Relational skills : needs experienced by nursing students 1

Objective: to identify the needs of nursing students in the field of relational competencies. Method: qualitative study with an exploratory-descriptive nature. The random sample included 62 students in the 2nd year of the nursing undergraduate program of a school located in the central region of Portugal. The inclusion criterion was the nonexistence of clinical teaching. Data were collected through a form designed to assess relational needs; content analysis was used to analyze data. Results: the results indicated that the students’ concept of nursing care at this stage of their education is focused on the performance of nursing tasks and techniques instead of on scientific knowledge. Overall, they are aware that greater personal development and better self-knowledge are determinant for their personal and social well-being and for them to become good professionals. Conclusion: these results will support the improvement of an intervention program to be developed with these students.


Introduction
Relational and interpersonal relationship skills are considered to be the backbone of nursing care and are recognized as the competencies that differentiate excellent nursing care (1) .The acquisition of these skills is considered a progressive process, developed according to various stages: beginning, advanced beginning, competent, proficient, and expert (2) .Admittedly, professional competence in nursing includes clinical and technical aspects, but relational aspects complement it.
The development of professional competence is achieved only after personal competence is developed (1) .There is no doubt about the relevance of personal competence for one's personal and professional realization or of its usefulness in training or inclusion in school programs (3) .
We assert that professional competence in nursing is primarily based on the nurses' personal qualities, on their personality, which determines the acquisition of education and experience.Competence in nursing comprises two essential aspects: the mobilization of personal competencies and the mobilization of different types of knowledge and know-how applied to nursing care (1) .
The more self-knowledge a caregiver has and the more complete it is, the better the care provided (4) .
Self-knowledge (recognition of one's own limitations, emotions, being able to work with one's own emotions), respect for others, relational distance, open-mindedness, professional attitudes and behavior, attentive listening, invention, and creativity are competencies essential to the quality of nursing interventions (5) .
In a clinical-reflective approach of an ecological matrix (6) , professional competence is a result of a set of micro-interactions: with oneself (intrapersonal interaction), with others (interpersonal interaction), and with knowledge in interactive relationships (multidisciplinary interaction).Considering that people are the essence of an organization, their full involvement enables their competence to be fully used to the benefit of the organization itself, also benefiting the implementation of intervention programs (7) .
It is also important to note that the quality of care is strongly marked by the attitudes and behaviors of those providing care.Competent professional performance requires knowledge able to mobilize, integrate, and transmit knowledge acquired during the educational process (8) , which may be enabled by the development of competencies from new pedagogical opportunities provided during initial stages of education (9) .

Specifically, nursing know-how incorporates in
itself the relational know-how (8,10) , while nursing care, considered to be the special attention provided to a person requiring help, is essentially developed via an interpersonal relationship, which requires complex competencies from nurses, competencies focused on humanist principles (unity, the tendency to update one's knowledge, autonomy, progress) and on supportive relationship (acceptance, authenticity, empathy, warm respect, congruence, attentive listening) (11) .

Objective
To identify the needs manifested by nursing students in the field of relational competencies.

Method
Qualitative and longitudinal study with an exploratory-descriptive approach, quasi-experimental Data were analyzed through content analysis as a set of analytical communication techniques (12) .We note that the development of categories followed the rules: homogeneity, exhaustiveness, uniqueness, objectivity, and relevance (12)(13)(14) .The process of content analysis began with a pre-analysis of the material though skimming the answers provided to each question.The material was then explored and coded with the identification and delimitation of units, organizing categories and subcategories, through an inductive process.A panel of experts ensured the validity and reliability of content analysis.
Table 2 shows the results of the analysis concerning the 318 units expressed by the students.They support the opinion that personal characteristics facilitate nurses' competence, especially communication skills (12.89%), followed by sympathy (8.81%), tolerance (6.92%), professionalism (6.60%), and self-esteem/ self-confidence (5.66%).When the students were asked about the characteristics and the personal competencies they needed to develop to improve their personal and social well-being, they reported self-esteem in 29.55% of the 132 studied units, communication skills (23.48%), assertiveness (15.91%) and emotional competence (12.12%) (Table 5).Tolerance, knowing to listen and sense of responsibility were less frequently reported.

Discussion
Highlighting the most significant results achieved in this study through the assessment of relational needs, the following conclusions were reached.Based on what the students reported as being competencies essential to the quality of nursing care, we verified that the categories (professional competence, and personal and social competence) illustrate the importance the students assign to the professional dimension (85%) and to the intra-and interpersonal dimensions (15%).
Such findings allow us to infer that the students, at this stage of their education, do not integrate concepts advocated by some theorists, for whom the quality of nursing care is marked by the nurses' behavior (8) and that professional competence is only achieved after personal competence is developed (1) .
Meanwhile, another piece of evidence related to the subcategories of Professional Competence is related to a greater appreciation of Know-How, due to the overvalorization of techniques and procedures at the expense of the subcategory Knowledge, especially scientific knowledge.This notion of nursing care is focused on the performance of nursing tasks and techniques instead of on scientific knowledge in nursing, essential for nurses' autonomy (15) .On the other hand, the students assigned Lopes RCC, Azeredo ZAS, Rodrigues RMC.
significant value to the subcategory Relational Know-How (42%), recognizing the importance of supportive relationships, humanistic principles and communication for the quality of nursing care (10)(11)16) .
In relation to the professional competencies the program should enable students to acquire, the results are related to the competencies that are essential to the quality of nursing care previously discussed.The students, again, under-valued Scientific Knowledge and evidenced bias toward Techniques and Procedures.
These findings contradict some previous studies addressing students from different undergraduate programs where the aspect most valued is "acquisition of knowledge", indicating that teaching institutions transmit more knowledge from the knowledge scope than from the know-how, know-to-be, and know-coexist scopes (17) .
Nonetheless, within Relational Know How, they exalt the development of competencies concerning supportive relationships and communication skills, while within the scope of Knowledge, they exalt personal and social competencies.These aspects are globally confirmed by conceptions that defend the view that competence in nursing comprises two essential aspects: the mobilization of personal competencies and the mobilization of knowledge and know-how applied to nursing care (1) .These aspects also highlight the importance of nurses' self-knowledge that promotes skills and quality of care, that is, the better and the more complete one's self-knowledge, the better the quality of care provided (5) .
The more self-knowledge a caregiver has and the more complete it is In relation to the personal characteristics that facilitate the competence of nurses, the students highlight communication skills but also value the ability to be tolerant, rigorous, organized, professional, understanding, assertive, and having good self-esteem and self-confidence.Overall, these findings seem to be in agreement with the idea that investing in communication skills on the part of nurses is associated with higher levels of personal growth (18) .
In regard to personal characteristics and competencies to which students need to pay greater attention in order to become good nurses, communication skills, self-esteem and assertiveness stand out.These results are consonant with those reported by studies that defend competence in interpersonal communication as an ability essential to be acquired by nurses, which enables them to provide conscientious, true and transforming care (19) .Closely related to the previous issue are the personal characteristics and competencies that students are required to develop in order to improve their personal and social well-being; they highlighted self-esteem, communication skills, assertiveness and also emotional competence.
Considering that undergraduate education should enable personal development, dimensions concerning the development of responsibility, positive relationships and cooperation emerge as having considerable relevance in empirical investigations focused on the academic success of undergraduate students (17) .In other studies that are focused on acquiring knowledge in Clinical Teaching, the students' personal characteristics and maturity demonstrated in interactions (6) , self-knowledge and factors intrinsic to the individual stand out (20) .
design and triangulation of quantitative and qualitative methods, to assess the efficiency of an intervention program.The studied population included 2 nd year students from an undergraduate nursing program taking the theoretical course in the 3 rd quarter of 2009-2010 in a college of nursing in the center region of Portugal.There were 166 students distributed into three classes.Considering the randomization of students distributed per class, the random sample was composed of 62 students.The inclusion criterion "non-existence of clinical teaching" was considered in the sample selection.A self-reported qualitative form addressing relational needs was used to collect data.It was composed of five open questions designed to identify relational needs expressed by the nursing students in their interpersonal and professional relationships and also their needs concerning education.According to ethical principles, the school's president authorized this investigation and the participation of students was voluntary and confirmed by their signatures on free and informed consent forms.This study was also approved by the Ethics Research Committee (Process No. 14-12/2010) at the Research Unit in Health Sciences-Nursing (UICISA-E) of the Escola Superior de Enfermagem de Coimbra.
content analysis concerning the opinion of students about what competencies are essential for the quality of nursing care and professional competencies the program should enable them to acquire showed a greater valorization of Know-How through an overvalorization of Techniques and Procedures at the expense of Knowledge, especially of Scientific Knowledge.The conclusion is that the concept of Nursing Care held by nursing students at this stage of their education is focused on the performance of nursing tasks and techniques instead of on scientific nursing knowledge, so essential for the autonomy of nurses and the science of nursing.It also became apparent that they attribute great value to the quality of Nursing Care and Relational Know How, especially through supportive relationships, humanistic principles and communication.The students reported that personal characteristics are required to improve their well-being or for them to become good nurses or to facilitate nursing competencies: the development of communication skills, emotional competence, self-esteem, and assertive behavior.Finally, we conclude that the students are aware that personal development and better self-knowledge are determinant of their personal and social well-being, as well as for them to become good professionals.www.eerp.usp.br/rlaeRev. Latino-Am.Enfermagem 2012 Nov.-Dec.;20(6):1081-90.3. Falcone E. Habilidades sociais: Para além da assertividade.In: R. Wielenska.Sobre comportamento e cognição: Questionando a ampliando a teoria e as intervenções clínicas e em outros contextos.São Paulo: SET Editora; 2000.p. 1-13.

Table 2 -
Categories, subcategories, and units concerning the personal characteristics students considered to be facilitators of nurses' competence

Table 3 -
Categories, subcategories, indicators and units concerning the students' opinions regarding the professional competencies the program should enable them to acquire …know to act assertively when facing diverse situations.(P44) Control emotions in the field because we establish a relationship with patients and we often put ourselves in their shoes or in the shoes of their families and close friends or when we are unable to establish a boundary that separates emotions from home and the nursing ward (P6)

Table 4 -
Categories and units concerning the personal characteristics and competencies to which students deemed need special attention in order for them to become good nurses I need to be more assertive and say 'no' in certain situations (P15) Be able to stand for myself; know how to say 'no' (P36) I need to work on my stubbornness; I'm too proud and I think that this feature can harm me.

Table 5 -
Categories, units concerning the personal characteristics and competencies the students need to improve their personal and social well-being