DEGREE OF THERAPEUTIC COMMUNICATION PRACTICE AMONG NURSING

STUDENTS OF UNIVERSITY OF NORTHERN PHILIPPINES

A Research Proposal
Presented to
the Faculty of the College of Nursing
University of Northern Philippines
Tamag, Vigan City

In Partial Fulfilment
of the Requirements for
NCM 111: Nursing Research

by

La Madrid, Hanna Mae B.

Labini, Dienizs
Crisostomo, Joan
Viernes, Lara Mae
Saraos, Daryl
 2020
Chapter I
THE PROBLEM

INTRODUCTION

Communication is the essence of human life, as claimed by Janice Light (2015). It has

been defined by many as the exchange of information, feelings, and thoughts among people

(Lambrini and Loanna, 2014; Berengere et al., 1997; Ennis et al., 2013). And according to

Brinkert (2010), communication is needed not only for transmission of information and

knowledge to one another, but more significantly to inter-relate as human beings everywhere

in the world. Papadantonaki (2006) also added that this occurrence is undeniably evident in

healthcare settings as well. Most times nursing as a health care science focuses on meeting the

health needs of human as a biopsychosocial and spiritual being. However, according to

Lambrini and Loanna (2014), nursing practice requires not only scientific knowledge, but an

additional effective interpersonal communication, intellectual and technical abilities and skills

as well.

In addition to that, Bach and Grant (2009) identified communication as a significant

attribute in nursing (Ennis et al., 2013) a medium through which information, in the context of

“care” is conveyed. Healthcare providers need to communicate with their clients, based on

Hippocrates medical principles, more than any other professionals. As nurses assume a more

complex roles and care for older and more culturally diverse populations, it is greatly essential

for them to strengthen their communication skills for the sake of their patient’s safety, health,

and well-being (UTA, 2019). In a definition by Watson (1998), nursing is viewed as a human

to human relationship where in, one person “nurse” affects and is affected by the other person

“patient”, in agreement with that Casey and Wallis (2011) therefore suggested that more

emphasis should be placed on the development of effective and therapeutic relationship among
other nursing skills in order to achieve the concept of “nursing is caring” and “patient-centered

care” which are paramount in nursing practice of now a days because of the improved care

satisfaction it brings for the patients.

The concept of "therapeutic communication" refers to the process in which the nurse

consciously influences a client or helps the client to a better understanding through verbal or

nonverbal communication. Therapeutic communication involves the use of specific strategies

that encourage the patient to express feelings and ideas and that convey acceptance and respect.

As claimed by Gamayon (2017), if interaction facilitates growth and development, maturing,

and improved functioning or coping, then it is considered therapeutic.

Moreover, the skills required in therapeutic communication are delicate and far

numerous than those required in general interpersonal interaction, and mastering of therapeutic

techniques helps the nurse understand the patient better. Sound interpersonal interaction skills

for the nurse are of great importance and necessary for effective therapeutic communication.

As Papagiannis (2010) stated, patients make impression of the nurses’ based on how these

nurses communicate and relate with them, and the impression nurses pass to patients will

influence their satisfaction and hence their healthcare output. Raya (2006) also argued that what

one says, how one says it, what one really means by it are extremely and all equally important

and could be life changing.

Therapeutic communication is indeed a vital tool every health care provider must

possess in order to connect with patients and recognize their problems and help them to

understand how they should take care of themselves. Unfortunately, many are short of effective

therapeutic communication skills to influence and skillfully collaborate and advocate for their

patients, especially newly graduated nurses and nursing students (Pines et al., 2012). There has
been, for decades, a concern that nurses might often be ineffective communicators and that

there are deficiencies in terms of their communication skills (Jarrett and Payne, 1995).

Additionally, there are few studies about nurse-patient communication in Iran. The

majorities of these studies have focused on communication barriers. In a qualitative study on

nurse-patient communication, found that job dissatisfaction, routine-centered care and lack of

trust to nurses from patients’ views were the major barriers for achieving effective

communication (Shafipour, et. al., 2014). Also, other factors such as heavy nursing workload,

hard nursing tasks, nurses’ fatigue, little time to speak with patients, fast rate of nurses’ speech,

a lack of welfare facilities for nurses and some problems with the patients such as weak memory

and auditory and visual disorders were considered as a barrier for communication between

nurses and patients (Jahromi, et. al., 2014; Anoosheh, et. al., 2009). Norouzinia (2016) also

concluded that difference in conversional languages between patients and nurse, overload of

works and emergency situation of patients were the most barriers in nurse-patient

communication. Furthermore, Azimian (2014) believed that routine-based culture is one of

barriers in establishing effective nurse-patient relationship.

Nursing students as one of the first healthcare providers who work closely with patients

must learn to be effective communicators. Thus, the concept of therapeutic communication has

been incorporated into the nursing curriculum to meet the students’ educational needs as well

as patients’ healthcare demands. In the Philippines, effective communication is taught through

theoretical lectures by nursing instructors and is evaluated through written exams.

However, some studies have indicated that education cannot guarantee the development

of therapeutic communication in nursing students, and they could not communicate effectively

with patients. This demonstrates the necessity of considering this concept more seriously

during formal academic training. Therapeutic communication, which is strongly affected by

different stakeholders including nursing students, patients, and nursing instructors, is a

complicated and context-based concept and needs to be disambiguated for better clinical

instruction. As argued by Reynolds and Scott (2000), ineffective communication skills still

impose a big challenge in healthcare that requires more awareness and solutions. Therefore,

there is a continuous need for training & creating awareness, with emphasis on the importance

of the use of effective therapeutic communication in nursing practice.

The researchers chose this study intending to expose the degree of therapeutic

communication practice among nursing students of the University of Northern Philippines

within clinical settings. The study also aims to specify how the performances of the students

are characterized by their respective clinical instructors as well as the registered nurses working

within the clinical areas of the affiliated hospitals during their rotations. Through this study,

further awareness about the scope of unfilled areas regarding effective therapeutic

communication practice will be instilled not only among the researchers but to the academe as

well.

Objectives

This study aims to explore and discover the degree of therapeutic communication

practice among level III nursing students of University of Northern Philippines, College of

Nursing, within clinical settings. Specifically, the study seeks to outline the different factors

contributing to the effectiveness of the students’ performance in therapeutic communication

engagement.
Related Literature Review

Therapeutic communication techniques have been studied and elaborated by different

scholars. Three related literatures in accordance to the title written by expert researchers were

reviewed. These literature review tells the researcher how the findings fit into what is already

known about the phenomena. It is not meant to confirm or argue existing findings.

Peplau’s (1952/1991/1997) Theory defines nursing as an interpersonal, therapeutic

process that takes place when professionals, specifically educated to be nurses, engage in

therapeutic relationships with people who are in need of health services. One of the earliest

theorists in nursing to explore the nursing communication and nurse-patient relationship was

Hildegard E. Peplau. Her theory has been described as drawing from developmental (Blake,

1980) interpersonal (Peplau, 1952) and learning (Lego, 1980) theories.

According to Peplau (1997) the common goal in nursing provides the encouragement

for the therapeutic process wherein nurse and patient give respect to each other as individuals,

in which both are learning and growing as a result of the interaction (Efternamn, 2017). She

introduced the theories of developmental stages of the nurse- patient relationship. The stages

included: the orientation phase, the identification phase, the exploitation phase and the

resolution phase. Her theories led the path to later nurse theorists and clinicians in developing

more sophisticated techniques (Sherko, et. al., 2013).

Adams (2017) also initates understanding to each phase of Peplau’s theory, analyzing

each one. He explains the start of the nurse-client relationship is at ‘orientation’ phase. This is
when the client exposes the issue that they are seeking the nurse’s support with. He further

continuous to the ‘identification’ phase which involves the nurse educating the client. This

stage of relationship according to him, sees a focus on building respect and working towards

meeting the needs of the client. The third phase in the theory is ‘exploitation’, wherein the

nurse aims for behavior modification for the client. Adams (2017) stated that ideally, the

client’s behavior change will help to meets their needs and the nurse will not be depended upon

as heavily. As for the final stage namely ‘resolution’, this phase involves the client being able

to self-manage their initial issue of concern. Adams elaborated that the nurse may evidently

then release the client from their care.

Assumptions of Peplau’s Interpersonal Relations Theory in nursing practice are: 1) the

nurse and patient can interact, 2) the nurse and patient will mature together as a result of

therapeutic interaction 3) communication and interpersonal skills remain fundamental tools in

nursing 4) nurses must clearly understand themselves in order to promote their patient’s growth

and to prevent the limitation of patient’s choices to those that nurses value. The theory narrates

that the purpose of nursing is to help others find their felt difficulties and nurses need to apply

principle of human relations to every problem that arise at all levels of experience.

Sheldon (2013) stated that Peplau’s theory of interpersonal relations is a landmark

theory in nursing that places emphasis on reciprocity in the interpersonal relationship between

nurses and patients. It is not a new theory but yet stays relevant to the current nursing practice.

The interpersonal relations concept provides a contextual framework for understanding many

of the challenges, which lie within the domain of professional nursing practice, especially

communication and relationship dilemmas.

According to D’Antionio, Beeber, Sills and Naigle (2014), the theory relates to modern

concepts such as motivational interviewing, client self-management, making informed

decisions, and client engagement. Adams (2017) added that Peplau’s theory involves the

healthcare professional working to understand their own behavior, as well as that of their

clients.

An article incorporating Peplau’s theory in promoting holistic communication between

older adults and nursing students was published by Deane WH and Fain JA (2016), stating that

despite educating students on holistic communication, there remains a lack of reliable

framework to undertake the task of teaching holistic communication skills. Thus, they

highlighted that Peplau’s theory provides nursing a useful set of three interlocking and

oftentimes overlapping working phases for nurses’ interaction with patients in the form of the

nurse-patient relationship. They further claimed that nursing education could adapt the phases

of Peplau’s interpersonal relations theory to educate students on holistically communicating

with their patients.

The relevance of this chosen theory is that firstly, the theory moves nursing’s

intellectual thinking from “what nurses do to patients” to “what nurses do with patients”; which

means it goes beyond technical care to nurse-patient relationship and patient-minded care.

Secondly, it establishes a communications guide, which enhances the effectiveness of a nurse-

patient interpersonal relationship, thereby envisioning nursing as an ongoing interactive and

collaborative process between nurses and patients. These values in Peplau’s theoretical

framework are very integral in this study, as the study is aimed on finding, supporting and

raising an awareness about the significance of therapeutic communication in nursing.

METHODOLOGY
This section presents the research design, locale of the study, study population, data

gathering instrument, data gathering procedure, ethical consideration, data analysis, treatment

of data, and establishing trustworthiness and authenticity of data of this study.

Research Design. The degree of performance and personal experiences of the nursing

students regarding their effectiveness in executing therapeutic communication practice will be

determined and analyzed through the conduct of a qualitative research approach. A grounded

theory research design will be utilized, a strategic method chosen for the study with the primary

purpose to evolve or “ground” a theory in the context in which the phenomenon under study

occurs. The means is to determine the necessary information and thorough understanding

regarding the phenomena.

Locale and Population of the Study. Twelve (12) participants in total will be selected

for the study using purposive sampling. All being considerably fluent in Ilocano, Tagalog and

English language. Four (4) of the participants must be third (3rd) year nursing students enrolled

in University of Northern Philippines who have completed the entire course of their second-

year clinical rotations in the different institutions affiliated with the college. Two (2) among

them will be males and another two for females. For the remaining participants, another four

(4) will consist of nursing educators (clinical instructors) from the college with five or more

years of experience in supervising nursing students within clinical settings. The last four (4)

involves registered nurses who have been working in the hospitals affiliated with the college

for 5 or more years.

 Data Gathering Instrument. For data gathering purposes, data will be collected

through open – ended interview technique, tape recording, and verbatim transcriptions. In each

interview, the participant will be the main speaker and the researchers will act as the facilitator

and listener. The interview will revolve in two point of views: the student’s, and the clinical

instructors’ together with the hospital nurses’. The interview will be based on the following

broad or grand tour question: “How do you establish a therapeutic communication with your

clients?” (How do the students usually establish a therapeutic communication with their

clients? – intended for C.I. and H.N.); “How do you relate your performance with the existing

theories regarding effective therapeutic communication?” (How accurate are the performances

of the students to the existing theories regarding effective therapeutic communication?); “In

which particular phase of therapeutic communication do you find the most challenging” (In

which area of the student’s performance do you think needs further enhancement?”; “What are

the different factors contributing to this existing difficulty?” (What do you think are the factors

causing a dent to the performance of the students in the practice of therapeutic

communication?). Each participant will be asked to validate if the statements, ideas, and words

reported by the researchers illustrate his/her experiences and/or viewpoints.

The interview will be audio taped, and field notes will be recorded. The researchers will

utilize three types of field notes during the research process: the transcript file, personal file,

and analytical file. The transcript file shall contain raw data from the interviews. The personal

file will consist of a detailed chronological account of the participants and their settings and

reflective notes on their experiences. The analytical file will be a detailed examination of the

ideas that emerged in relation to the research questions as the research progresses. Each

participant shall be coded so that only the researchers has the knowledge of the person who

participated in this research. Confidentiality of the participants will be guaranteed and

pseudonyms will be used.

 After the initial interviews, the researchers will immediately listen and analyze the

recorded data, and make extensive, detailed notes as well as verify the need for a follow-up

interview. A second interview, if need be, shall be conducted, in order to give the researchers,

the opportunity to expand, verify and add descriptions about the phenomenon under

investigation and also to assist the participants in clarifying inadequate descriptions.

Data Gathering Procedure. In this study, the researchers will write a letter asking

permission from the Dean of the College of Nursing in the University of Northern Philippines

as well as to from the respective Heads of the different institutions affiliated to the school,

where participants in the conduct of the study are concerned. These institutions involve Metro

Vigan Hospital, Northside Doctor’s Hospital, Pira Hospital Inc., and Ilocos Sur Provincial

Hospital Gabriela Silang.

The researcher then presented a request letter to each participant containing the terms

and conditions of the interview and requesting them to join the study. Then, the researcher

arranged for an interview date, time, and place with each participant. The method that shall be

utilized in the data collection for the study will be a through a semi-structured interview with

the participants. This method does not strictly follow a formalized list of questions. Instead,

they will ask more open-ended questions, allowing for a discussion with the interviewee rather

than a straightforward question and answer format. This allows the interviewer to be prepared

and appear competent during the interview. Semi-structured interviews also allow informants

the freedom to express their views in their own terms.

Data collection shall continue until data saturation is met, which means that no new

information extracted from the participants. The participants will be reminded that their

participation is voluntary and that they can decline or withdraw from the study anytime without
any obligation. However, their full participation to the success of this research is fully

encouraged.

Ethical Considerations.

Research that involves human subjects or participants raises unique and complex

ethical, legal, social, and political issues. Research ethics is specifically interested in the

analysis of ethical issues that are raised when people are involved as participants in research

(Walton, 2007). Ethical principles were considered, and the researcher made sure that there

was no conflict of interest in the conduct of the study.

To maintain privacy and confidentiality of the respondents and confidentiality of the

data collected, the participants will be given codenames in order to protect their identity as well

as their responses. Data that will be gathered from recorded audiotapes will be kept in a locked

file wherein only the researchers have access on. Encoded information will be stored in a

password secured laptop in the personal possession of the researchers and soft copies will be

deleted after the study is completed, presented and/or published. The participants will be

informed that the interview will be tape recorded and transcripts will be anonymous and

likewise, copies of the transcription will be given to them if requested.

Informed consent is the cornerstone of ethical research (Cassel & Young, 2002) and

important aspect of this is the quality of information provided to potential studies. Therefore,

the researchers will provide the participants with an information sheet, which will contain all

the terms and information regarding the research process in a clear and concise manner. A

consent form containing pertinent information including benefits, possible risks and

advantages of the study will be formulated, explained, and signed by the participants to assure
their agreement to take part in the study. In the event that the participants have further

clarification or queries, they are free to ask questions to the researchers. Also, respect to their

right to self-determination will be addressed. The researchers will also explain to the

participants regarding the objectives of the study and the risk/benefit ratio will be carefully

taken into consideration. It shall state the risks and benefits of participating and that they have

the right to withdraw from the study at any point in time they wanted to.

Recruitment. Participants will be selected based on the inclusion criteria set. Twelve

(12) participants in total will be selected for the study using purposive sampling. All being

considerably fluent in Ilocano, Tagalog and English language. Four (4) of the participants must

be third (3rd) year nursing students enrolled in University of Northern Philippines who have

completed the entire course of their second-year clinical rotations in the different institutions

affiliated with the college. Two (2) among them will be males and another two for females. For

the remaining participants, another four (4) will consist of nursing educators (clinical

instructors) from the college with five or more years of experience in supervising nursing

students within clinical settings. The last four (4) involves registered nurses who have been

working in the hospitals affiliated with the college for 5 or more years.

The participants will be treated fairly throughout the course of the study and maintain

anonymity of the participants shall be granted. Each of them will be given equal treatment

without judgment and prejudice. Voluntary participation is upheld thus no compensation was

given to the participants so as not to elicit false responses from the respondents. Lastly, a copy

of this proposal shall be submitted to the Research Ethics Committee of University of Northern

Philippines, Vigan City for review and approval.

Vulnerability. In conceptualizing vulnerability, it is common for the researchers to

assume that some participants will be more vulnerable on the basis of their membership to a
particular group or because they exhibit particular characteristics. Vulnerability may be defined

in different ways and may arise as a result of vulnerability due to age. Participants may not be

conventionally ‘vulnerable’ but may be in a dependent relationship that means they can feel

coerced or pressured into taking part, so extra care was needed to ensure their participation is

truly voluntary. Vulnerability in college students can impact on their ability to trust others in

order to disclose some personal information regarding their lives. This age group is often

subjected to psychosocial vulnerability. Level of trust established between the participants and

the researchers shall be fully established in order for them to disclose sensitive issues. To

address this, the researchers will ensure that the participants will receive adequate information

about the study, and skillful conversations on the part of the researchers to provide

opportunities for the disclosure of vulnerabilities. Their participation in this study shall be

voluntary and a signed consent will be signed by them. However, even after they had signed

the informed consent, they are still free to withdraw at any time they want and without giving

a reason. Withdrawing from the study will be assured to not affect the relationship they have

with the researchers.

Risk. A minimal risk for this study is anticipated. The participants may experience a

slight cognitive distress as they recall their experiences and/or encountered events in the

clinical areas, dealing with various patients. To minimize this distress that they might feel, the

researchers shall assure that the objectives of the study is clearly stated and easily understood

by the participants. Interview guide questions will be translated in the vernacular language and

that they were told that they were free not to answer questions they deemed not providing an

answer.

Assent. Participants involved in the study are all within legal ages to permit themselves

or decide whether to take participation in the conduct of this research or not.

 Compensation. Operational expenses during the conduct of the study shall be

personally funded by the researchers. Participants who took part in this research shall not

receive any type of incentives whether it is in terms of money or in any kind.

Community Considerations. The conduct of this study can be an assessment

mechanism for the institutions to determine the current individual status of its students, thus,

results of this study can have an important implication to the faculty and administration of the

school and to the community as well. It is of expection that the results of the study will provide

further measures and strategies to the nursing students as well as to the nursing

educators/clinical instructors regarding the degree of therapeutic communication practice of

the students and which areas needs further enhancements. Likewise, the researchers may

recommend effective measures to students within the boundaries of the same phenomenon, and

to the academe on how to deal and assist the students. The results of the study are planned to

be disseminated to the concerned institutions by conducting an awareness seminar that could

serve as an avenue to share the outcomes and recommendations of this study. It is expected to

serve as an eye opener and a motivator to realize the value of maintaining an effective

therapeutic communication practice among the aspiring nursing students.

Specimen Handling. Not applicable in the study.