Therapeutic Communication Skills Training: An Effective Tool to Improve the Caring Behaviors of ICU Nurses

Background Caring behaviors are crucial in intensive care units (ICU) because patients in these wards require high levels of care. Effective communication with patients is one of the most important factors in caring behaviors of nurses working in ICUs. Therefore, the aim of this study was to evaluate the effect of therapeutic communication skills training on the caring behaviors of ICU nurese. Materials and Methods This experimental pre-test/post-test study was carried out on 105 nurses working in ICUs of hospitals affiliated to Yazd University of Medical Sciences in Iran in 2019. Nurses were randomly assigned into control (52 nurses) and intervention (53 nurses) groups. A two-day therapeutic communication training workshop was conducted for the participants. Data were collected using demographic information questionnaire and caring behaviors questionnaire before and one month after the intervention. Results The findings showed no significant difference between the control and intervention groups regarding the nurses’ caring behaviors in the pretest (P = 0.148). However, after implementation of the training program, a significant difference was observed in the mean scores of caring behaviors between the two groups. In the control group, the mean scores of caring behaviors decreased significantly after the intervention (P = 0.001); whereas, the mean scores of intervention group increased significantly after the intervention (P = 0.001). Conclusion According to the results, ICU nurses’ training in therapeutic communication skills had a positive effect on their caring behaviors. Therefore, we suggest the authorities prepare and implement educational packages of therapeutic communication skills as a coherent program for other nurses. As a result, the caring behaviors and the quality of cares can be improved for patients.

Therapeutic communication refers to the process in which a nurse deliberately helps the patient's 23 improvement using verbal and non-verbal communications (10). In fact, it refers to a purposeful 24 relationship between the patients and care givers. It is a tool for the therapist to communicate 25 with the patient to create hope and positive change for the patient's recovery (11). Admission in 26 ICU creates anexiety for the patients (12) due to the disease, separation from family, immobility, 27 and environmental noise, which can lead to patients' impatience, depression, and irritability (13). 28 In addition, ICU nurses have difficulty in communicating with patients using mechanical 29 ventilation due to the lack of knowledge and skills. Therefore, they need education on 30 communication skills that improves the patients' care quality (9). Happ (2013) conducted a study 31 in the USA over the effcet of intervention on nurse-patient relationship in ICU among the 32 intubated, awake, and responsive patients. The findings showed that communicating with these 33 patients was a common problem that caused distress and fear in patients and stress among nurses 34 (14). A study reported that unconscious ICU patients were able to hear (15). Since hearing is the 35 last sensation lost in patients with brain damage, speaking to and touching these patients were considered as important factors to communicate with these patients (16). A study in Canada  In general, the nurse-patient relationship improves the patient's health. The care team should be 41 aware that the patient-nurse relationship not only improves the patients' disease, physical 42 condition, and treatment, but also affects the patients' physical, mental, and social health 43 significantly (18). In fact, communication skills training can improve the care team ability to 44 show their empathy and the patients' ability to express their feelings (19). Popa-Velea et al.

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(2014) reported that the therapeutic communication training was necessary for the health care 46 teams, especially physicians and nurses. Furthermore, they believed that communication barriers 47 were tendency to judge, criticize, advise, and label patients, which lead to patients' distrust. They 48 stated that the type of words used to speak with the patients in order to transfer the sense of trust 49 and empathy, the tone and melody of the voice, body language, honest attitude, and observance 50 of the confidentiality principle were important in establishing a therapeutic relationship (20 included 57 items dealing with six sub-skills of being accessible, explains and facilitates, comforts, anticipates, trusting relationships, monitors and follows through. The questions should 103 be answered on a five-point Likert scale ranging from least important (1) to most important (5).

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The minimum score in this scale is 57, while the maximum attainable score is 285 (27). The

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Persian version of this questionnaire was validated by Pashaei (2014) using the translation re-106 translation method. In order to determine the content validity, the experts' view points were used 107 and to determine the reliability, the test/re-test method was applied (r =0.87) (28).

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Outcome measurement 109 The caring behaviors' questionnaire was used to measure the nurses' care behaviors in control with the code of (IR.KMU.REC.1396.1726). Initially, the hospital authorities were provided with 118 an introduction letter and the necessary coordination was made to conduct the study. A cover 119 letter explaining the study goals and the data collection procedure was also presented to the 120 eligible participants before the data collection. Then, signed written consent forms were obtained 121 from the participants and they were ensured about the data confidentiality and anonymity. Data were analyzed by SPSS version 21 using descriptive (frequency, percentage, mean, and 128 standard deviation) and inferential statistics (independent samples t-test, paired t-test, and chi-129 square). The significance level was set at P < 0.05.

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Demographic characteristics 132 Most nurses in both groups were married women with a work experience of less than five years 133 in ICUs. Most participants had a bachelor's degree and were in the age range of 23-33.    Rask's study, patients were surveyed, but in the present study, the findings are based on the 172 nurses' self-reports. 173 The results showed that the highest mean difference of caring behaviors in the intervention group 174 was related to the "trusting relationship" dimension, while the lowest difference was attributed to 175 "being accessible" dimension. The "trusting relationship" dimension was considered as the most 176 important factor in the current study because the educational content of therapeutic 177 communication skills' training as well as skills such as trust and empathy were emphasized in our 178 study. In the same line with the present stusdy, the results of a study by Hillen et al. (2015) 179 indicated that effective communication between the treatment staff and patients, especially skills in other studies, and prioritization based on a survey of patients and students (28,44).

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In addition, we found that education had the least effect on "being accessible" dimension, which 206 can be explained by the nurses' high work load, occupational burnout, and being neglected by 207 high-level managers. These factors can prevent nurses from appropriate implementation of 208 caring behaviors and effective communication with patients (45). The high workload of nurses, 209 especially those in ICUs, low number of nurses, and lack of time make nurses just rely on the 210 physical tasks and consider "being accessible" dimension less important (46). Contrary to our 211 findings, a study in Iran (44) showed that "being accessible" and "patients' monitoring and follow 212 up" dimensions had the higest priority for students. Less important dimensions in this study were 213 "explaining to patient", "patient's physical and emotional comfort", "trusting relationship", and 214 "predicting the patients' needs". The students of this study selected "being accessible" dimension 215 as the top priority, which indicates that they considered physical caring behaviors more 216 important than the emotional behaviors and they were more concerned with the physical 217 problems of patients. The priority of "being accessible" dimension and timely implementation of  This study has several limitations that should be considered by the furture researchers. One was 223 the investigation of hospitals affiliated to Yazd University of Medical Sciences. The other constraint was lack of attention to the individual differences of participants. Moreover, the most 225 important limitation of this study was the self-reporting data collection method. Therefore, we 226 suggest application of observational checklists or patients' surveys in the future studies. Another 227 problem was the collection of information one month after the intervention. In order to achieve 228 more accurate results, 3-6-month follow ups are recommended. Then, the results of different 229 follow ups should be compared to determine the long-term impact of the training.