Knowledge, applicability and importance attributed by nursing undergraduates to communicative strategies

Conocimiento, aplicabilidad e importancia atribuidos por graduandos de enfermería a las técnicas comunicativas

ABSTRACT

Objectives:

To evaluate the knowledge, applicability and importance that nursing students attribute to therapeutic communicative strategies.

Methods:

This is a quantitative study (survey) with nursing undergraduates from a public institution. The online questionnaire by the SurveyMonkey tool, comprising the informed consent form and six questions, had its relevance, clarity and operability assessed by experts.

Results:

Of the 104 graduates, 50 participated in the study; the most well-known and applied strategy was Therapeutic Communication, followed by Ask-Tell-Ask, NURSE and Tell Me More; the least were PACIENTE and SPIKES. Most use the strategies they know best; all were considered important by at least 82% of the students.

Conclusions:

The partial knowledge and application of these strategies by the students contributes to reflect on the complexity of their teaching-learning process.

Descriptors:
Nursing; Teaching; Communication; Strategies; Health Communication

RESUMEN

Objetivos:

Evaluar el conocimiento, la aplicabilidad y la importancia que los estudiantes de enfermería atribuyen a las estrategias comunicativas terapéuticas.

Métodos:

estudio cuantitativo (survey) con los graduados en Enfermería de una institución pública. El cuestionario online mediante la herramienta SurveyMonkey, conteniendo el consentimiento y seis preguntas, tuvo la pertinencia, la claridad y el funcionamiento evaluadas por expertos.

Resultados:

De los 104 graduados, cincuenta participaron en el estudio; la estrategia más conocida y aplicada fue la Comunicación Terapéutica, seguida de Ask-tell-Ask,NURSE y Tell Me More; y las menos conocidas fueron PACIENTE y SPIKES. La mayoría de ellos emplean más las estrategias que mejor conocen; y el 82% de los estudiantes consideran todas las estrategias importantes.

Conclusiones:

El conocimiento y la aplicación parcial de estas estrategias por parte de los estudiantes contribuyen a la reflexión sobre la complejidad de su enseñanza-aprendizaje.

Descriptores:
Enfermería; Enseñanza; Comunicación; Estrategias; Comunicación en Salud

RESUMO

Objetivos:

Avaliar o conhecimento, a aplicabilidade e a importância que estudantes de Enfermagem atribuem às estratégias comunicativas terapêuticas.

Métodos:

estudo quantitativo (survey) com concluintes do curso de Enfermagem de uma instituição pública. O questionário on-line pela ferramenta SurveyMonkey, contendo o consentimento e seis questões, teve a pertinência, clareza e operacionalidade avaliadas por peritos.

Resultados:

Dos 104 concluintes, cinquenta participaram do estudo; a estratégia mais conhecida e aplicada foi Comunicação Terapêutica, seguindo-se Ask-tell-Ask,NURSEe Tell Me More; as menos foram PACIENTE e SPIKES. A maioria utiliza mais as estratégias que conhece melhor; todas foram consideradas importantes por pelo menos 82% dos estudantes.

Conclusões:

O conhecimento e aplicação parciais dessas estratégias pelos estudantes contribuem para a reflexão sobre a complexidade do seu ensino-aprendizagem.

Descritores:
Enfermagem; Ensino; Comunicação; Estratégias; Comunicação em Saúde

INTRODUCTION

Health communication is fundamental for quality patient care, and nurse-patient communication is a skill required of nurses, generalist or not, in their clinical practice. Clinical practice is understood as the professional’s actions in the care context arising from their own deliberation, those established in organizational protocols and those resulting from other professionals’ prescriptions. Such actions are mediated by communication, in its different aspects. However, the use of communication strategies has been limited by the knowledge on this content, both by professionals⁽¹⁾ and students⁽²⁾, and also by its complexity.

The literature presents several communication strategies to help professionals achieve success in their tasks. These may be for obtaining information for the diagnosis or assessing a situation⁽³⁾, as well as for resolving or minimizing a patient’s symptom, that is, therapeutic management of a situation^(4-12). Some communicative strategies of therapeutic aspect are listed below.

The Tell Me More strategy aims to clarify information or address the patient’s emotion to understand the problem at hand. It involves identifying, in the patient’s speech, a problem that needs to be addressed and express interest by saying: “tell me more”, thus stimulating the patient’s verbalization^(4,6). Another strategy, with the same objectives and that contributes to establishing a bond and support is Ask-Tell-Ask. In its first Ask step, the professional/student begins the communicative process by querying the patient’s doubt or the topic of care. In the second step, Tell, the health professional expounds on the situation in question, and if necessary, should provide room for understanding. In the third step, Ask, the professional query the patient’s understanding, asking them to summarize the explanation to confirm it^(4,6).

The NURSE strategy, an acronym for Naming, Understanding, Respecting, Supporting, Exploring, aims to address emotions for their recognition and acceptance. In the first step, the patient’s emotion is objectively appointed; the second validates it; the third step refers to showing respect for the patient’s feeling, performed non-verbally; the fourth involves statements of support and offering coping strategies; the last step aims to express interest in the patient’s main concerns^(4,6-7).

The SPIKES or BUCKMAN protocol,also an acronym, consists of six guiding steps to facilitate communicating bad news to the patient. The first step (Setting up) refers to an interview planning, in which the professional is prepared and where the report will take place; the second step (Perception) comprises assessing the patient’s perception, it serves to verify the patient’s knowledge about their condition; in the third step (Invitation), the patient is expected to ask and define what, and to what extent, they want to know about their illness; in the fourth step (Knowledge) the bad news is revealed objectively and the patient must confirm they understand; the fifth step (Emotions) involves accepting emotions through an empathic response; the sixth step (Strategy and Summary) refers to willingness to discuss interventions, if that moment is appropriate, and reducing anxiety by presenting and explaining treatment options^(6,8-10).

Because of existing cultural diversity and the particularities surrounding each country, a study⁽¹¹⁾ considered the need for a protocol focused on the Brazilian context, based on SPIKES. The PACIENTE protocol consists of seven steps based on the Portuguese word Paciente (Patient), also for communicating bad news. The first five steps are similar to the SPIKES protocol, being the sixth its differentiator, named as: do not abandon the patient. In this step, it should be made clear that the health team is still responsible for the patient and their treatment - even without the prospect of a cure -, continuing to provide care and offering biopsychosocial support to the patient and their family⁽¹¹⁾.

Among the most widely disseminated strategies in the Brazilian nursing field, is the proposal of some studies^(4,12), resulting from the selection and grouping of several therapeutic communicative techniques, sorted into three categories: expression, clarification and validation. The expression category favors the initial approach, seeking to verbalize feelings and problems the patient faces. This group includes: “listen reflectively, use silence therapeutically, verbalize acceptance, interest, use open or reticent phrases, repeat a patient’s remark, ask questions, return a question asked, use descriptive phrases, allow them the choice of subject, focus on the main idea (if it escapes focus), verbalize doubts, say no, encourage expressing underlying feelings, and use humor therapeutically”⁽⁴⁾.

The clarification category helps to understand or clarify the messages received by the professional, especially ambiguous ones; this grouping includes: “stimulate comparisons, ask the patient to clarify unusual terms, to specify the agent of action, and describe the events in a logical sequence”⁽⁴⁾. Finally, the validation category is responsible for establishing the common meaning of what the patient said, thus avoiding misunderstandings. Techniques in this category include: “repeating the patient’s message, asking them to repeat what was said, and finally the professional summarizing the interaction content, clearly and objectively”⁽⁴⁾.

The therapeutic communicative techniques used by undergraduate nursing students during their practical activities were evaluated in a descriptive study observing the students’ interactions with hospitalized patients; this study found that 90% of the students reported knowing the communication techniques, however, they showed difficulties, insecurity and inexperience in interacting with patients when applying their theoretical knowledge on communication. The authors recommended implementing actions to reduce difficulties with patient relationship, like creating opportunities for training and developing communication skills before entering the hospital environment and encouraging the use of theoretical concepts during curricular internship activities⁽²⁾. Such suggestions are relevant when considering the complexity of teaching this topic, as well as that the lack of knowledge about therapeutic communication can impair the quality of nursing care.

Communication teaching approaches in the nursing field have been an object of interest in the literature; the use of active methodologies, games and even expository and dialogued classes that include them are considered useful in the teaching-learning of different skills and communicative intervention techniques^(12-14). In our institution, the different courses that cover this topic use diverse teaching methodologies, predominantly lectures, discussions, skills training in pairs, besides simulations and situations arising from care scenarios.

Whether addressing emotions or communicating difficult news, offering support or even aiming at solving problems, employing these strategies requires essential nurse skills, as several factors can represent obstacles to effective communication. The most prominent are those concerning the patient, nursing and the environment⁽¹⁾. Difficulties often cited by nursing professionals were establishing limits for the patient, limited knowledge about the communication process, offering support and anxiety⁽²⁾, professional availability for the task, inadequate knowledge, omniscient attitude, disease state and family interference⁽¹⁾.

Given the complexity of the topic, it is essential that nursing students learn how to communicate effectively with patients and their family members, learning how to apply therapeutic strategies, favoring the management of difficult situations, controlling emotional involvement, responding empathically to the patients’ needs, solving and supporting the exposed problems, as well as their emotions. Assuming a knowledge gap in this area, the motivation for this study arose, whose secondary purpose was to contribute to reflect on the teaching of such strategies.

OBJECTIVE

To evaluate the knowledge, applicability and importance that nursing students attribute to therapeutic communicative strategies.

METHODS

Ethical aspects

The ethical and legal components present in all phases of this study are in accordance with Resolution 466/12 of the Brazilian National Health Council. The project elaborated for the development of this study was approved by the Research Ethics Committee of the institution. Confidentiality was ensured and no personal data or sociodemographic variables were collected.

Study design, location and period

This is a quantitative study of survey type, guided by the Strobe tool, being developed with final-year Nursing undergraduates in a public educational institution in the countryside of the state of São Paulo, through an online questionnaire made available via the platform SurveyMonkey.

Inclusion and exclusion criteria

The inclusion criteria were: be in the last year of undergraduate study; provide an email address and formally respond to the researcher’s invitation sent to such address. The exclusion criterion was prior involvement as an evaluator in the construction of the questionnaire. Students in the last academic year (n=104) were considered as potential participants because they would have already received, throughout the course, information about the strategies and possible knowledge gaps could be identified.

The study had 65 participants: five nurses as experts; ten students as evaluators of the instrument; and fifty students who answered the data collection instrument.

The five experts, specialists in the communication field, initially assessed the content of the online questionnaire and its layout; they were all female, and higher education in nursing, aged between 27 and 42 years (mean of 31.2 years). Regarding the length of experience in the area of Nursing Communication, the mean number of years dedicated to teaching was 4.8, 5.6 to research, and care was 2 years.

Ten students of the institution’s undergraduate course, recruited through the snowball method, participated in evaluating the questionnaire regarding its clarity. Of these, eight were female and two were male, aged 20 to 24 years (mean age of 21.8 years).

Of the 104 undergraduate students, thirty were not interested in participating. After an initial expression of interest, 23 did not answer the invitation email and one did not answer the questionnaire.

Instrument creation and evaluation

This study used the SurveyMonkey platform, useful for the questionnaire creation, collection and analysis of the data of interest. The online questionnaire has several advantages both for the researcher, as it performs the data analysis, and for the participants, as the student has free access, filling it out at their own availability; ensures less resolution time, eliminates writing, eases possible constraints, among other factors. Furthermore, the literature reiterates that online instruments are increasingly recommended, both because they are fast, enabling large samples in different geographical regions to be covered, and favoring the respondent’s participation and rhythm or their anonymity^(15-16). In this study, the immediate data analysis after the students’ answers, the protection of the autonomy of the best moment to answer the questionnaire, the reduction of possible constraints and the short estimated time for its resolution were considered by the authors as positive aspects.

The literature indicates that the length of the question⁽¹⁷⁾, attributes such as the color and font size used, the way in which it is written, and the length of the questionnaire can affect the response rate and the participant’s interpretation in an online questionnaire. These aspects were evaluated by experts and potential users.

Another controversial aspect concerns the existence or not of a barrier to proceed to the next questions; such a process can be considered a disadvantage⁽¹⁸⁾ since participants may feel discouraged or increase the non-response bias or the measurement error. However, another study⁽¹⁵⁾ states that the resource “show question based on answer” is positive, as it avoids unanswered questions. To minimize this possible bias, it is suggested to offer “I don’t know”, “It doesn’t apply” or “I would rather not answer” as answer options⁽¹⁸⁾. The present study did not use this alternative; participants could close the website and the questions already answered were saved.

The authors built the questionnaire based on the bibliographies of strategies Tell Me More^(4,6), Ask-Tell-Ask^(4,6), NURSE^(4,6-7), SPIKES protocol^(6,8-10), PACIENTE⁽¹¹⁾ and Therapeutic communication^(4,12). It comprised seven questions, the first being the invitation to participate in the study and the informed consent form. After formal agreement, access to other questions was allowed, introduced to students with the reminder that they should answer the questionnaire considering their training and experience in employing communication techniques when caring for patients throughout their undergraduate course. Question 2 asked the student to indicate whether or not they knew each of the six studied strategies. Question 3 asked about their frequency of use (“not used” to “used frequently”). Question 4 asked to point out which objectives (approach to emotion, clarification of obtained information, encourage the expression of feelings and thoughts, validation of obtained information and communicating difficult news) corresponded to each strategy, with the item belonging to more than one of them. Question 5 asked to indicate all the steps of each strategy, among 38 alternatives, described in Table 1. Question 6 asked to assign the level of importance of each strategy (“unimportant” to “very important”) and Question 7 to order, by degree of importance (6 being very important and 1 unimportant), the six strategies.

Table 1
Distribution of correct answers regarding the objectives of communication strategies by undergraduate nursing students (n=42)

Communication strategies	Objectives
Ask-Tell-Ask	Approach to emotion 8.89%	Clarification of the information obtained 71.11%	-
Tell Me More	Approach to emotion 28.89%	Clarification of the information obtained 31.11%	-
NURSE	Approach to emotion 25.64%	-	-
SPIKES	Communicating difficult news 66.67%	-	-
PACIENTE	Communicating difficult news 13.79%	-	-
Therapeutic communication	Clarification of the information obtained 28.26%	Encourage feelings and thoughts expression 67.39%	Validation of the information obtained 26.09%

The questionnaire was made available through a link, sent to the respective emails of the experts and evaluating students, accompanied by an invitation, the specific ICF and the instrument to carry out its evaluation.

The experts evaluated the questions and their alternatives, answering yes or no as to their clarity and relevance, suggesting changes when appropriate. The other evaluated aspect was the operationality of the questionnaire, regarding the items: accessibility; legibility; font and background color; indicating whether or not they were appropriate and suggest changes, if necessary.

The experts considered all questions relevant. All the judges agreed on the clarity of Questions 1, 3 and 4, considered as relevant. In the others, both questions and alternatives were considered of partial clarity, ranging from 60% (Q4 and alternatives of Q3 and Q5) to 80% (other items).

In assessing the adequacy of its operationality, the experts considered the accessibility, legibility of the information and the font and background color of the questionnaire as 100% adequate. Only one of them highlighted the font size inadequacy, but this proposal was discarded, because the SurveyMonkey tool did not allow layout changes.

The experts’ suggestions considered the clarity of the questions, its alternatives and the stages of the strategies, as well as changes in the spelling of the names of the strategies, as shown in Chart 1.

Chart 1
Suggestions issued by experts and students during the process of creating the questionnaire to assess knowledge, applicability and importance attributed to nursing communication techniques by undergraduates.

Questions	Item	Original Version	Experts' suggestions	Students' suggestions
Question 2	Content	Mark, in the appropriate column, your knowledge (I know, I do not know) of the intervention techniques (listed in the left column) used by nurse's when talking to patients.	Mark, in the appropriate column, your knowledge (I know, I do not know) of the intervention techniques, listed in the left column, used by nurse's when talking to patients.
	Alternatives	Ask tell ask, Tell me more, Nurse, Spikes, Paciente, Therapeutic communication.	Ask Tell Ask, Tell Me More, NURSE, SPIKES, PACIENTE, Therapeutic communication.
Question 3	Content	Regarding the communication techniques mentioned, mark the frequency you use each one (not used, less used, used moderately, used frequently).		Regarding the communication techniques mentioned below, mark the frequency you use each one (not used, less used, used moderately, used frequently).
	Alternatives	Ask tell ask, Tell me more, Nurse, Spikes, Paciente, Therapeutic communication.	Ask Tell Ask, Tell Me More, NURSE, SPIKES, PACIENTE, Therapeutic communication.
	Other changes	There was misspelling: frequently.	Frequently
Question 4	Content	Mark the techniques according to their respective objectives (right columns). There may be identical objectives in different techniques; in this case, you must tick the columns corresponding to each technique.	Mark the respective objectives in the communication techniques (right columns). There may be identical objectives in different techniques; in this case, you must tick the columns corresponding to each technique.	Indicate for each communication technique described below their respective objectives (right columns). There may be identical objectives for more than one technique. In this case, you must tick the columns corresponding to each technique.
	Alternatives	Ask tell ask, Tell me more, Nurse, Spikes, Paciente, Therapeutic communication.	Ask Tell Ask, Tell Me More, NURSE, SPIKES, PACIENTE, Therapeutic communication.
Question 5	Content	Mark all the steps listed in the left column belonging to each of the techniques mentioned	Mark, for each of the communication techniques mentioned, all the relevant steps listed in the left column.
	Alternatives	Ask tell ask, Tell me more, Nurse, Spikes, Paciente, Therapeutic communication.	Ask Tell Ask, Tell Me More, NURSE, SPIKES, PACIENTE, Therapeutic communication.
	Strategy steps	Item 9: Identify a problem in the patient's speech. Item 10: Encourage the patient to speak more on the problem Item 19: Uses silence therapeutically. Item 21: Verbalize interest in the focus of interaction. Item 27: Allow them to choose the subject Item 32: Use humor therapeutically Item 35: Ask to specify the agent of action	Identify a concern/emotion in the patient's speech. Encourage the patient to speak more on the problem Use silence therapeutically. Verbalize interest in the main objective of the interaction. Allow the patient to choose the subject. Use humor therapeutically. Ask to specify the agent of action.
	Other changes			Layout revision
Question 6	Content	Mark the level of importance (unimportant, less important, moderately important, relatively important, important) that you assign to each technique mentioned. Only one alternative for each technique must be checked.
	Alternatives	Ask tell ask, Tell me more, Nurse, Spikes, Paciente, Therapeutic communication.	Ask Tell Ask, Tell Me More, NURSE, SPIKES, PACIENTE, Therapeutic communication.
	Gradation of alternatives	Unimportant, less important, moderately important, relatively important, important.	Unimportant, less important, moderately important, very important.
Question 7	Content	Mark the order of importance you assign to each technique. Consider 1 for more important and 6 for less important.		Mark the order of importance you assign to each technique. Consider 6 for the most important and 1 for the least important. The same order of importance cannot be assigned to more than one technique
	Alternatives	Ask tell ask, Tell me more, Nurse, Spikes, Paciente, Therapeutic communication.	Ask Tell Ask, Tell Me More, NURSE, SPIKES, PACIENTE, Therapeutic communication.

After these changes, the instrument was made available to the ten students, so that they could assess its clarity. Except for Question 7 (90%), the students indicated 100% clarity for the questions and alternatives of the questionnaire. However, some suggestions, shown in Chart 1, were issued. They concern the wording of Questions 3, 4 and 7 and layout of Question 5, requested to appear on a single page because of its length, to facilitate online use.

Chart 1 shows the original questionnaire made by the authors and the changes proposed by the two groups of evaluators. All considerations were accepted, in their respective stages, except for the font size used.

Question 1 is absent from Chart 1 because it is the participants’ informed consent form and received no changes; also, the alternatives of the answers without change suggestions, which can be seen in Tables 1 and 2.

Table 2
Distribution of correct answers on the steps or techniques of communication strategies by undergraduate nursing students (n=42)

Communication strategies	Steps/techniques	Percentage frequency
Ask-Tell-Ask	1. Ask the patient their question, or reason for interaction	50.00
	2. Talk about the subject in question	16.67
	3. Ask what the patient understood about what was said	64.29
Tell Me More	1. Identify a concern/emotion in the patient's speech	14.29
	2. Encourage the patient to speak more on the problem	61.90
NURSE	1. Name the patient's emotion	17.50
	2. Explain whether or not the patient's feeling was understood	17.07
	3. Express respect for the patient	26.19
	4. Show patient support	12.50
	5. Show interest in the patient's focus of concern	4.88
SPIKES	1. Plan the interview	9.52
	2. Assess how much the patient knows about their problem	7.14
	3. Get the patient's request about what they want and how far they want to know about their problem	4.88
	4. Transmit information	14.29
	5. Welcome the patient's emotions	2.38
	6. Devise a treatment strategy	9.52
PACIENT	1. Plan the interview	7.14
	2. Assess how much the patient knows about their problem	9.52
	3. Get the patient's request about what they want and how far they want to know about their problem	9.76
	4. Transmit information	4.76
	5. Welcome the patient's emotions	4.76
	6. Devise a treatment strategy	4.76
	7. Do not abandon the patient	7.14
THERAPEUTIC COMMUNICATION	EXPRESSION CATEGORY
	1. Listen reflectively	57.14
	2. Use silence therapeutically	64.29
	3. Verbalize acceptance	43.90
	4. Verbalize interest in the main objective of the interaction.	38.10
	5. Use open or reticent phrases	28.57
	6. Repeat the patient's last words	14.29
	7. Ask questions	4.88
	8. Return the question to the patient	4.88
	9. Use descriptive phrases	17.07
	10. Allow the patient to choose the subject	30.95
	11. Focus on the main idea	14.63
	12. Verbalize questions	7.14
	13. Say no	28.57
	14. Encourage feelings and thoughts expression	38.10
	15. Use humor therapeutically	54.76
	CLARIFICATION CATEGORY
	16. Encourage comparisons	12.20
	17. Ask to clarify unusual terms	7.32
	18. Ask to specify the agent of action	11.90
	19. Describe events in logical sequence	9.76
	VALIDATION CATEGORY
	20. Repeat the patient's message	9.52
	21. Ask the patient to repeat what was said	9.52
	22. Summarize the content of the interaction	16.67

Study protocol

For recruitment and data collection, the recommendations of a study⁽¹⁶⁾ that highlights the importance of face-to-face recruitment and registration of the interested parties’ emails was used, as well as online data collection by email invitation, with the questionnaire link, to those who agreed to participate in the study.

Data collection was performed by the previously evaluated and aforementioned questionnaire made available online to participants through the SurveyMonkey tool.

The invitation was made in two moments: the first in person, held between classes or before it, by a member of the Research Group responsible for the study or by the author, respecting ethical aspects; on this occasion the interested parties made their email addresses available. In the second moment, there was formal confirmation by replying the invitation email sent by the researcher. Subsequently, a second email containing the questionnaire link was sent.

Result analysis

The data set stored in the SurveyMonkey tool made it possible to download the individual questionnaires and the respective tables in full, with simple frequencies and percentages. All study variables were analyzed by descriptive statistics. Furthermore, the relationship of the knowledge versus importance variables attributed to the strategies was evaluated by Fisher’s exact test, processed in the R i386 v.3.4.0 program.

RESULTS

Fifty students participated in the study. Of these, 42 (84%) answered the entire questionnaire, although some items were incomplete. Another five only answered the initial questions and three only replied to the consent form.

The participant’s average response time was 9 minutes and 4 seconds.

Three questions (2, 4 and 5) of the instrument sought to assess whether the student knew the strategies described, as well as their steps and objectives.

The best-known strategy (Question 2) was Therapeutic Communication (92.68%); followed by Ask-Tell-Ask (70.73%), NURSE (62.50%), Tell Me More (53.65%), PACIENTE (36.58%) and SPIKES (24.39%).

To assess the knowledge of the objectives of these strategies (Question 4), the rate of appropriate answers for each item was considered. It should be noted that an item could be assigned to more than one strategy, as shown in Table 1.

In other words, Ask-Tell-Ask, Therapeutic Communication and SPIKES showed better success rates of correct objectives.

The success rate on the assignment of the strategies steps studied (Question 5) shows partial knowledge. Three of the strategies had steps correctly assigned by most students (Ask-Tell-Ask, Tell Me More and Therapeutic Communication). Of the 22 techniques of Therapeutic communication, those in the Expression category were the most cited. On the other hand, the success rate for the other Categories were low. Both the NURSE strategy and the SPIKES and PACIENTE protocols had low rates of correct answers, as shown in Table 2.

Question 3 sought to identify the student’s usage frequency for each of the strategies. Therapeutic communication was referred to as the most used, by the options “used frequently” and “used moderately” (57.14% and 29.41%, respectively). Followed by Ask-Tell-Ask (26.82% and 31.70%), Tell Me More (21.95% and 26.82%;) and NURSE (17.07% and 19.51%); the least mentioned in these categories were the PACIENTE (20.00% and 7.50 %) and SPIKES (5.00% and 12.50%) protocols.

Question 6 assessed the importance the students attributed to each strategy. Therapeutic communication (90.48%), Tell Me More (82.93%), Ask-Tell-Ask (73.81%), NURSE (66.71%) and PACIENTE (58.8%) were assessed as very important; in this category, the SPIKES protocol was cited by less than half of the students (40%), but was considered moderately important for professional practice by 42% of the participants. When considering the two options (very and moderately important) all obtained scores higher than 82%.

Question 7 sought to identify the assigned order of importance, where score 6 should be attributed to the one considered most important and 1 to the least important. The technique with the highest frequency of score 6 was Therapeutic communication (50%), followed by NURSE (16.67%) and Tell Me More (15%). With score 5, the most cited strategy was Tell Me More (35%); and with degree of importance 4 was Ask-Tell-Ask (42.86%). The strategies that received the highest frequency of score 1 were SPIKES (37.84%) and PACIENTE (34.21%).

When comparing the response frequencies among the students who answered questions 2 (strategies cited as known) and 3 (use of strategies), it was found that Therapeutic communication and PACIENTE are those frequently used by at least 50% of the participants who knew them; three others are mentioned as used moderately (between 32 and 50%). However, at least 50% of the students who reported knowing the strategies employ them moderately or frequently in clinical practice, as shown in Table 3.

Table 3
Distribution of simple frequencies (n) and percentage (%) of usage of the strategies described as known by the students

Strategy	Use n (%)
	No	Low	Moderately	Frequently	Total
THERAPEUTIC COMMUNICATION	0	3 (7.89)	12 (31.57)	23 (60.52)	38
ASK-TELL-ASK	2 (6.89)	3 (10.34)	13 (44.85)	11 (37.93)	29
TELL ME MORE	3 (13.63)	0	11 (50.00)	8 (25.00)	22
NURSE	3 (12.00)	7 (28%)	8 (32.00)	7 (28.00	25
SPIKES	4 (40%)	1 (10.00)	3 (30.00)	2 (20.00)	10
PACIENTE	1 (7.14)	3 (21.42)	3(21.42)	7 (50.00)	14

For the relationship between knowledge (Question 2) and degree of importance attributed to communication strategies (Question 6) only the Ask-Tell-Ask strategy presented significant value, as shown in Table 4.

Table 4
Relationship between knowledge and importance attributed to communication strategies

Strategy	Knowledge	Importance				p value
		None	Low	Moderately	High
ASK-TELL-ASK	I know	0	1	2	22	0.001*
	I don't know	0	0	6	2
TELL ME MORE	I know	0	0	2	18	0.096
	I don't know	0	0	5	9
NURSE	I know	0	1	3	17	0.135
	I don't know	0	1	5	6
SPIKES	I know	0	0	1	6	0.303
	I don't know	0	2	10	13
PACIENTE	I know	0	0	3	10	0.551
	I don't know	0	1	7	11
THERAPEUTIC COMMUNICATION	I know	0	0	2	33	1.000
	I don't know	0	0	0	1

• Note:
• ^*
  p<0.05 Fisher's exact test

Although the students did not know some strategies, they were able to assign a degree of importance to them. Hence, it is noteworthy that most students adequately identified the purpose of the SPIKES protocol, even though it and its steps were referred to as lesser known.

DISCUSSION

This study aimed to evaluate the knowledge, applicability and importance that final-year nursing undergraduates attribute to therapeutic communicative strategies, by an online questionnaire. Despite the relevance attributed to the theme by the literature^(11,15), the highlights to the contributions of the online instruments^(11,15-16), the recommendations of the steps and the participants’ familiarity with the Internet⁽¹⁹⁾, these aspects deserve further reflection, given the researchers’ growing use of tools of this nature and the need to consider how they may impact the results obtained.

In this study, even using face-to-face recruitment and sending an invitation email, in compliance with the literature recommendations⁽¹⁶⁾, one third of the eligible potential subjects had no interest in participating and of those who initially registered, a quarter did not answer the invitation email or the questionnaire. Authors state that, among the potential disadvantages of online surveys, the main one is the low response rate to questionnaires^(17,20). Although the reasons for the non-response were not verified, this could benefit future studies⁽¹⁷⁾, the need for a formal response to the invitation email, for later availability of the questionnaire access link, may have influenced the participation of students.

There was a higher dropout in participation from Question 5, which corroborates a previous study⁽²¹⁾, in which the final questions of the questionnaires had a higher non-response rate. Although the authors responded to the evaluating students request, and changed the Question 5 layout to improve usability, the length of the question may have interfered, as already described⁽¹⁷⁾.

Analyzing the students’ answers, the strategy identified as best known was Therapeutic communication, followed by Ask-Tell-Ask^(4,6) and Tell Me More^(4-6). Assessing the knowledge about the steps of each strategy, more than half of the participants recognized the initial and final steps of Ask-Tell-Ask^(4,6) and more than 60% recognized the step encourage to talk more about the problem in Tell Me More^(4-6). The SPIKES^(6,8-10) and PACIENTE⁽¹¹⁾ strategies, cited as the least known, had the lowest identification rate of their steps. The result obtained in the present study is attributed to the disclosure of the purpose of this protocol in the medical field, with a high correctness rate about its objective.

The Therapeutic communication strategy adopted ^(4,12) has several techniques, and those of the expression category, which establish listening, therapeutic use of silence, therapeutic humor and expression of feelings were the most recognized. Although using all techniques in a communicative strategy is optional, it is useful to employ techniques from the three types of categories.

Prioritizing the expression category was also a trend found in similar studies^(2,22-24).

To analyze therapeutic communication in the interaction between health professional and hypertensive patient in the Family Health Strategy, authors⁽²²⁾ developed a checklist with such techniques, for non-participant systematic observation. They found that the health professionals of the research unit used techniques from the three groups, and those of the expression category above all. However, the authors draw attention to an ineffective use, as they are hardly explored in consultations, which makes the communicative process less effective and efficient. Another study, with a similar result, was performed with professionals working in the intensive care unit; it showed that nurses use more frequently the techniques related to expression (listening reflectively, therapeutic humor, verbalizing acceptance, therapeutic use of silence, asking questions, returning the question asked, using descriptive phrases), when compared to the other categories^(24).

Regarding the applicability and importance of the studied strategies, the results obtained agree with those regarding the strategies best known by the students. In this respect, when analyzing the applicability of therapeutic communicative strategies, participants in a study⁽²³⁾ stated that they predominantly use those that help the patient’s expression and nursing therapeutic measures. They also recognized the importance of using strategies when providing patient care. These results are similar to those described here, since students also attach greater importance to the Therapeutic communication strategy and predominantly use the techniques of the expression category.

Similarly, in another study⁽¹⁴⁾, when simulating patient care, students who used Therapeutic communication to manage emotions showed a predominant use of techniques in the expression category, with clarification and validation being less used.

Also, in this study⁽¹⁴⁾, students who participated in the simulated activity could select the strategy they deemed necessary to achieve the goal of managing the patient’s emotions. Most groups used the NURSE and Ask-Tell-Ask strategies incompletely. However, the Tell Me More strategy was fully utilized by most groups. Such results are similar to that of the present study, since the strategy Tell Me More was considered as known by most participants (69.57%) and was the second most frequently used.

As seen in Table 3, it is worth highlighting the relationship between the knowledge of the strategies and their use, which showed that the strategies indicated as known were described as used by at least 50% of the participants. The best known (Therapeutic communication) showed a higher percentage of frequent use in care practice, emphasizing that the learned content is used.

In this study, all strategies were classified as very or moderately important by at least 82% of the students. The analysis between knowledge and assigned importance had a positive relationship (p<0.05) only for Ask-Tell-Ask. However, the other strategies showed a high degree of importance regardless of their knowledge (p>0.05). Regarding Therapeutic communication, almost all students reported knowing and attributed high importance to this strategy (p=1.00).

One study identified that the SPIKES protocol was unknown to 60% of the participants, although most thought important to use a protocol for this purpose⁽²⁵⁾. The students’ assessment of the SPIKES protocol as being of moderate importance, despite its unfamiliarity, may be due to its relevance and use in the health area for cancer or terminal patients.

The aforementioned study⁽²⁵⁾ about the SPIKES protocol also showed that among those health professionals who communicate bad news to patients, most considered their communication skills good. However, 60% considered their learning of this technique to be bad or very bad during graduation.

Regarding the teaching of these communicative strategies, despite not being the object of this study, the results pointed to the reflection on such practices in the student’s education and the content formally addressed, given the identified gaps in knowledge or skills and its relevance to clinical care. Additionally, in the institution hosting this research, the recent experience of using the Arco de Maguerez (Maguerez’ Arc), with a video prompting the problem-situation and the simulation in the phase of practical use followed by debriefing, was successful in teaching therapeutic communicative strategies, highlighting how reflection is important to complement and sediment knowledge and competencies in this area⁽¹⁴⁾.

The importance of learning communication in Nursing has been highlighted, despite difficulties^(26-27) and complexity, both for teaching and for its employment in clinical practice. Moreover, it is important to point out that the development of communicative skills in nursing undergraduate programs does not seek to achieve complete knowledge, but present a theme that, because of its complexity, will be improved throughout the professional trajectory⁽²⁶⁾. Thus, professors play an important role in preparing the students; understanding both the perspectives and difficulties of nursing students can provide valuable information about their views on communication and their main doubts.

Study limitations

Although the strategy adopted for data collection allowed for a fast analysis of the data, it presented some difficulties inherent to its method, like the need for prior email communication confirming interest in the invitation already made in person and release of the instrument access link. Another aspect was the length of Question 5, with several items to be answered, considered a possible interference factor in the results obtained. Furthermore, when considering the knowledge of a given strategy, when partial, some students may have reported lack of knowledge, since the corresponding question only presented two possible answers. The fact that the study was carried out with students from a single institution, does not allow generalizations.

Contributions to the field

Given the relevance of therapeutic communicative strategies in clinical nursing practice and the results expressed by the students in this study, reflections on its teaching contributed, at the host institution, to implement more participatory methodologies and content expansion, comprising all strategies addressed in this study. However, despite the complexity of teaching such strategies, the results obtained suggest that the educational institutions should intensify learning opportunities on this theme throughout the course, in the different health care scenarios, for the development and sedimentation of therapeutic communicative skills, with people in different age groups and health conditions, since knowledge about them provides their employment. They are also useful for reflecting on continuing education and monitoring of health professionals regarding the contribution of communicative strategies in clinical practice. In this respect, the survey proved useful for the proposed assessment, and can be employed by other researches. Studies that use more robust methodologies to assess the effective acquisition of competencies in this area, both in undergraduate and clinical practice, are still necessary.

CONCLUSION

The students participating in this study reported knowing, using and attributing greater importance to the Therapeutic communication strategy, followed by Tell Me More and Ask-Tell-Ask. The NURSE strategies, SPIKES and PACIENTE Protocols were cited as less known and used, although considered important by most students. Their knowledge about the objectives and steps of these strategies was partial.

Based on the results and considering the knowledge of such strategies to be complex, but necessary to provide comprehensive care, encourage the expression of feelings, clarification of information, data collection, approach of emotions and communicate information or difficult news, we suggest reflection on how to teach such content and encouraging its use in the students’ clinical practice, throughout nursing courses. Furthermore, we encourage new studies with more robust methodologies to assess the communicative skills of health team members and students, as well as the effects of educational strategies employed in this field.

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Edited by

EDITOR IN CHIEF: Antonio José de Almeida Filho

ASSOCIATE EDITOR: Priscilla Broca

Publication Dates

• Publication in this collection
  10 Aug 2020
• Date of issue
  2020

History

• Received
  13 Aug 2019
• Accepted
  16 Mar 2020