Improving social skills in care management provided by nurses: intervention researchMontezeli, Juliana HelenaI Haddad, Maria do Carmo Fernandez LourençoI Garanhani, Mara LúciaI Peres, Aida MarisII
- IUniversidade Estadual de Londrina. Londrina, Paraná, Brazil.
- IIUniversidade Federal do Paraná. Curitiba, Paraná, Brazil.
to analyze the process of introducing an educational intervention for the improvement of social skills in care management provided by nurses.
intervention research, according to its complexity, carried out in a South-Brazilian public university hospital. To identify learning needs, 11 nurses were interviewed and educational meetings were held with 20 participants, who evaluated with open-ended questions: what they would stop doing; what they would continue doing; and what they would start doing on the issues addressed. The data was analyzed comprehensively.
we developed 30 educational hours on social skills of communication, work, assertiveness, and other themes inherent in care management mentioned by the participants as deficient. The evaluation revealed intentions of advances in: self-monitoring, communication, empathy, assertiveness, leadership and search for knowledge. Monthly meetings on care management were formally requested by the institution.
social skills are intertwined in care management relationships and their improvement has proved to be dialogical, recursive and hologrammatic.
Nursing, Management, Administration of Patient Care, Interpersonal Relationships, Hospital Service in Nursing
Relationships of care built in the various instances of the organizational culture constitute one of the essential elements for the success of care actions. This is because human resources must be considered the center of care practices and, at the same time, the scientific, technical and social basis of the health system(1).
However, in the current days where capitalist priorities are prevailing in health institutions, there is a paradoxical trend that scientific and technological advances will end and rationalize the relationships between people, making human beings experience not knowing what ‘being' means, in the sociocultural context(2).
Thus, strengthening social practices among health workers and, therefore, nurses, is important to enable improvement in the quality of care provided. To do so, we must know and develop the components of interpersonal relationships, among them Social Skills (SS), which are the classes of social behaviors that individuals use to act in an adequate way in interpersonal relations(3).
Social skills are divided into: self-monitoring, communication, civility, assertiveness, empathy, work and expression of positive feelings. Self-monitoring, class one, is a skill by which people observe, describe, interpret, and regulate their thoughts, feelings, and behaviors in social situations. Social communication skills, class two, highlight that in interpersonal relationships a person with good social competence can coherently articulate the meanings of verbal and non-verbal communication. Social skills of civility, class three, express courtesy; they are peculiar to brief and occasional social encounters, in which transactions between people occur with little or no mobilization of emotions. Social skills of assertiveness, class four, correspond to a set of well-developed aptitudes, in defense of one's rights and those of others(3).
Empathic social skills, class five, correspond to the capacity to understand and feel what one thinks and feels in a situation of affective demand, communicating adequately such understanding and feeling. Social skills of work, class six, are those that meet the different interpersonal demands of the work environment; and social skills of expression of positive feelings, class seven, emphasize that the demands of affectivity are inherent to interpersonal relations and make up the daily life of any person(3). Although there is such separation, SS permeate the encounter between people and, in this way, distance themselves from paradigmatic reductionist models(3).
A paradigm is the reference for how one acts and perceives the world, conceiving a social or scientific standard to be followed. Thus, Nursing is influenced by the epistemological basis in force and, as the positivist premises do not meet the current global demands, they are not enough to support the practices of this profession(4).
Considering the statements, care management in Nursing is no longer impervious to care itself and is now considered contextual and relational. The incipience of positivism is visualized, therefore, in the relationships that permeate the management actions of nurses with focus on care. In view of this question, the need to consider the pluralities in nurses' work process emerges, to consolidate their performance in multiplicity and complexity(4).
Care, as well as its management, takes on expanded dimensions from the demands of the current world of work. Whatever the nursing work space is, it is essential to also expand the issues related to the references that make its execution feasible, with valorization of the multifaceted aspect, to culminate in differentiated forms of interventions in the health-disease process(5).
In this context, the interpersonal relationships created in care management provided by the nurse are involved; given that, in their SS, they must be used in an integrated and interconnected way, understanding that the interactions between people are produced and used in care actions.
Nevertheless, we consider that SS, although inherent in individuals, must be developed in a permanent way, aiming to break with the mechanistic standards and to soften the automation of care management.
In addition, it is important to carry out SS studies with health professionals, since they can be the basis of knowledge for better interpersonal relationships among team members and between professionals and clients(6). From this context, the following question emerged, which guided the study: How can we improve social skills in nurses for care management in hospitals?
Analyze the process of introducing an educational intervention for the improvement of social skills in care management provided by nurses. The specific objectives were: to identify the needs of improvement of social skills in care management in nurses; introduce an educational process to improve social skills in care management in nurses; and evaluate the educational process introduced.
The ethical standards in force in Brazil were followed, with approval of the project by the Committee of Ethics in Research involving human beings of the institution.
Type of Study
This is qualitative research of the type research-intervention, performed together with the researched population, aiming at the procedural modification of the object under study, making use of daily interferences(7).
Research was conducted in three stages - exploratory, intermediate and evaluative, during 2016 and 2017, with nurses from a public university hospital in the South of Brazil.
In the exploratory stage, semi-structured interviews were carried out, by the main author, with a minimum duration of 15 and maximum of 30 minutes, and 11 nurses were interviewed during the day shift, from different sectors of the hospital selected intentionally and by saturation.
We identified the nurses of the day shift because, in this institution, the concentration of management activities to be developed by these professionals was greater during the day. Moreover, even occupying the same hierarchical position in the organization chart as the other shifts, they were more recognized as leaders in their workplaces, because they often made impactful decisions for the other shifts.
Other inclusion criteria were: to be a nurse for at least one year in the previously selected sectors; to have a legal relation with the hospital, since we sought that participants acted as multipliers of the reflections constructed during the educational intervention, to improve social skills; and be willing to follow the schedule defined for the investigative process, in addition to agreeing on the method of work focused on group intervention.
We excluded those who were on vacation, those who after three approaches did not confirm their participation and those who were on leave for any reason during the period for data collection.
The invitation to participate in the study was carried out personally by the first author, in an approach in the work environment. On this occasion, the interview was scheduled and held in the workplace, in a private setting.
Before beginning the interview, the nurse was clarified about the SS classes, by means of a brief explanation, using a table with their classes and subclasses(3). A guiding instrument was used, consisting of a part of the participant's characterization (age, gender, time of work as nurse, place/work shift and permanence in the current sector) and three open-ended questions: 1) Considering the explanation previously provided, how do you perceive social skills in Nursing care management?; 2) Discuss in what situations of Nursing care management social skills are needed. 3) Talk about the facilities and difficulties you encounter in the performance of social skills for care management.
Audio interviews were recorded on a cell phone and, to avoid possible bias in research, participants were prevented from having prior contact with each other so as not to exchange information on the content of the questions which they were made.
After the listening and verbatim transcription of the words, to unveil the phenomenon, a comprehensive analysis was used, which takes place from the researcher's immersion in raw data, with several readings for the appropriation of discourses. Next, a process of signification for them took place, which allows for inferences and interpretations, culminating in the emergence of categories(8). The presentation of categories has examples of excerpts from the statements coded from E1 to E11 (nurse 1 to nurse 11), to ensure the anonymity of participants.
In the intermediate stage, educational meetings were held in August and September 2017, the number of which was established according to the amount of social skills and their respective difficulties of development in the study setting, information obtained through the analysis of interviews. In addition, it arose from prior experience with similar events for the interpersonal development of authors. We emphasize that creating and planning the educational meetings was made by all authors, and the conduction of these meetings was carried out by the first two.
Twenty nurses selected by the Nursing Board participated in these meetings, of which eight were interviewed at the initial stage of the study (the other three interviewees were on leave during the period). The option to request that the Nursing Board list the participants of this stage was because it knew, in more depth, leaderships in the different sectors. In this way, they could be multipliers, together with their respective teams, of the themes worked on meetings.
The evaluative stage was carried out in the last training and happened in two moments. In the first, each nurse received sheets of paper in three different colors and the following instruction: Regarding the topics addressed in the educational meetings (self-monitoring, assertiveness, communication, empathy, giving/receiving feedback, leadership, planned change, conflict mediation, negotiation and decision making), answer: GREEN SHEET – What will I continue doing? PINK SHEET – What am I going to stop doing? BLUE SHEET – What will I start doing?
The sheets were posted on the wall and separated by color, and the topics were read collectively to validate the answers to each question and to agree on the changes listed during this educational process. These topics were categorized by similarities to present the results.
In the second evaluation, the standard form used in the training given at the institution was applied, composed of four objective topics followed by two open-ended questions. For this study, only the last two questions were used: 1) Do you believe that this training will contribute to change your way of working in the hospital? Comment your answer.; 2) General comments. Responses were submitted to comprehensive analysis and the excerpts used to illustrate the text of results were coded from C1 to C20.
A public university hospital in the South of Brazil.
We interviewed 11 nurses, intentionally chosen, to identify learning needs; and educational meetings were held with 20 participants, selected by the Nursing Board of the institution.
Data collection and organization
As previously specified, the data in each of the stages was collected and organized as follows: a) exploratory – semistructured interview with full transcription; b) intermediate – educational meetings; c) evaluative – processing of evaluative forms.
Steps of the study
The constituent steps of intervention research can be seen in Figure 1.
Representative diagram of the steps of deployment of intervention research
At each stage, data analysis was as follows: a) exploratory – comprehensive analysis with identification of improvement needs in SS; b) intermediate – educational meetings with active methodologies, instructional moments and experiential processes; c) evaluative – processing of evaluative records with categorization by similarity and comprehensive analysis that revealed intentions of advances in self-monitoring, communication/empathy, assertiveness, leadership and search for knowledge.
Exploratory stage: interviews
The 11 people interviewed were female, with an average age of 41.3 years; nurses working from 11 to 25 years (average of 17.2 years) and in the current sector, ranging from 1 to 10 years of experience (average of 4.3 years).
The analysis of interviews provided the identification of the need for improvement in SS mentioned by nurses, shown in Chart 1.
Need for improvement in social skills (SS) identified by nurses
|CLASS OF SS||SUBCLASS OF SS||EXCERPTS FROM TESTIMONIES|
|Listen more/speak less|
|End a conversation|
|Assertiveness||Express anger/unpleasantness- needs moderation|
|Assertiveness||Express anger/unpleasantness- needs moderation|
|Apologize and admit failures|
|Deal with criticism|
|SS of work||Coordinate a group|
|Speak in public|
The findings in the exploratory stage subsidized planning and constructing the subsequent stage, in which the intervention itself was carried out.
Intermediate stage: educational meetings to improve social skills
All the 20 participants of this stage were female, with an average age of 38.7 years; nurses working from 7 to 27 years (average of 15.6 years) and in the current sector, ranging from 1 to 26 years of experience (average of 4.6 years).
Seven educational meetings were held twice a week, totaling 30 hours. Each had a duration of four hours, with a break of 20 minutes for snacks, and on some days, there was a few minutes more for the closure.
At the initial meeting, the results obtained in the first stage of research and the themes that would be worked out during the educational process were presented, presenting the schedule of activities. The following social skills classes were discussed: Communication, Assertiveness and Work. However, considering that SS should not be understood separately for their full understanding, at several times it was necessary to address other SS along with complementary and inseparable themes for Nursing care management: self-monitoring, empathy, giving/receiving feedback, leadership, planned change, conflict mediation, negotiation, and decision-making.
Evaluative stage: categorization of the sheets and analysis of the open-ended questions
The similarities of reports in the colored sheets and the comprehensive analysis of the answers in the open-ended questions of the standard form allowed us to list five categories of intentions, as summarized in Chart 2.
Synthesis of the evaluation process at the end of the educational meetings
The intention to search for knowledge was not only mentioned by the nurses in both steps of the evaluation (colored sheets and form), but also the object of a formal request made to the Nursing Board, through the elaboration of a document with a suggestion of monthly meetings for reflections on the management work process of nurses.
The fact that nurses recognize that there is a need for learning about SS to improve their relational framework and, consequently, for the management and quality of care, allows us to conjecture that this perception is anchored in the principles of complex thinking(9).
In relation to the dialogical principle, which allows us to live with duality in the context of unity, two themes, simultaneously complementary and antagonistic, are associated(9). In this reasoning, management and relationships should be understood as antagonistic (rational versus emotional), but at the same time there is complementarity between them since, when practiced separately, they are not beneficial to the final quality of Nursing care, therefore, they have a dialogical characteristic.
Considering this, we argue that the relations carried out by nurses in their management practice (in which SS are required) enable the provision of care. Moreover, they are those who produce the interpersonal interactions between patients and Nursing professionals. Thus, if on the one hand management practice is based largely on rational scientificity, on the other, for its effectiveness, subjective elements arising from the relational web are needed, because it is a social process.
Nurses' perceptions of their SS deficits also correspond to a process of recursion, based on an empirical analysis performed by them on care management and on what needs to be improved in this sense, for the final quality of care.
The recursion principle is related to the fact that products and effects are both causes and producers of what produces them(9). Similarly, care and management are produced by the interaction between individuals (in which nurses' SS are involved). However, care, once produced, not only modifies itself, but retroacts on those who have developed and modifies them.
Similarly, the constructed educational process can also be considered recursive, since the use of active methodologies provided the construction and sharing of knowledge through the social interactions between participants. That is, advances in relational knowledges resulting from interventions provided the reach of a product and a feedback from it on those who produced it.
In addition, the performance of this intervention research showed an intimate kinship with the hologrammatic principle of complexity, since the identification of learning needs on SS (part) allowed the construction of knowledge of the whole (care and its products). During the educational meetings, through the experiential techniques and other active methodologies employed, possible reflections were made on care management (the whole) practiced by nurses and, thus, not only the SS (identified parts) were improved in the interviews, but also other themes that intertwined with those mentioned during the work process.
At this point of the discussion, we must discuss the experiences used as a pedagogical option in the educational meetings having fundamental importance for the whole process to approach the ideas of this complex thinking.
It is a method of group learning that is structured in an analogous or symbolic way to the daily situations of social interaction of participants, mobilizing feelings, thoughts and actions, aiming to supply deficits and/or maximize SS in training. Such techniques are indicated, since the development of SS can be accomplished through systematic training using well-managed group strategies. The use of group contexts for the promotion of SS is feasible, especially since it facilitates the use of active and experiential procedures(10).
Hence, the educational process was permeated by recursive circularity, that is, the effects were produced, but they were also causes of what produced them. The interactions experienced by nurses produced learning and reflections, and these, in turn, impacted nurses, marking them with certain characteristics of the collectively shared process. The recursion principle breaks with the linear idea of cause and effect and values human subjectivity. Subjectivity, which is translated into a result of social, cultural and biological conditions and, in the context of this study, is translated into the fertile soil of SS development. By establishing the subjectivity of each nurse in the process of learning and development of SS, there was also a feedback on the work process of management, culture and the social institution to which they belong.
Also regarding holography, considering that SS require study and understanding, individually and together, this principle of complexity would already be contemplated from the conception of the study. However, because the hologrammatic idea is linked to recursion and in part to the dialogical principle(9), we infer that the educational process on SS implemented was congruent with all the dogmas of complex thinking.
More thoroughly, in the recursion logic knowledge of the parts turns to the whole; in the same way, when knowing about the whole, the points are identified without organization and, therefore, it turns to the parts(9). These considerations of the findings of this study, articulated with the principles of complexity, are represented in Figure 2.
Demonstrative diagram of the exploratory and intermediate stages of the study under the principles of complexity
We emphasize that the learning needs elucidated by participants demonstrate that SS are closely related to the different management abilities performed by nurses. This assertion is supported by the fact that, as required from nurses in their daily lives, a person who communicates properly and has good social skills can consistently articulate the meanings of verbal and non-verbal communication(3).
Likewise, the social skills of work identified as deficient by participants are of fundamental importance in care management, because they are those that attend to the different interpersonal demands of the work environment, with the intention to fulfill goals, to preserve the welfare of the team and respect the rights of each individual(3). Assertiveness, as well as perceived by the interviewees, is also an essential social skill in nurses' management activity. By behaving assertively, individuals simultaneously generate reinforcing consequences and create the likelihood of medium and long-term reinforcing consequences to the group to which it belongs. This fact causes balance in relationships; thus, being assertive is a more competent behavior for social purposes(11).
In convergence, the current world of work signals the need for individuals to know their strengths to intensify them increasingly; and even their weaknesses, in to improve their possible deficits. Therefore, educational processes are essential to create spaces for reflection and actions that contribute to personal development, in addition to facilitating discussions on several significant issues with efficient social and professional performance(12).
The reports from the evaluation stage show that, although it is a relatively homogeneous group with regard to the hierarchical position, many sayings are repeated in the three evaluation dimensions (continue doing, start doing and stop doing), which allows us conclude that nurses have personal idiosyncrasies regarding SS repertoire. However, when categorized, we noted that such particularities did not give rise to differences to the final issues agreed by the group.
In other words, the intersection of the findings in the three dimensions of evaluation points to a change in the use of SS and, consequently, to behavioral changes towards care management based on more accurate interpersonal relationships. This can be represented, graphically, by the interlacing point of the three circles in Figure 3, and by the emersion of an empirical category listing the intention of advances in leadership.
Demonstrative diagram of the evaluative stage of the study under the principles of complexity
Allied to that, recognizing that knowledge of SS is not perennial and punctuating the intention of continuous search for improvement of self-monitoring, denotes an approximation with the holography of complexity. It is recognized that nurses' actions in the relations (part) have influence on the management practice and the context of their place of action (the whole) and vice versa. We also point out the recursion process of feedback and dialogue, considering the complementarity present in antagonistic concepts illustrated by Figure 3.
The identification by participants of the need for continuous improvement in self-monitoring as SS, even though it did not appear at the individual interview stage, is consistent with the need for a shift in thinking into a complex perspective, since learning about self-observation contributes to the learning lucidity. That is, learning about understanding and lucidity is never a completed road and must be continually restarted(13). In addition, it reaffirms the fact that SS are complementary in the daily work of this category of professionals.
The horizon of meanings at the end of the educational process points to the complex progression in the participants to value relational aspects in their daily management practice, with concrete intentions and actions (such as the request for continuity of the meetings on the subject) by a more proficient SS repertoire, demonstrating that nurses incorporated the subjective and the importance of such skills in their management abilities. This is, therefore, an important impact on the reality studied. As it is known, not only technical and scientific aspects cause change in the quality of care, but also the subjective dimension of their providers(2).
We observe, although empirically, based on the interaction during the educational meetings with the participating nurses, that the path taken has provided a motivational increase in these professionals to reach a more humane and sensitive care management. This finding was corroborated in a survey of newly trained Australian nurses, where satisfaction with the work environment enhanced by educational actions alongside professional transition programs was significantly associated with the expectation of remaining in employment(14).
Accordingly, the motivation of professionals is determinant for the quality of care, as well as for the satisfaction of their clients, culminating in a better clinical development. This can be favoured through changes in the organizational culture, inserting practices for greater appreciation of the human dimension in the work process, both for clients and employees(15).
Notwithstanding, it is a fact that the progression in valuing skills that surpass merely technical skills, emphasizing, among others, how to work in team, speak in public and weave an empathetic and assertive communication(16-17), denote convergence with the slogans constructed in this research trajectory.
Research, although representing an advance in the use of the dictates of social skills as scientific supporter of the construction of knowledge in Nursing, presents limitations that deserve to be pointed out. One of these limitations refers to the fact that validated and specific psychological instruments were not used to evaluate the participants' repertoire, which would undoubtedly provide more objective and complementary indicators to uncover the phenomenon. To do so, we suggest future research with different designs, mixed methods and in partnership with psychologists, since many of these instruments are for the exclusive use of these professionals.
The fact that the phenomenon has been studied only under nurses' perspective is also a limiting factor. Thus, for other investigations to illuminate in greater depth the social skills involved in Nursing care management, it would be pertinent to value the view of other actors involved in this relational web, such as Nursing technicians and the patients themselves. In this way, we believe that the recursion circularity and the holography preached by the complex thought would be better explored, since these actors represent parts of a whole (the hospital), that influence and are influenced by the relationships built in the care and management process , and from the expanded view of the part and the whole, the diagnosis for future interventions would be broader, allowing the expansion of educational approaches.
Contributions to the Nursing field
The intervention initiative can be improved and replicated in other realities to assess Nursing as a relational practice, surpassing merely technical information and valuing the subjective in the management performance of nurses, to increase the state of art of this profession. Moreover, the novelty of conducting qualitative research in the field of social skills should be valued, since it is a topic of study closer to Psychology and previous investigations are based on quantitative drawings, mainly of experiment or quasi-experiment type.
Although much has been produced about Nursing under the perspective of complexity, this study is a pioneer in the intertwining of complex thinking with social skills and care management, developing an innovative reasoning in the national setting, not only in the foundation of the testimonies obtained with the interviews, but also in the pedagogical strategies applied during the educational meetings.
This active and multifaceted approach, used in the intervention stage of the study, distanced itself from the possibility of reaping previous knowledge brought by participants. On the other hand, it provided reflections from this knowledge to identify what was laconic and, from there, to build new knowledge.
By meeting the objectives of the study, we could show that the process of introducing intervention research covered non-linear trajectories of understanding and effectiveness. This reinforces the urgency about perennial search for complexity as a supporting reference of interpersonal relations and the SS in the routine of care management practiced by nurses.
We emphasize that, in times when the art of caring ends up being absorbed by the massification of institutional rules, often imposed by a capitalist reality, it is praiseworthy the attitude of the Hospital Board, the setting of this study, to provide actions such as those developed in research.
Finally, we acknowledge that the findings of research do not end the theme of social skills in care management in Nursing, nor the use of complex thinking as a theoretical reference in Nursing research and in the practice of this profession. Rather, we strive for their slogans to converge to the valorization of interpersonal relations as central reference of professional nurses' abilities.