Int J Med Sci 2011; 8(5):397-401. doi:10.7150/ijms.8.397 This issue
1. Department of Psychiatry, Gulhane Military Medical Academy, GATA Psikiyatri AD.06018 Etlik, Ankara, Turkey
2. Department of Emergency Medicine, Gulhane Military Medical Academy, GATA Psikiyatri AD.06018 Etlik, Ankara, Turkey
3. The University of Utah School of Medicine, Utah, USA.
Objective: To determine the effects of a communication skills training program on emergency nurses and patient satisfaction.
Methods: Sixteen emergency nurses attended a 6-week psychoeducation program that was intended to improve their communication skills. The first 3 sessions of the psychoeducation program consisted of theoretical education on empathy and communication. Other sessions covered awareness, active communication, and empathic skills on a cognitive behavioral basis using discussion, role play, and homework within an interactive group. The effects of the program were assessed using a communication skills scale, empathy scale, and patient satisfaction survey and were reflected by the reduction in the number of undesirable events between nurses and patients in the emergency department.
Results: The mean communication skill score (177.8±20) increased to 198.8±15 after training (p=0.001). Empathy score also increased from 25.7±7 to 32.6±6 (p=0.001). The patient satisfaction survey of 429 patients demonstrated increased scores on confidence in the nurses (76.4±11.2 to 84.6±8.3; p=0.01); the nurse's respect, kindness, and thoughtfulness (72.2± 8.1 to 82.1 ± 6,5; p=0.01); individualized attention (71.3± 6.2 to 73.2 ± 9.8; p=0.2); devotion of adequate time to listening (84.6± 9.3 to 89.8 ± 7.6; p=0.03); and counseling and information delivery (71.1± 10.2 to 80.2 ± 9.7; p=0.01). The number of undesirable events and complaints during nurse-patient interactions decreased 66 % from 6 to 2.
Conclusion: “Communication Skills Training” can improve emergency nurses' communication and empathy skills with a corresponding increase in patient satisfaction and reduction of the undesirable events and complaints during nurse-patient interactions.
Keywords: Communication Skills, Training, Nurses, Emergency
In our previous study, we developed and administered a communication skills training program to our emergency medicine residents (1). Our study showed that participation in a communication skills training program was associated with improved communication skills of emergency medicine residents, increased patient satisfaction and decreased complaints. Emergency nurses, just like emergency physicians, need special communication skills that can affect both their professional success as well as patient satisfaction.
Emergency nurses have multiple challenging responsibilities including dealing with overstressed patients and their relatives, the homeless, mentally ill patients, victims etc. They must perform these responsibilities in a short period of time in the busy environment of the emergency department (ED). It is also well known that poor communication can effect patient satisfaction, which is becoming an increasingly important measure of performance in today's patient-oriented health care systems (2).
Communication skills can be summarized as sensitivity to verbal and nonverbal messages, effective listening and responding (3). Despite the views which support that communication skills are innate and intuitive, many studies have proven that various components of communication techniques can be learned and teachable (4). Although the expectation is that communication skills are acquired by nursing students during nursing education programs, some descriptive studies indicated that there remains a training inadequacy (5-6).
We aimed to determine the effectiveness of a 6-week communication skills training program in emergency nurses by addressing the following questions: What is the current level of communication skills and empathy in emergency nurses? Does this training program increase their communication skills and empathy? Will this training program affect patient satisfaction? And, will this training program decrease both the number of undesirable events between nurses and patients and the number of patients' complaints?
The study included sixteen emergency nurses in the GATA Department of Emergency Medicine. Following approval from the local ethics committee, a psychoeducation program that was intended to improve communication and empathy skills in emergency nurses was held for 6 weeks (90 minutes per week).
Patient satisfaction surveys on the nurse-patient relationship were filled out by patients who presented to the ED within the previous 2 months (April 2010-May 2010) and after completion of the program (July 2010-September 2010). Patient satisfaction scores before and after the training were compared to determine significant changes. Surveys were delivered to patients or their families after completion of their respective procedures in the ED or when the decision to discharge or admit had been made. The patients were informed that the survey was not mandatory and were asked to leave completed surveys in a designated box.
The number of undesirable events between emergency nurses and patients or relatives and the number of patient complaints were retrieved from the registry of the administrative office of the ED. All events that were reported by nurses and all complaints by the patients about the nurses were noted for analysis.
In our previous study, we developed and used a communication skills program to our emergency medicine resident successfully. The same training program was modified and used for emergency nurses (1). There were some reasons of the modification of the previous training program. First of all, the second part of the training program was composed of discussions and role plays which require active participation of the trainees. Since the doctors and nurses experience different problems during their interactions with the patients and/or their relatives, different scenarios were prepared for doctors and nurses group. At the beginning of these studies, the researchers have also thought to give this psychoeducation to emergency medicine residents and nurses together. However, when the undesirable events in the emergency department were analyzed, it was seen that doctors and nurses diversed in the conflict areas during their patient interactions. This might be due to the differences between the two professions in terms of their responsibility areas. Therefore, the case examples might not lead to similar empathic associations in a doctor-nurse mixed trainee group. So, the emergency medicine residents and nurses took different psychoeducation trainings only in terms of case scenarios, role plays and discussions specifically designed for their professions. Moreover, since our training program includes active participation, small number of interaction groups was especially preferred.
The psychoeducation program was developed based on theoretical adult learning principles and incorporating effective elements for delivery of communication skills training; the content and process was specifically designed for this study and was based on best available evidence. The curriculum of the training program was presented in our previous study (1).
The first 3 sessions of the psychoeducation program consisted of theoretical education on empathy, communication, and relationships between the patient and health care team. Other sessions covered dominant, passive, and aggressive communication types and the differences between them; and verbal and nonverbal communication, active listening, recognizing and understanding feelings, expression of feelings and thoughts, identification with others, and establishing empathy—all of which were intended to improve awareness, active communication, and empathic skills on a cognitive behavioral basis using discussion, role play, and homework within an interactive group.
Workshops were also held, presenting case examples that represented the communication problems that are encountered frequently in EDs. All participants were asked to note their experiences on the subjects that were discussed before the next session, when these experiences were discussed.
Effectiveness of the psychoeducation program was assessed using a communication skills inventory and empathy scales for nurses and satisfaction surveys for patients before and after the program. In addition, sociodemographic data forms were filled out by patients and the nurses who participated in the psychoeducation program.
The Communication Skills Inventory (CSI) was developed by Ersanli and Balci (7). The first version of the inventory, for which validity and reliability studies have been performed, consisted of 70 items. Subsequently, the inventory was given to 500 university students, and total number of items was reduced to 45 after an analysis of factors (3). The inventory measures the mental, emotional, and behavioral aspects of communication. Higher scores on each dimension or higher total scores reflect better communication skills. The total score ranges from 45 to 225.
This scale was developed by Lawrence et al. to measure empathic attitudes (8) The psychometric characteristics of Turkish samples were studied by Bora and Baysan (9). The original scale consisted of 60 items, 40 of which measured empathy; the remaining 20 items prevented participants from focusing on the objectives of the test. The total score ranges from 0 to 44.
A short version has been developed using the 22 items that measure empathy (10). The short version was used in this study. A reliability study of the short form in Turkish samples generated a Cronbach alfa value of 0.814. The total score for items on the short form correlates significantly with that of the long version (r=0.90, p<0.0001). The test-retest correlation is r=0.72 (9).
This form was used to collect data from nurses who participated in the study on age, gender, marital status, number of children, and their level of knowledge on communication skills.
This survey consisted of 2 sections. The first section recorded patient data, such as age, gender, level of education, profession, symptoms, time of admission, length of stay in the ED, number of admissions to the ED, established diagnosis, presence of chronic disease, and any problem that was experienced in the ED. In the second section, patients were asked to evaluate their nurses with regard to their confidence, respect, and kindness; individualized attention; devotion of time to listening; and counseling on the disease and treatment, rating them on a Visual Analog Scale from 0 to 100.
Statistical analysis was performed using SPSS for Windows 15.0. (SPSS Inc, Chicago, IL). Data are presented as mean, standard deviation, and percentage. Data on the nurses were compared by t-test between dependent groups and by Wilcoxon signed ranks test, and data from the patient satisfaction survey were compared between independent groups by t-test. A p-value of <0.05 was considered statistically significant.
Sixteen emergency nurses from the GATA Emergency Medicine Department participated in the training program. The mean age of the nurses was 30.4 ± 5.2 years, and all were female. None of the nurses had attended a training program, and 4 nurses had read a book on communication skills and empathy. The mean communication skill score (177,8±20) increased to 198,8±15 after training (p=0.001). Empathy score also increased from 25.7±7 to 32.6±6 (p=0.001).
The changes in pre- and posttraining scores on the satisfaction surveys from 429 patients were as follows, respectively: confidence in the nurse increased from 76.4±11.2 to 84.6±8.3, p=0.01; the respect, kindness, and thoughtfulness of the nurses climbed from 72.2± 8.1 to 82.1 ± 6.5, p=0.01; time devoted to listening increased from 84.6± 9.3 to 89.8 ± 7.6, p=0.03; and the counsel that was provided by the nurses increased from 71.1± 10.2 to 80.2 ± 9.7, p=0.01. Individualized attention from the nurses was comparable between groups. (71.3± 6.2 vs 73.2 ± 9.8, p=0.2)
The comparison of pre- and posttraining scores on communication skills, empathy, and patient satisfaction is presented in Table 1. The sociodemographic data of patients who filled out patient satisfaction surveys in the 2 months before and after the training are shown in Table 2. The 2 groups were comparable with regard to the variables that were examined.
The number of undesirable events and complaints during nurse-patient interactions decreased 66 % from 6 to 2.
Pre and Post Training Scores
|Communication skills score Mental Emotional Behavioral Total||61.0±6 57.5±8 60.3±6 177.8±20||66.5±5 64.6±8 68.0±5 198.8±15||P=0.006 P=0.003 P=0.025 P=0.001|
|Patient satisfaction score Confidence in nurses Respect, kindness, and thoughtfulness Individualized attention Time devoted for listening Counseling||76.4± 11.2 72.2± 8.1 71.3± 6.2 84.6± 9.3 71.1± 10.2||84.6 ± 8.3 82.1 ± 6,5 73.2 ± 9.8 89.8 ± 7.6 80.2 ± 9.7||p= 0.01* p=0.01* p=0.2 p=0.03* p=0.01*|
|Number of undesirable events and complaints||6||2|
Sociodemographic data of the patients
|Number of patients||208||221|
|Number of admission to ED First Second More than 2||97 43 68||104 49 68||0.78 0.06 0.16|
|Result Discharge Referral Hospitalization Death Refusal of the treatment||194 3 11 - -||205 2 14 -||0.84 0.33 0.20|
|Duration of waiting at the ED||116.4±98.8||121.4±80.8||0.26|
Our study shows that the communication skills training program can increase the communication and empathy skills of emergency nurses. This result is consistent with the finding of a recent review -evaluating the effect of empathy education in nursing- which concluded that it is possible to increase nurses' empathic ability with a training program (11). In this review 17 studies were evaluated, and it was found that the most promising models of education use experiential styles of learning such as role play and case scenario-based learning. We used both of these learning styles in our training program, which could be one of the possible reasons of our success. Clinical cases were chosen from real events to create scenarios that accurately reflect the clinical setting and participants were asked to play different roles in the relationship in order to give the nurses the opportunity to understand the patient's and relatives' emotional states.
Communication skills scores were evaluated in three separate fields: mental, emotional and behavioral. The effect of training surprisingly has been observed in all three fields. Our previous study, which was conducted on emergency medicine residents, showed an effect primarily on the mental field rather than on the emotional and behavioral (1). Other than this, there was no significant increase on empathy scores of residents. We did, however, notice a significant change in nurses' scores. We attribute the discrepancy to gender differences in both groups, since in the first study most of the residents were male (19/1), and in this study all nurses were female (0/16). Previous studies have shown gender as an affecting variable of communication skills and empathy training (11-12).
We include the evaluation of patient satisfaction scores about the nurse care in our study in order to see the effect of training on behavioral changes in a real-world situation- the ED. Patient satisfaction scores were improved after the training. This result was found to be consistent with the previous studies. Raid and coll. in a similar study which includes didactic, modeling, and role playing approaches to improve the nurses' active listening and understanding of the patient, showed significantly higher scores and increased patient satisfaction after the training (13). Mayer and coll. show that a training program improves patient satisfaction and ratings of physician and nurse skill (14).
Most of the complaints in the emergency departments have been related to communication problems rather than poor medical practice (15-16). Hunt reported that 37.7% of the complaints were related to behaviors while 11.5% were related to poor communication, and stated that communication skills training would help to decrease the number of complaints (16). In our study, after the training and in addition to the increase in patient satisfaction, number of undesirable events and complaints between nurses and patients decreased from 6 to 2, representing a 66% reduction.
The limitations of our study include sample size, which is limited to 16 participants, and lack of control group. Comparison of the scores of scales or questionnaires was limited to assessment of statistical significance.
In conclusion, participation in a communication skills training was found to be associated with improved communication and empathy skills of emergency nurses, which in turn increased patient satisfaction and reduced complaints. Our results support the promotion of professional and well-designed training, applied in small groups as an integral part of nursing education.
The authors are thankful to all participating nurses of GATA Department of Emergency Medicine for their essential contributions to the study.
The authors have declared that no conflict of interest exists.
1. Cinar O, Ak M, Sutcigil L, Congologlu ED, Canbaz H, Kilic E. et al. Communication skills training for emergency medicine residents. European Journal of Emergency Medicine. 2011 Published ahead of print, doi: 10.1097/MEJ.0b013e328346d56d
2. Pytel C, Fielden NM, Meyer KH, Albert N. Nurse-patient/visitor communication in the emergency department. J Emerg Nurs. 2009;35(5):406-11
3. Buckman R. Communication skills in palliative care: a practical guide. Neurol Clin. 2001;19(4):989-1004
4. Levinson W, Roter D. The effects of two continuing medical education programs on communication skills of practicing primary care physicians. J Gen Intern Med. 1993;8(6):318-24
5. Wheeler K, Barrett EA. Review and synthesis of selected nursing studies on teaching empathy and implications for nursing research and education. Nurs Outlook. 1994;42(5):230-6
6. Gijbels H. Interpersonal skills training in nurse education: some theoretical and curricular considerations. Nurse Educ Today. 1993;13(6):458-65
7. Ersanlı K BS. Developing a communication skill inventory:Its validity and reliability. Turkish Psychological Counseling and Guidence Journal. 1998;10(2):7-12
8. Lawrence EJ, Shaw P, Baker D, Baron-Cohen S, David AS. Measuring empathy: reliability and validity of the Empathy Quotient. Psychol Med. 2004;34(5):911-9
9. Bora E, Baysan L. Psychometric features of Turkish version of Empathy Quotient in university students. Klinik Psikofarmakoloji Bulteni. 2009;19:39-47
10. Wakabayashi A B-CS, Wheelwright S. Development of shorts forms of the empathy quotient (EQ-short) and the systemizing quotient (SQ-short). Pers Indiv Diff. 2006;41:929-40
11. Brunero S, Lamont S, Coates M. A review of empathy education in nursing. Nurs Inq. 2010;17(1):65-74
12. Becker H, Sands D. The relationship of empathy to clinical experience among male and female nursing students. J Nurs Educ. 1988;27(5):198-203
13. Reid-Ponte P. Distress in cancer patients and primary nurses' empathy skills. Cancer Nurs. 1992;15(4):283-92
14. Mayer TA, Cates RJ, Mastorovich MJ, Royalty DL. Emergency department patient satisfaction: customer service training improves patient satisfaction and ratings of physician and nurse skill. J Healthc Manag. 1998;43(5):427-40
15. Hunt MT, Glucksman ME. A review of 7 years of complaints in an inner-city accident and emergency department. Arch Emerg Med. 1991;8(1):17-23
16. Richmond PW. Complaints and litigation--three years experience at a busy accident and emergency department 1983-5. Health Trends. 1989;21(2):42-5
Corresponding author: Mehmet AK, MD, Assistant Professor, E-mail: drmehmetakcom, makedu.tr; Phone: 00905056000681