Social skills communication in humanized nursing care: a diagnosis for a socio-educational intervention

Objective: To evaluate the social skills necessary for communication in humanized nursing care. Method: Study with quantitative, descriptive and transversal approach carried out from November 2018 to January 2019 in a public hospital in San Luis Potosí, Mexico. Data collection was carried out with 30 hospitalized patients and 30 inpatient nurses using three instruments: “CECOP” (acronym in Spanish for Nurse Communication Behavior observed by patients); “ACEP” (acronym in Spanish for Self-assessment on the nurses’ form of communication with their patients); and Evaluation of Humanized Care Knowledge, analyzed with descriptive statistics. Results: 60% of the nurses obtained an average level for empathy and communication, and 63.3% of patients perceive high level. When assessing respect, understanding and kindness on the analogous scales, it was found that the average classification ranged from 8.73 to 9.03 on a scale of 0 to 10. The 97.4% of patients wish to be understood and treated. In knowledge, 67% of nurses obtained a low level. Conclusions and Implications for practice: The study identified the necessary social skills that the nursing professional needs to strengthen an effective communication. The results are a key piece to design the socio-educational intervention.


INTRODUCTION
The humanization of the attention can be understood as […] the act of caring for the individual, the family and the community from the recognition of the other as equal to me, respecting dignity as a human being, and reflecting on their health needs, of care and of the answers to those needs, so that it can be assisted from the ethical imperatives promoting the possibilities of a speedy recovery of their self-care 1:43 , currently it is a matter of national and international importance and necessity since it has transcended for decades that the World Health Organization attests that scientific and technological advances promote a relevant change in the field of health, where the interpersonal needs of patients are affected. 2,3 According to the author Jean Watson, representative of the theory of human care, the field of health is a dynamic and flexible environment, which requires preventive premises to avoid the destabilization of its human and scientific bases that can generate problems in the humanization of care, so it is necessary to rescue human quality in the nursing professional. 4 To strengthen the humanization of care in the nursing professional as an essential part of clinical practice, it has been studied since the crusades for quality in 2001, whose main objective was to offer humanized care to both patients and family members who use the health system, 5 these studies concluded the need to strengthen the communication skills that these professionals use in the care they offer.
On the other hand, the care management that is responsible for organizing, guiding and monitoring the continuity of the same, requires that the competencies of the nursing professional be exercised in order to adequately perform in their work role, this can be achieved through the use of training programs and of continuing education in the health institutions that will be translated in our country as fundamental elements in the quality indicators. 6,7 It is worth mentioning that the quality of health care in Mexico is delimited by the establishment of quality indicators that aim to favor the health care and quality granted by all health professionals towards their patients, these elements are made up of a large percentage of social components of user satisfaction.
Likewise, within the management systems of care quality, the perception that patients show towards the care they receive is a mixture of skills that are reflected in the communication process. 8 Thus, the communication process is structured by the message, the content that is wanted to make known to the patients and the way in which the information is made known, that is, content skills: those that are described according to the objective pursued, of process: how the message is made known, in what code it is made and the tools used for it and of perception: it is the way in which the receiver understands what has been made known to him. 9 This content regarding the elements that make up the communication are of social nature and need to be approached from a socio-scientific model to work on it, if what is required is to model, train or exercise socio/personal aspects.
The objective of this study was to evaluate the social skills necessary for communication in humanized nursing care that contribute to the development and structuring of a socio-educational intervention project that effectively allows through a training process, to strengthen the social skills involved in humanized communication and care of nursing staff.
For the development of this project, it was necessary to include socio-educational intervention because its structure and different types of modalities allow contextualizing the concepts towards the practice of the professional and assessing their impact, with opportunity for short or long-term development.

LITERATURE REVIEW
In the area of health, technological innovations and scientific progress cause some of the knowledge to become obsolete in short periods of time, so continuing education is the basis for generating new knowledge and experience; currently, in nursing, staff use evidence-based practice since certain studies have concluded that there is an improvement in nursing practice when staff are constantly educated with experiences related to professional life.
Continuing education contributes to a quality practice in nursing work, so an important part of this type of education is the motivation to achieve the participation of the nursing staff, since it is of the utmost importance, that nursing staff be constantly educated, since it is they who have the first contact with the population that requests their services, and since new scientific and technological advances are the order of the day, it is feasible to develop innovative education models for these personnel. 10,11 Different current studies have shown that training social aspects allows improving the content and structure of the communication used in humanized care, and it has also been included that the strengthening and development of communication skills in the nursing professional should be granted from the training in the schools. [12][13][14] Communication understood within the context of health institutions can be defined as: the right of the user to ask the questions he deems necessary and to receive all the information related to his illness, being clear and understandable for him. 15 Thus, there are skills involved in the communication process that directly influence the therapeutic relationship with patients: empathy, respect, kindness and understanding. This process is a fundamental part of the acceptance of the treatments and the disease by the users, so the training and development of the aforementioned skills allow to positively influence this process, increasing the quality of health attention and care, seeing itself reflected in the dignified care.

Communication and humanized care in nursing
Oviedo AD, Delgado IAV, Licona JFM So, dignified care is one of the main forms of patient perception towards the care and treatment they receive from health professionals, specifically speaking of nursing staff, it is necessary to strengthen these skills, since as mentioned before it is the nursing professional who has the greatest contact with patients and family members. 16 Dignified care is evaluated based on the perception that users have towards nursing staff, since this profession is a social-humanistic discipline, with a scientific focus and its main objective is the care of people and communities, hence the importance of educating the nursing staff to improve the skills involved in communication, to guide patients and maintain good interpersonal relationships. 17,18 The strengthening of skills, therefore, implies developing a new process of social education, since these types of problems are of a daily and common nature that are observed in any field where you want to convey a concept or an idea.
Within the scope of social education there is socioeducational intervention, which Covalan defines as: the social action produced through the unacceptability of an experiential situation of a group of individuals that would be caused by the base of the system. 19 The socio-educational intervention can then be defined with different models, which are a schematic representation that explains and organizes a series of guidelines related to experience, behavior and learning, these models are: scientific-technological, interpretive-interactionist, partner critical and academic-disciplinary, which are developed in dimensions of space, time and results, in this case strengthening thinking and learning for health. 19,20 A socioeducational intervention for the nursing professional acts as a social change, with the participation of various actors, where critical and cognitive thinking is promoted, for the projection of new ideas and problem solving. 21 The socioeducational intervention has a formative nature where the various methodological tools are used, not only to identify didactic needs, but also to apply the intervention. 22 Different studies have reported that training favors the growth of skills where communication is involved and also improves the therapeutic / interpersonal relationship that staff has with patients. 23,24

METHOD
Descriptive study, with a quantitative and cross-sectional approach, developed in the period from November 2018 to January 2019. Participation criteria: resident nursing staff in the internal medicine hospitalization service for men and women. Patients: being in hospital for more than 48 hours. Thirteen nurses and 30 patients who met the criteria were selected by convenience. The instruments used for patients and nurses were three, the first one called CECOP 14 (Nurse Communication Behavior observed by patients) regarding the validation of the CECOP with 23 reagents, a KMO was obtained (sample adequacy measure with expected values close to one) of .791 with a level of significance of .001, which indicates that there is homogeneity between the variables of each factor and heterogeneity between the variables of other factors; Bartlett's test showed a significance of .001, and indicates that the factorial model is adequate to explain the data.
This instrument has three sections, the first one contains 23 questions divided into two skills to be evaluated: respect and empathy, valued with a Likert scale, with a value of one to five, the second section consists of three analogous scales that assessed understanding, satisfaction and respect with valuation of at one as minimum and ten the maximum, considering the latter as the best to obtain and, in this same instrument the third section consists of a desirability assessment with a dichotomous answer of "yes" and "no". In addition to having socio-demographic data that allowed their identification and their period of hospital stay. This instrument has a Cronbach's alpha of .87.
The second instrument called ACEP 13 (self-assessment on the nurses' form of communication observed by themselves), consists of ten questions with a Likert scale assessment with a number of one to five, which assesses two skills: respect and empathy, this instrument features a Cronbach's alpha of .87.
Finally, the third instrument is a questionnaire that evaluates the knowledge of nursing staff regarding the indicator of dignified care, has 20 items that include concepts and divisions of the understanding of the indicator, the cited instrument has a Cronbach's alpha of .87.
Data collection was carried out in hospital shifts for morning, afternoon and night nursing.
The research project was approved by the Academic and Research Committee of the Postgraduate and Research Unit of the Faculty of Nursing and Nutrition of the UASLP Mexico and the Nursing Education Subchief of the public hospital of the city of San Luis Potosí, Mexico, where was made.

RESULTS
The participating population in the diagnosis was of 30 patients and 30 nurses and operating nurses in the area of internal medicine being women and men. The surveyed patients had a prevalence of women (53.3%), with predominant age groups of 34 to 60 years, as well as their married marital status (46.7%), in addition the educational level with more preponderance was complete secondary (Table 1).
In this same plane, the results describe the socio-demographic characteristics of the nursing staff participating in this study (Table 2), where a majority influence of the female gender (80%) was found, with an age group of 43-51 years (66.66%), a work seniority of mostly 11-20 years (36.6%), with a predominance of the night shift (36.6%).
For the evaluation of communication skills (empathy and respect), they were arranged in scoring groups, in Table 3 these scores and their grouping according to patients and the self-evaluation of nursing staff can be observed.
The data allow us to observe different areas of improvement opportunity for the performing of an intervention of the socio-educational Communication and humanized care in nursing Oviedo AD, Delgado IAV, Licona JFM type. The patients evaluated the nursing staff according to their criteria regarding empathy with 33.3% for a medium level, 63.3% at a high level and only 3.3% at a low level. As shown in this same table, the level of evaluation for the ability to respect patients was placed at an average level of 80%, different from the self-assessment in which the nursing professional reported that their level of empathy is in a medium level, for empathy and respect in both cases with the same score of 60%.
In Table 4 that reflects the skills on understanding, respect and satisfaction perceived by the patients in which the minimum and maximum values ranged from 6 to 10, respectively, the average remained between 8.73 and 9.03. As mentioned above,    *Source: CECOP behavior inventory; *Descriptive statistics obtained in these skills is 10, a value that was not found in any of the results.

Communication and humanized care in nursing
Oviedo AD, Delgado IAV, Licona JFM the maximum value to be obtained in these skills is 10, a value that was not found in any of the results.
The results of the knowledge assessment of the dignified care indicator can be seen in Table 5, where 70% of the personnel evaluated have a low level of use of the indicator, which suggests that knowledge of this indicator needs to be strengthened as part of the communication process, an aspect which should be taken into account as a guideline for the design of the socio-educational intervention.

DISCUSSION
Regarding the sociodemographic data obtained from the patients in the diagnosis, some of them such as gender, and education were comparable to those of another study conducted in a hospital of similar characteristics in Mexico City, reported in an article in the year 2015. 15 The other sociodemographic data obtained by nurses, are consistent with what databases such as INEGI and SIARHE report, according to gender and age. 25,26 In the nursing staff's self-assessment it was found that most of the staff turned out to be female, in addition to that in this study it showed that there is a medium level in empathy and communication in the nursing staff and 97.4% of the patients wish to be understood and taken care of which suggests this factor as an element of improvement since, communication in the nursing professional is a work tool with which they interact with other patients, it also allows patients to be guided to a better style and quality of life. 27 Therefore, through a socio-educational intervention where the participation groups are few people, it tends to show good results in the education of new knowledge and the contextualization of the concepts taught, as well as the critical moments in which communication may be affected.
Likewise, another area for improvement regarding the communication process is the therapeutic relationship maintained by the nursing staff during the hospital stay of the patients, which is very important since, it is part of the safety of the patients, as well as the process of education which is granted to them, so it is important to highlight that the direct and indirect beneficiaries of a socio-educational intervention are reflected when the former are oriented towards the understanding of critical thinking and use their skills to improve the perception of patients towards quality of services provided by nurses, which results in one of the most important factors, since the quality of care provided is redirected to humanized care, an indicator of quality where the opinion of the patients define the attitude of the nursing staff. 28,29 This attitude that the nursing staff demonstrates in the presence of patients is remunerated in a positive attitude about the experience of the disease and its acceptance, so, training and educating the nursing staff in social skills, allows to exploit intensively human care skills. The promotion of self-care in patients is another premise that emanates from an effective communication process, however, it is not enough to talk about communication and its consolidation as part of quality, it is necessary to explore in depth how to contribute to its strengthening. 30 On the other hand, another area for improvement that is important to highlight is the knowledge that nurses have about the use of the Decent Care indicator, which was found in 70% of nursing staff at a low level, therefore the socio-educational intervention must contain elements that strengthen knowledge and attitudes to develop a vision of dignified care associated with their professional practice.
From the quality crusades in Mexico, it has been sought that the nursing professionals manage to establish in the three levels of hospital care, a good interpersonal relationship with the patients and their families, because good results such as the acceptance of a treatment depend on it and the promotion of self-care reflection of a quality of care.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE
The performing of the diagnosis allowed to evaluate the communication skills that have been considered necessary in the nursing staff, according to the results obtained, it is appropriate to strengthen skills such as empathy, respect and understanding. A socio-educational intervention implemented in small groups of participants will allow the proposed methodology post-diagnosis to be adequately carried out, reflecting on the dignified care and quality of attention provided by nursing staff. It is important that the hospital institutions educate the nursing staff in social problems since it is these incidents that decrease the quality of the services, as it is the nursing staff who has the greatest contact with the patients and it is they who transfer an important part of the social image of the institutions.
This diagnosis highlights that it is necessary to strengthen the communication process and fully integrate the social skills involved in it, given that there is an opportunity to improve and expand the concept of humanized communication and care so that this fine line facing the support of the quality of the institutions continue contributing towards the health of the patients, the acceptance of the disease and to medical treatments.