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PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION Ms. KRUPA ELIZABETH JOY FIRST YEAR M.Sc NURSING PSYCHIATRIC NURSING YEAR 2011-2013 EAST WEST COLLEGE OF NURSING, NO 63 OFF MAGADI MAIN ROAD, VISHVANEEDAM POST BENGALURU-560091 1 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES. BANGALORE. KARNATAKA. PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION. Ms. KRUPA ELIZABETH JOY 1. NAME OF THE CANDIDATE AND 1ST YEAR M.Sc. NURSING ADDRESS EAST WEST COLLEGE OF NURSING #63,BEL LAYOUT,OFF.MAGADI ROAD, VISWANEEDAM POST, BANGALORE-91. 2. NAME OF THE INSTITUTION EAST WEST COLLEGE OF NURSING. BANGALORE. 3. COURSE OF THE STUDY AND M.Sc NURSING SUBJECT PSYCHIATRY NURSING 4. DATE OF ADMISSION 01/07/2011 “ASSERTIVE COMMUNICATION AND ITS BENEFITS IN NURSE PATIENT RELATIONSHIP” AMONG IV YEAR B.SC NURSING STUDENTS. 5. TITLE OF THE STUDY 2 6. A BRIEF RESUME OF THE INTENDED WORK 6.1. INTRODUCTION If you just communicate you can get by, but if you skillfully communicate, you can work miracles .- Jim Rohn. Communication is an activity of conveying meaningful information; it is exchanging information in the form of messages, symbols, thoughts, signs and opinion. It is a process by which meaning is assigned and conveyed in an attempt to create shared understanding.1 Communication is defined as the exchange of thoughts, ideas, feelings, information, opinions, and knowledge. It is also defined as an act by which one person gives or receives from person information about that person’s needs, desires, perceptions, knowledge or affective status2. Communication process is classified into different types based on certain criteria like the channels used for communication, style of communication, and relationship of the communicators. One such communication is therapeutic communication. It is a process in which the nurse consciously influences a client or helps the client to a better understanding3. Therapeutic communication is defined as the face to face process of interaction that focuses on advancing the physical and emotional well being of a patient4. According to a research by Press Ganey Associates Inc. The nurse patient relationship sets the tone of the care experience and has powerful impact on patient satisfaction. Nurses spend the most time with patients. Patients see nurses’ interactions with others on the care team and draw conclusions about the hospital based on their observations. Without a positive nurse patient relationship, there cannot be patient and family satisfaction. Quality of communication in nursing has the highest impact on the life of the patients5. 3 Communication is a life long learning process for the nurse. Nurses make the intimate journey with clients and their families from the miracle of birth to the mystery of death. It is necessary to build therapeutic communication for this journey. Like any therapeutic agents, the nurse’s communication can result in both harm and good3. Communication style is defined as how people communicate. Every posture, every small expression and gestures, every word spoken, every attitude held all have the potential to hurt or heal. This gives a tremendous ethical responsibility to each one to communicate effectively. 6 Communication must be respected for its potential power and not carelessly misused to hurt, or manipulate others. Good communication empowers others and enables people to know themselves and make their own choices, an essential aspect of the healing process. Nurses have wonderful opportunities to bring about good things for themselves, their clients and their colleagues through proper communication. According to Patient Care Seeking Communication (PCSM) there are nine sub constructs and assertive communication is one among them7. Assertive communication is defined as a communication in which individuals clearly state their opinions and feelings and firmly advocate for their rights and needs without violating the rights of others. Assertive communication is as a type of communication which helps the communicator to feel good about oneself and increases his or her self esteem. It helps to feel good about other people and increases the ability to develop a satisfying relationship with others. Assertive communication style such as open, dramatic, contentious are very essential for a nurse8. Patients and families count on nurses to keep them informed, to connect them to their physicians and other caregivers, to listen to them, to ease their anxiety, and protect and watch over them during their healthcare experience. Because of these high expectations of nurses, it’s no wonder that nursing performance, and more specifically, the nurse patient relationship, is so central to patient satisfaction and a quality patient experience for which assertive communication is very much required.5 4 Lack of assertive communication in nurses while caring for a patient causes anxiety, frustration, discontentment, discouragement in the patient and thus affects the health of the patient. Prioritizing all these issues it’s the need of the hour to focus more on the aspect of educating the budding nurses about assertive communication and its benefits in nurse patient relationship thus the quality of nursing care can be increased7 6.2 NEED FOR STUDY Society views nurses favorably, often as benevolent, virtuous and admirable. Nurses have been positively stereotyped as ‘ministering angels’ or ‘angels of mercy’. And there is an increasing need for nurses to wok more in order to experience this positive view of the profession first hand in clinical practice. It is important for the nurse to become aware of and recognize their own behavioral responses.9 The ability to respond assertively is especially important to nurses who are committed to further development of the profession. Assertive communication skills facilitate the implementation of change- change that is required if the image of nursing is to be upgraded to the level of professionalism that most nurses desire10. Assertive communication is useful in the political arena for budding nurses who chose to become involved at both state and national levels in striving to influence legislation and ultimately improve the system of health care provision and automatically the health of our country7. According to an article by Wendy Leebov’s in AMERICAN NURSE TODAY he defines a much more relevant goal for nurses- a goal to help nurses communicate expertly. A study like this helps the budding nurses to remove the barriers and create the conditions that make it possible for them to serve their patients and families with diligent and compassionate care. And finally, to engage nurses’ hearts and minds in strengthening their communication with patients and families11. Nurses are so swamped. Their multiple responsibilities has become task-oriented, not people oriented. Seeing nurses focus on the tasks and activities of their jobs, patients 5 and families wonder, “Where has all the care gone?’’The caring is still there, but it might as well not be if patients and families don’t see or feel it. That’s why there is a crying need today to help the future nurses speak the language of caring, love, acceptance and understanding so that their caring reaches the people they serve, and thus easing their patients’ anxiety. Most of the research on nurse-patient interaction focuses entirely on the nurse’s communication in the encounter, assuming the power position in the relationship.12 In a study of social judgment and the social process of care experienced by patients in a medical hospital setting, Johnson and Webb in 1995 found that nurses exerted power over patients and that interactions were filled with conflict and struggle, resulting in ‘acquiescence of patients to the nursing and medical goals of care’13. According to a study conducted by Harrison in 1989, he found that a difference in communication behaviors based on nursing related work experience. His study emphasized on nursing students who had nursing related work experience and those with no nursing related work experience. It was concluded that as nursing students gain more experience and education, communication behaviors become less desirable. He postulated that students may have learned appropriate communication skills but did not fully incorporate the into their usual communication patterns. It has been suggested that the health care environment prevents the integration and utilization of assertive communication behavior. Further research in this area is warranted to deepen our understanding of these processes and help the nursing students to know its benefits on them as well as those entrusted to their care14. Based on the researcher’s personal experience when working as a clinical instructor, students in the final year of there studies became less sensitive to others feelings and used threats to gain compliance or cooperation, disagreed frequently and interrupted more and were unaware of the patients view. Being aware of the patients desire to be respected and valued as a person, researcher identified that knowledge of assertive communication and its benefits in nurse patient relationship is very necessary for the fourth year nursing students so that they can treat the patient with respect.. As a 6 valued person, displaying understanding and holding normal conversation with the patients and enabling them to have meaningful control over their care. Researcher personally feels that assertive communication will indeed help the nurse to understand patient’s personal experience of health and illness and to relay meaningful information to the patients, which in turn will promote their wellbeing. Keeping in view the above fact, the investigator planned to conduct a structured teaching programme to the fourth year nursing students after assessing their knowledge level in that area, which will find some information for further studies. 6.3 CONCEPTUAL FRAMEWORK The conceptual framework Ludwig Von- Bertalanflyy (1968) theory has been selected for this study. It is based on concept of general systems theory with input, throughput, output and feedback. 6.4 REVIEW OF LITERATURE Review of literature refers to the activities involved in identifying, searching for information on a topic and developing an understanding of the state of knowledge on that topic15. Knowing what data are available often serve to narrow the problem itself as well as the techniques that might be used. Literature reviews allows the researcher to acquaint himself with current knowledge in the field or area before delving into area of study16. In this study review literature has been divided into following: 1. Studies and literature related to assertive communication. 2. Studies and literature related to nurse patient relationship. 3. Studies and literature related to knowledge of assertive communication and its benefits in nurse patient relationship among nursing students. 7 1. Studies and literature related to assertive communication: A descriptive study was conducted to analyze the concept of assertive communication in Pusan National University. The purpose of this study was to analyze and clarify the concept of assertiveness. This study used walker and Avant’s process of concept analysis. The study was conducted on 100 students from Pusan National University in Korea. The findings of the study were definition of assertiveness such as self esteem, comprehension to others, and clarification of the subject, verbal communication, and non verbal communication. The study concluded that assertiveness is a core human behavior and is key to interpersonal relationships. Using the concept of assertiveness many conflicts in any situation can be effectively prevented.17 A quasi experimental study was designed to assess the effects of assertive communication in interpersonal relations and social behaviors. The objective of the study was to examine the effects of assertive communication in interpersonal relations. The sample included 44 students from college of nursing Korea University, Seoul, Korea. 20 in the experimental group, and 24 in the control group. Data was collected using structured questionnaires over a 3 month period. There were greater significant increases in scores of interpersonal relations and content of communication in the experimental group than the control group. Also there was a significant decrease in the score of interpersonal conflicts in the experimental group than the control group. Thus the study concluded that assertive communication has an effect on increasing content of communication and decreasing interpersonal conflicts.18 A study was patterned to assess the effectiveness of assertiveness training in communication related behaviors among nurses. The purpose of the study was to investigate the effects of assertiveness training on nurses’ assertive behaviors, interpersonal relations and communication conflicts. A non- equivalent control group pretest posttest design was used in this study. 39 nurses were assigned into experimental or control groups. An assertiveness training program for nurses designed by Park was used for the study. The assertiveness training program was effective in improving the 8 nurses’ assertive behavior. The study concluded that a significant contribution in attempting such an intervention from nursing management perspectives is needed19. 2. Studies and literature related to nurse patient relationship: A descriptive study was fashioned to assess the knowledge of effective nurse patient relationship. The purpose of the study was to assess the knowledge of nurses about nurse patient interaction, patient communication, nurse patient relationship and its effects on patient. The study was descriptive in nature. 100 nurses from Brant community health care system, Brantford, Canada were taken as samples and structured questionnaire was used for the assessment. The study found that the way a nurse interacts with the patient influences the health of the patient. The study concluded that a significant study be carried out in this area gives quality to nursing profession20. A study was conducted to assess the nurse patient relationship in the context of life threatening or terminal illness, in patient chronic illness and primary care. The purpose of study was to assess the behavior of nurse and the patient in all the above said areas. Interviewing method was used on both nurses and patients to assess their experiences of a nurse patient relationship.50 nurses and 50 patients from a psychiatric unit from United Kingdom participated in the study. The study found that patient in nurse patient relationship believes that these relationships were therapeutic however nurses frequently expressed doubt about the value of their relationship with the patient. The study concluded that time and attitude of both patient and nurse is essential in order to develop a satisfying nurse patient relationship.21 A descriptive study to examines social judgment and social processes of care as experienced by nurses and patient was conducted in a medical hospital setting in Egypt the purpose of the study was to assess the social skills, awareness and previous experience enabled him to successfully manage his social standing in this environment of care.80 hospitalized patients participated in the study and it’s found that patients acted purposefully and knowledgably in his interaction with the nursing staffs base on their 9 previous experience. The study concluded that the ability to assess and negotiate the social environment of care is limited to patient and the interaction of the nursing staff22. 3. Studies and literature related to knowledge of assertive communication and its benefits in nurse patient relationship among nursing students. A study was conducted to evaluate the multiple component intervention to support the implementation of a 'Therapeutic Relationships' best practice guideline on nurses' communication skills among nursing students in school of nursing, university of Ottawa, Canada. The purpose of the study was to determine if there was an improvement in nurses' communication skills 5 months after a multiple component intervention to implement the Registered Nurses' Association of Ontario best practice guideline 'Establishing Therapeutic Relationships'. A matched pair, before and after design was used. Eight client scenarios with corresponding client comments were read aloud to nursing students who were asked to respond verbally, as though they were interacting with the client. Responses were audio-taped and transcribed. The frequency and quality of nursing students' active listening, initiating and assertiveness skills were measured preand post-implementation of the guideline. Twenty-two nursing students responded at both time points. Active listening skills were most frequently used. There was a statistically significant decrease in the number of active listening skills used, but a statistically significant improvement in the quality of active listening and initiating statements and frequency of initiating skills. Nursing students demonstrated improvements in selected communication skills following the implementation of a multiple component intervention that included a best practice guideline. The study concluded that improvements in communication skill are essential to the establishment of therapeutic nurse patient relationship23. A study was formulated to evaluate an assertiveness training program on nursing and medical students' Nursing Department, Tri-Service General Hospital, Taiwan on assertiveness, self-esteem, and interpersonal communication satisfaction. This study's objective was to evaluate the effect of an assertiveness training program on nursing and medical students' assertiveness, self-esteem, 10 and interpersonal communication satisfaction. Using a longitudinal research design,69 participants whose scores on the Assertive Scale were < or = 50% (i.e., low assertiveness) and who were willing to participate were included and assigned to an experimental group (33 subjects) or comparison group (36 participants; participants were matched with the experimental group by grade and sex).Participants in the experimental group received eight 2-h sessions of assertiveness training once a week. Data were collected before and after training and again one month after the end of the training using the Rotter's Internal versus External Control of Reinforcement Scale, Sex Role Inventory, Assertive Scale, Esteem Scale, and Interpersonal Communication Satisfaction Inventory. The generalized estimated equation (GEE) method was used for statistical analysis. The assertiveness and self-esteem of the experimental group were significantly improved in nursing and medical students after assertiveness training, although interpersonal communication satisfaction of the experimental group was not significantly improved after the training program24. A study was designed to assess the effects of assertive communication in interpersonal relations and social behaviors. The objective of the study was to examine the effects of assertive communication in interpersonal relations. The study employed a quasi experimental design. The sample included 44 students from college of nursing Korea University, Seoul, Korea. 20 in the experimental group, and 24 in the control group. Data was collected using structured questionnaires over a 3 month period. There were greater significant increases in scores of interpersonal relations and content of communication in the experimental group than the control group. Also there was a significant decrease in the score of interpersonal conflicts in the experimental group than the control group. Thus the study concluded that assertive communication has an effect on increasing content of communication and decreasing interpersonal conflicts18. A study was done to assess the factors Essential for effective communication in nursing students such as assertiveness, conflict management, delegation, and motivation for their future practice. The purpose of the study was to assess the ability to communicate effectively with a multidisciplinary team in an assertive manner to resolve conflict, motivate others, and delegate tasks among nursing students to promote a 11 harmonious work environment.70 nursing students from Memorial Sloan Kettering Care Centre, New York, USA were taken as sample. The study found that Acquisition of this skill is often a combination of inherent attributes and learned experiences. Nursing students are encouraged to seek expertise from other departments (e.g., Human Resources) to help them develop similar programs.25 6.5. STATEMENT OF PROBLEM ‘ A Study To Assess The Effectiveness Of Structured Teaching Programme on “Knowledge on Assertive Communication And Its Benefits In Nurse Patient Relationship” Among IV Year B.Sc Nursing Students In Selected Nursing Colleges At Bangalore’. 6.6. OBJECTIVES OF THE STUDY 1. To assess the pre test levels of knowledge on assertive communication and its benefits in nurse patient relationship of IV year B.Sc nursing students. 2. To assess the post test levels of knowledge on assertive communication and its benefits in nurse patient relationship of the study participants. 3. To evaluate the effectiveness of structured teaching programme on assertive communication and its benefits in nurse patient relationship by comparing the differences between the pre test and post test knowledge scores. 4. To associate the pre tests mean knowledge score with selected socio demographic variables of the study participants. 6.7. OPERATIONAL DEFINITION Effectiveness: It refers to the outcome of structured teaching programme in increasing the knowledge of IV year B.Sc nursing students regarding assertive communication and its benefits in nurse patient relationship. 12 Knowledge: Awareness of information or understanding regarding assertive communication and its benefits in nurse patient relationship among IV year B.Sc nursing students which is obtained through structured knowledge questionnaire. Structured Teaching Programme: It refers to a well planned and organized contents on assertive communication and its benefits in nurse patient relationship for IV year B.Sc nursing students. Assertive communication: It refers to positive and confident way of communication by a nurse in nurse patient relationship. Nurse Patient relationship: It refers to the therapeutic relationship between the nurse and a client on a series of interacting and developing overtime. Nursing students: Male and female individuals studying in IV year B.Sc nursing course in selected recognized nursing colleges at Bangalore. 6.8. HYPOTHESIS H1: There will be significant difference between the mean pre-test and post-test knowledge scores. H2: There will be significant association between pre-test knowledge scores and posttest knowledge scores with selected demographic variables. 6.9. ASSUMPTION IV year B.Sc nursing students may not have much knowledge on assertive communication. 7. METHODOLOGY 7.1.Research approach: Quantitative research approach. 7.2. Research design: Pre-experimental research design. 13 7.3. Setting: The study will be conducted in selected Nursing Colleges Bangalore. 7.4. Population: All IV year B.Sc nursing students from Rajajinagar, Bangalore. 7.5. Sample size: N= 60 7.6. Sampling techniques: In this study Simple randomization technique will be adopted. 7.7. Sampling criteria: Inclusion criteria Both male and female fourth year B.Sc nursing students Students who are willing to participate in the study. Students who are available at the time of data collection. Exclusion criteria Students who are not available at the time of study. Students who are not willing to participate. 7.8. Tools for data collection: Tool I: Socio demographic data sheet. Tool II: Structured questionnaire to assess the knowledge on Assertive communication and its benefits in nurse patient relationship among nursing students. 14 7.9. VARIABLES: Dependent variables: Knowledge of IV year B.Sc nursing students regarding assertive communication and its benefits in nurse patient relationship. Independent variables: Structured teaching programme on assertive communication and its benefits in nurse patient relationship. Extraneous variable: Age, gender, religion, socio economic status, occupation and source of information on assertive communication. 7.10. Method of collection of data: After obtaining permission from the concerned authorities and informed consent from the samples, the investigator will collect the data. Pretest will be conducted to assess the knowledge of fourth year B.Sc nursing students on assertive communication and its benefits in nurse patient relationship with the help of structured questionnaire. On the same day structured teaching will be conducted. Post test will be conducted with the same questionnaire after 7days of structured teaching programme. 7.11. Methods of data analysis: The data collected will be analyzed by using descriptive and inferential statistics. Frequency, percentage, mean and standard deviation will be used to assess the level of knowledge and paired-t test will be used to compare knowledge. Chi square test will be used to find the association between selected demographic variables with level of knowledge among the study participants. 7.12. Duration of data collection: 6 – 8 weeks. 15 7.13.Projected outcome: This study helps the nursing students to be clear in their duty role in all working relationship in their future carrier. 7.14. Delimitation: Study is delimited to IV year B.Sc nursing students in selected nursing colleges at Bangalore. 7.15. Does the study require any investigation to be conducted on patient or other human or animals? If so please describe briefly. Yes, only information collection and delivery of information. No invasive or trial of drug, procedure included. 7.16. Has the ethical clearance has been obtained from your institution in case of 7.15? Yes, the copy has been enclosed. 16 8. LIST OF REFERENCES: 1. Sr. Nancy. Text book of principles and practices of nursing;5thed; N R publications; NewDelhi; 2005; p:452-59 2. Caur Mahinder .Text book of nursing education;2nd ed; V publications; New Delhi;2000; 3. Potter .A. Patricia and Perry Anne Griffin; Text book of fundamentals of nursing, 6th ed; Elseiver publication; New Delhi; p: 168-71. 4. Gupta R.K. Text book of new approach to mental health nursing; P.V.Publications; 2000;p:142-3 5. Articles related to nurse patient relationship the free encyclopedia available from URL:http://www.quality patient experience.com. 6. Clement I.Text book on communication and educational technology. 1st ed; EMMESS medical publishers; 2008. 7. Articles related to communication, the free encyclopedia. Available from: URL:http://www.en.wikipedia.org 8. Dr. Mrs. Lalitha K. Mental Health and Psychiatric Nursing An Indian Prospective; I ed; V M G Book House publications; Bangalore; 2007;p: 498 9. Becker.H.S, outsiders: studies in the sociology of deviance, free press, New York; URL:http://www.medline.com 10. Gibb.H and o’brien B,journal of advanced nursing. URL:http://www.medline.com 11. Wencly leeboys ,article on American nurses today, new York. URL:http://www.pubmed.com 12. Alt schul A, international journal of nursing studiesURL:http://www.google.com 13. Carveth J A perceived patient deviance and avoidance by nurses, nursing research. URL:http://www.en.wikipedia 14. Harrison T, assessing nurses communication a cross sectional relationship, western journal of nursing research. URL:http://www.en.wikipedia 15. Poilt D F and Hungler B P nursing research; Text book of principles and practice; Lippincott publications;Philadelpia;1999;p:657-58. 17 16. Dr. Mr. Kothari. Research methodology: method and technique. Google result. 2008. Available from: URL: http//www.books.google.co.in 17. Tachan Kanho Hakhoe Chi. Article in Korea; College of nursing; Pusan national university URL: http://www.wikidoc.org/index.php 18. URL: http://www.wikidoc.org/index.php 19. Kang M.J Pusan national university hospital, department of nursing, Pusan Korea. URL: http://www.wikidoc.org/index.php 20. Mathew S P measurement of psychological aspects of the nurse patient relationship, nursing research. URL:http://www.google.com 21. Trojan l and yonge o.developing caring relationships,home care nurses and elderly clients, journal of advanced nursing. URL:http://www.pubmed.com 22. Parson t the social system the free press glance. URL:http://www.medline.com 23. Edwards N,Peterson,Davies bc patient educ couns,epub,2006URL:http://www.pubmed.com 24. Lin YR,shiah IS, Chou K R,nurse educ today,2004.URL:http://www.pubmed.com 25.Walzak mb,absolon PL,J .nuses staff DEV memorial sloan kettering care centre new York,USA. URL:http://www.pubmed.com. 18 9. Signature Of The Candidate: 10. Remarks Of The Guide: 11. Name And Designation Of (In Block Letters): 11.1 The Guide: 11.2 Signature: 11.3 Co-Guide: 11.4 Signature: 11.5 Head Of The Department: 11.6 Signature 12.1 Remarks Of The Principal: 12.2 Signature 19