (1984). A comprehensive interpersonal skills program for nurses. J. Nurs. Ed. 23, 353-355. Buhmeyer, K. J. and Johnson, A. H. (1977). Personality profiles of physician extenders. Psycholog. Rep. 40, 655462. Carkhuff, R. R. (1969). Helping and Human Relations: A Primerfor Lay and Professional Helpers. Rinehart and Winston, Montreal. Clark, J. M. (1981). Communication in nursing. Nurs. Times 77, (l), 12-18. Daniels, T. G., Denny, A. and Andrews, D. (1988). Using microcounselling to teach RN nursing students skills of therapeutic communication. J. Nurs. Ed. 27, 246-252. Forsyth, C. L. (1979). Exploration of empathy in nurse-client interactions. Ad. in Nu. Sci. 1,53-61. Hills, M. D. and Knowles, D. (1983). Nurses’ level of empathy and respect in simulated interactions with patients. ht. J. Nurs. Stud. 20, 83-87.
NURSES’ INTERPERSONAL
BEHAVIOURS
AND THE DEVELOPMENT
OF HELPING
SKILLS
11
Hogan, R. (1969). Development of an empathy scale. J. Consult. Clin. Psychol. 33, 307-316. Iwasiw, C. and Olson, J. (1985). A comparison of the communication skills of practicing diploma and baccalaurete staff nurses. Nurs. Papers 17, 38-48. Murray, R. B. and Zentner, J. P. (1979). Nursing Conceptsfor Health Promotion. Prentice-Hall, Engeiwood Cliffs. Patterson, T. W., Marron, J. P. and Patterson, N. B. (1970). Behavioral patterns of occupational therapy students on the FIRO-B. Am. J. Occupat. Ther. 24, 269-271. Schulz, W. (1978). FIR0 Awareness Scales Manual. Consulting Psychologists Press, Palo Alto. Seliick, K. and Bolton, B. (1989). Counselling. In Psychology for the Health Sciences. N. J. King and A. G. Remenyi (Eds), pp. 171-183. Nelson, Melbourne.
