Relational skills and preserving patient privacy in the caring process

Objective: to analyze the development and mobilization of relational skills central to the caring process among nursing students throughout their professional training. Method: this was a quantitative study, descriptive and cross-sectional in design. The sample consisted of nursing undergraduate students from the Higher School of Health Sciences, in the city of Évora, Portugal. Data were collected using the previously validated Helping Relational Skills Inventory. Results: the students gradually acquired “generic skills”, “communication skills” and “contact skills”, presenting the highest mean score in the last year of the program. However, the highest mean score for the “empathetic skills” subscale was presented by second-year students. Conclusion: age and year in program were found to be decisive variables regarding the acquisition of specifi c skills (empathetic and communication) by nursing students.


INTRODUCTION
Care is an inherent part of nursing, and as such, this discipline must maintain its essence both through its practice and academic training.To do so, it must seek new knowledge to help manage daily caring processes, both at the technical and at the relational level.
The caring process in nursing manifests itself through the encounter of care among caretakers, in which the wayof-being of their existence constitutes itself authentically, promoting the exchange of experiences, feelings and emotions, building a caring relationship (1) .
As a helping occupation, nursing is based on the interpersonal relationship between those who provide care and those who receive it (2) .During the caring process and the formation of interpersonal relationships, students are often unaware that they are crossing the line that divides that which is inherent to their interventions and the patient's privacy.However, nursing is described "as an interpersonal therapeutic process that implies a professional form of intimacy" (2) .
Respect for patient privacy must be maintained throughout the entire caring process.Privacy is a human right and need, and is essential to the dignity of human beings.
In the nursing profession, according to the Portuguese nursing code of ethics, interventions must be conducted while defending the freedom and dignity of individuals and nurses (3) .Thus, nurses play a respectful role towards patients throughout the caring process as a whole.
The process of acquiring and consolidating skills is initially associated with academic training.It is influenced by several factors, namely those of personal order and by the life experiences of each student.
Skills are defined as "an integrated set of cognitive capacities, psychomotor skills and social-affective behaviors that allow individuals to perform functions, tasks or activities at the level of performance required for entering the labor market" (4) .
Throughout academic training, skills are gradually developed, representing an evolving phenomenon.As such, skills are put into action as students learn to mobilize their acquired knowledge.
It can be said that students possess certain skills when three dimensions are displayed: 1) the resources available for taking action (knowledge, know-how, cognitive capacities, behavioral skills), 2) the consequent actions and results, that is, professional practices and performance, and 3) reflexivity, which occurs when professionals distance themselves from the previous two dimensions (5) .
The process of acquiring relational skills does not happen as fast as other dimensions, as it depends on student-patient interaction; in other words, relational and ethical knowledge must be ready to be put in practice.
The purpose of this study was to identify how nursing students developed relational skills during the caring process while preserving patient privacy.
It is essential for nursing students to develop their academic training so that patient privacy may always be preserved during the caring process, or the student-patient process of inter-relation.

METHOD
We chose to conduct a quantitative study, cross-sectional and descriptive in design.The sample population consisted of students from the Higher School of Health Sciences, Évora, Portugal.We included all students who had already begun their clinical instruction, which in this institution begins in the first year.
Data were gathered using a questionnaire to characterize students and their clinical context and an Inventory of Relational Help Skills (ICRA) (6) , which assessed the acquisition of relational skills by nursing students in the caring process.
Subjects responded to the items on the ICRA using a 7-point Likert scale.
Ranging from 1 (completely disagree) to 7 (completely agree) and organized so that the greater the score, the more helping relational skills displayed by the individual.The total score can range from a minimum of 51 to a maximum of 357 (6) .
This scale is called a semantic differential and is a variation of the Likert scale.It is used to assess how a person interprets an attitude or a given theme and to measure different aspects of such attitude (7) .
The items in the final version of the ICRA are grouped by the thematic dimensions of the scale's conceptual framework (generic skills, empathetic skills, communication skills, and contact skills).
Data collection took place between April and June 2010.Data analysis was conducted with the help of statistical techniques for organizing, assessing, interpreting and communicating the information obtained, using the Statistical Package for the Social Sciences (SPSS), version 17.
Regarding ethical issues, permission was obtained from the nursing school's administration.This study was also approved by the health and wellbeing research ethics committee segundo año tienen un valor promedio más alto.Conclusión: la edad y el año del curso son variables determinantes en la adquisición de habilidades específicas (Empática y la comunicación) de los estudiantes de enfermería.Palabras clave: Educación Basada en Competencias; Estudiantes de Enfermería; Privacidad; Atención de Enferméria.
Maria Otília Zangão E-mail: otiliaz@uevora.ptCORRESPONDING AUTHOR of the University of Évora.All students were asked to sign an informed consent form before participating.Furthermore, we abided by all ethical procedures inherent to research with human subjects.

RESULTS
The sample comprised 115 students, of which 91.3% were female and 8.7% were male.Although most students (60%) in the program were aged between 20 and 29 years old, 35.6% were under the age of 20 years (15-19).Only 3.5% of students were in the 30-39 age group.We also observed that most students were single (96.5%).
For most of the sample (86.1%), nursing was their first choice of program, as was the choice of school (68.7%).Most students (87%) only studied.Of those who worked full or part time (13%), only 5.2% held a student-worker status.
Regarding the type of monitoring received by students, most (58.4%) were accompanied by the nurses who supervised the services in which their clinical instruction took place.
Total ICRA scores ranged from 223 to 337 points, with a mean score of 280.83 and a standard deviation of 26.7.
Regarding the subscales, we also found that the students displayed relational skills within the average limits for each subscale, as illustrated in Table 1.In order to better assess the students' skill levels, we calculated the weighted means for the total score and for each subscale.The results showed that the values fell above the intermediate value (a score of 4 from a range between 1 and 7).The weighted means varied from 5.05 to 5.78.The contact skills subscale presented the lowest mean score, and the generic skills subscale, the highest.
With regards to school year and mean subscale scores, the means for all scales in the present study were higher than those identified by the developers of the scale.On the other hand, we found that the mean score for each skill increased as the students progressed in the program.In other words, firstyear students presented a lower mean (274.39)than secondyear students (281.73).Third-year students presented a slightly lower mean (280.65)than second-year students.The highest mean score was displayed by fourth-year students (290.83).In other words, students acquired more skills as they advanced in the program, as illustrated in Table 2.
An analysis of gender and subscales revealed that male students presented a higher mean on the empathetic skills subscale.On the other hand, we found that male students presented lower means than female students on the contact skills, generic skills and communication skills subscales, as shown in Table 3.The results showed that, on average, students between the ages of 20-29 years presented more helping relational skills (287.83),followed by students between the ages of 30 and 39 (284.50).Those with the lowest mean were under the age of 20 years (275.40),as shown in Table 4.
Regarding the correlation between type of monitoring received during clinical instruction and skill subscales, we found that students accompanied by supervising nurses presented the highest overall helping relational skills.The empathetic skills subscale was an exception, as the highest mean was presented by those instructed by supervising nurses or by the professors responsible for the school, as illustrated in Table 5.

DISCUSSION
The vast majority of students at the school were female.The percentage found in our study differs somewhat from the national figure presented by the Ordem dos Enfermeiros (Nursing Council) in 2013 (8) , which also showed a tendency toward female predominance, but showed that of the 65,872 nurses in Portugal at the time, 81.69% were women.Such predominance of women is associated with the history of nursing, in which women were inseparably associated with the practice of care.Currently, this trend persists, as shown by the percentages in the present study, which overlap with those of other studies (9) .In terms of the correlation between student gender and total ICRA score, we found that the mean score for total helping relational skills among men was slightly higher than among women (although the difference was not statistically significant).This finding corroborates that of another study conducted with nurses in which "men seemed to present, even if slightly, higher values of overall helping relational skills compared with women" (10) .
Nonetheless, regarding the overall scale score, the results of that study showed that: Undergraduate nursing students presented higher generic skill scores, with a statistically significant difference.Female students presented higher means in all dimensions of helping relational skills and developed their generic, empathetic and communication skills significantly better than men.Regarding contact skills, no statistically significant differences were found between genders (10) .
Another researcher also concluded that, "Although there were differences between genders in terms of helping relational skills, these were not statistically significant" (10) .
The fact that the values obtained in our study for gender and empathetic skills were not statistically significant is justifiable, for "one of the main expectations of the client who communicates with the intervening professional is to be understood," regardless of the caretaker's gender (11) .Another study concluded that although there were no statistically significant differences in terms of gender, there was a tendency for all helping relational dimensions to be higher among women (12) .
The sample was considerably young, as a great number of students were under the age of 20 and this "implies a sample that is not very mature, in the sense that they do not have a great variety of personal experiences that are essential to building and developing such skills" (13) related to health care.In terms of age and skill subscales, we observed a statistically significant difference between age group and the communication skills.The students aged between 20 and 29 years presented a higher mean in this subscale than other age groups.Researchers have different opinions on this finding, and in one study, the researchers stated that "the older students get, the more life experience they have; their cognitive capacity becomes increasingly more complex and they have an easier time understanding others" (11) .In contrast, another researcher found that "the older the student, the less developed their helping relational skills" (10) .The same study concluded that, "there was an association between age and the development of contact skills, being that older subjects presented lower scores (and the younger students developed these skills to a greater extent)" (10) .No associations were found between age and the other skill dimensions.
We can consider that the students' choice of program, school and the fact that some studied and worked, are all variables that affect their performance.These are only some of the numerous factors that contribute to individuals reaching their potential for development (14) , in the sense that the students are motivated to practice their profession, especially because they identify with the field of nursing (13) .
The data showed that generic skills, communication skills, and contact skills subscales means were higher among fourth-year students.Furthermore, the same students tended to present greater values of total helping relational skills.Another study found that nurses presented higher means in all dimensions of helping relational skills with the exception of generic skills, in which all nurses presented very similar scores (10) .In other words, the more students advanced in the program, the more helping relational skills they displayed, with the exception of empathetic skills, for which secondyear students showed higher scores.In contrast, another study signaled, "the development of helping relational skills was not specifically associated with the training obtained in the nursing program" (10) .
Nonetheless, we found a statistically significant correlation between communication and empathetic skills and school year.Fourth-year students presented higher levels of skills in both dimensions.In a study conducted with nursing students, the developer of the ICRA also stated that, "these differences were statistically significant with respect to communication skills" (6) .
Statistically significant correlations were observed between type of monitoring for clinical instruction and the acquisition and development of relational skills.Specifically, students who were accompanied by the nurses who supervised the services in which they conducted their clinical instruction presented the highest communication skills scores.This finding can be explained, as "the aspects that most have a positive effect on the development of skills throughout the program are those associated with the unit in which clinical instruction and internships (practical training) take place" (13) .
The pedagogical relation between teachers and students allows for the latter to live certain experiences that will influence the future decision to follow this or that path, as teaching nurses can serve as a models to their students (13) .
Such positive and healthy interactions lead to more horizontal relationships, contrary to the more commonly found relationships in which teachers are in a place of authority due to the knowledge they possess.
We analyzed how students preserved patient privacy by using the following subscales: 1) empathetic skills, which showed how students place themselves in other's shoes, the way in which they recognize patients in their singularity and accept their points of view; 2) contact skills, which demonstrated their stance, attitude and how they place themselves before patients; and 3) communications skills, which encompassed important communication resources (6) .
Regarding the relationship between independent and dependent variables, statistically significant correlations were found between age and communication skills.On average, students between the ages of 20 and 29 years displayed the highest means.In terms of school year and skill subscales, we found a statistically significant correlation between the empathetic skill subscale and second-year students, who presented higher scores.In contrast, fourth-year students obtained the highest overall means.Considering gender, male students presented more empathetic skills than female students; regarding contact and communication skills, however, there were no statistically significant differences between genders.
In terms of skill subscales and type of monitoring received during clinical instruction, we found that students who were accompanied by the nurses who supervised the services in which clinical instruction took place displayed higher communication skill scores than those who received their instruction from other professionals.
The present study found that the empathetic, communication and contact skills subscales obtained higher weighted means (5.31, 5.61, and 5.05, respectively) than the generic skill subscale (5.7).This finding corroborates that of another study with nursing students, whose weighted means ranged from 4.74 to 5.95, the highest value corresponding to generic skills and the lowest value, to contact skills (10) .
The values obtained for the contact skills subscale can be explained by the fact that "professionals who find it difficult to be intimate with clients use distance as a form of protection" (11) , establishing a superficial and non-committed relationship.
Relative to empathetic skills, another study concluded that "the development of empathetic and communication skills is directly and positively correlated with psychological maturity" (2) .
Establishing a helping relationship, as an autonomous intervention, is an undeniable part of the nursing caring process, as it plays a primordial role in meeting the needs of individuals, translating into better quality of care (15) .

CONCLUSIONS
The present study demonstrated that the value of the helping relational skills presented by the nursing students corroborated the findings of other studies that used the same scale.The means for the skill subscales were within the average limits for each subscale.
We were able to conclude that the acquisition and development of communication skills were influenced by the year in program, as well as the type of monitoring received during clinical instruction.On the other hand, we found a correlation between age and skill subscales, in which older students presented higher means in the generic, empathetic and contact subscales.The communication subscale presented a higher mean among younger students.
In terms of preserving patient privacy, the findings show that second-year students and male students displayed higher empathetic skills, and fourth-year students and female students showed higher contact skills.Older students are the ones who presented higher subscale means.
Thus, we conclude that the helping relational skills displayed by these students were acquired and developed throughout the program; however, we observed that, on average, second-year students displayed more skills than third-year students, but were always surpassed by fourth-year students.On the other hand, we emphasize that as nursing students develop helping relational skills, they also acquire skills related to the preservation of patient privacy, as these two aspects are inseparable parts of the patient care process.
Despite the small sample size, we consider this study to be an important contribution to increasing the understanding the way in which helping relational skills are developed by nursing students in the care process throughout their professional training so as to preserve patient privacy.

Table 2 -
Students by school year and skill subscales, Évora, 2015