Concept Analysis of Interpersonal Skills in Nursing

C o n Abstract Objective: To determine a broad definition of the term interpersonal skills in nursing. Materials and methods: This theoretical study follows Walker and Avant’s method of concept analysis to examine the defining attributes of the concept. A literature search on interpersonal aspects of nursing was conducted in databases, e-books, and institutional repositories to recognize the uses, attributes, antecedents, consequences, and empirical referents of the concept. Experts on professional and relationship skills were consulted between 2009 and 2019. Results: This information was analyzed, concluding that interpersonal skills in nursing are defined as the abilities of professional nurses to express their knowledge, abilities, attitudes, and values in relationships with colleages, patients, and their relatives and achieve a humane and person-centered practice. Conclusion: The concept of interpersonal skills in nursing is limited, given a lack of clarity in practice and research on the indistinct use of terms related to interpersonal skills and interpersonal knowledge. This analysis advances nursing theory towards practice and research.


Introduction
Nursing competence comprise knowledge, abilities, attitudes, and behaviors integrated into and aimed at holistic care (1). This competence is not innate but developed in a complex process to which the environment and internal motivations contribute. Nursing competence is a multidimensional concept; its attributes include professional values, critical judgment, leadership, and effective interpersonal relationships (1,2), the latter being the most relevant considering the growing need for human care in the world.
Developing behaviors aimed at establishing optimum interpersonal relationships do not always occupy essential places in institutional or educational nursing programs (3), in addition to the fact that nursing professionals with little experience find it difficult to put into practice effective methods to build up relationships with care recipients (3). Therefore, the need for interpersonally competent nurses is explicit.
Then, care as affection and interpersonal relationship (4) shows that these aspects are the most important for interpersonal skills in nursing. Care as affection reflects the emotional commitment to the other, and care as an interpersonal relationship is the essence of caring; it is the means through which the other is reached, which requires a genuine interest in the welfare of the other (5,6). In other words, the interpersonal dimension of care establishes the ontological and epistemological aspects of the relationships with the subjects of care, the interpersonal nursing skills being necessary.
When inquiring about this topic within the literature and practice, concepts such as social skills, communicative aptitudes, communicative skills, relational knowledge, among others, are commonly used. However, the term "skill" is not fully grasped, and, as it is not clearly defined, a conceptual void is left. Therefore, a concept analysis of interpersonal skills in nursing is required.
For clarity purposes, concept analysis is a theoretical development strategy of the discipline, even being considered a form of theoretical research in nursing (7). It is a strategy that allows examining the attributes or characteristics of a term; it is a formal linguistic exercise that must be rigorous and precise to approach a definition, focusing on the potential and actual uses of words that convey the meanings of a concept (8). In this case, the term interpersonal skills in nursing arises from an attempt to narrow down the diversity of concepts on relational function in nursing found in the literature that are unclear to be used in research and applied in practice. This article aims to provide a broad definition of interpersonal skills in nursing as a theoretical approach that contributes to nursing research, practice, and education.

Materials and methods
A concept analysis was carried out as the most suitable and rigorous method to define the concept of interpersonal skills in nursing.
Comparing the different forms of analysis, Walker and Avant's (8) methodology has fewer steps to follow than Wilson's (8), which allows to exemplify what the concept is and is not; in contrast to Rodger (9), which only includes the model case and it does not require explicit assumptions as proposed by Meleis (7). Walker and Avant's steps were followed for concept analysis: 1) Select a concept; 2) Determine the aim and purpose of the analysis; 3) Identify all uses of the concept; 4) Identify the defining attributes of the concept; 5) Construct a model case; 6) Construct borderline, related, and contrary cases; 7) Identify antecedents and consequences; 8) Define empirical referents.
Two strategies were employed to gather information on the concept and perform the analysis: literature search and consultation with an expert in the field. Both strategies are described below: Literature search: It was conducted in Science Direct, Pubmed, Medline, Academic Search Complete, PsycARTICLES, BVS, and Scopus databases. We narrowed down the search to articles written in English, Spanish, and Portuguese and published between 2009 and 2019. This time range is adequate to cover the theoretical-conceptual evolution and the current state of the topic because the initial search yielded results per year, with a marked increase in articles related to professional competence and interpersonal skills in nursing since 2009. DeCS and MeSH terms 'nursing research,' 'nursing education research,' 'nursing practice,' 'professional competence,' and 'interpersonal skills' were searched using the Boolean operators AND and OR.
The literature review only included research articles, dissertations, thesis, and books addressing interpersonal aspects in nursing. Critical appraisal of manuscripts that presented research results was conducted using CASPe tools (10). The search and selection strategy of manuscripts is described in Figure 1.

Subject experts:
Although the concept analysis methodology does not explicitly consider nurses' experiences regarding the conception and uses of the concept, we decided to include two nurses. They were part of the main study of the dissertation in which this analysis is immersed and were interested (voluntarily) in talking about the subject. Thus, from their experience, they fed what was found in the literature. Given the scope and uses of the concept, knowing the nurses' definition of interpersonal skills was considered relevant. With their prior consent, these nurses with graduate degrees in nursing and education were invited to participate in a semi-structured interview. They have researched into professional competence and communication skills; both have extensive practical experience, and nowadays, they work as lectures in nursing schools and departments in Spain and Colombia. They were asked about their knowledge, perception, and definition of competence and interpersonal skills; the main questions asked were the following: "When talking about the concept of interpersonal skills in nursing, what is the first thing that comes to Search in databases with limits and Boolean operators (n = 2580) Documents (theses and books) identified by institutional repositories (n = 310) your mind? How do you define it? What aspects make it up? Answers were audio-recorded, transcribed, and analyzed according to relevant themes and attributes using Atlas ti.

Data analysis:
The analysis of the information collected aims to follow the steps proposed in the concept analysis methodology, the literature review, and the consultation of subject experts. However, the review process is described according to Whittemore and Knafl (12), and the interviews with the experts were subjected to thematic analysis (13), as presented in Table 1. They were then compared with each other to define the critical attributes of the concept, as shown in the results.  2. Literature search: As presented in Figure 1 Phase 2. Generation of categories or initial codes: In a detailed reading, the general topics are highlighted.
3. Data assessment: Critical reading is performed as presented in Figure 1.  In analyzing the information from the literature and interviews, attributes and concepts emerged repetitively, showing strength in the data and characterizing the concept with aspects such as empathy, confidence, emotional intelligence, and negotiated decision making. These aspects are expanded in the uses of the concept and the critical attributes.
Finally, to follow the ethical principles of research, this concept analysis is embedded within a dissertation endorsed by the Ethics Committee of the Nursing School, Universidad Nacional de Colombia. Additionally, the participating experts signed informed consents for the interviews. This information is in possession of the first author, which will be retained and kept confidential for five years and then eliminated.

Results
Following the steps of concept analysis, the results are described below.

Concept selection and aim of the analysis
Multiple definitions of this term were found during the literature search on different nursing skills. However, when approaching the interpersonal aspects, we determined that the concept of interpersonal skills in nursing had not been clearly defined within the discipline since this concept tends to be confused with others, such as social skills, communication skills, empathy, or emotional intelligence, which, although linked, convey different meanings. Then, it is essential to clarify the meaning of interpersonal skills in nursing by offering a constitutive and operating definition.

Uses of the concept
The literature on the discipline and the experts in nursing skills were consulted to verify the uses of the concept. In this way, we could determine that the concept of interpersonal skills has been addressed mainly by nursing education research, clinical practice, and some nursing theories focused on interaction as a form of care. This section describes some aspects found in the literature review that can be divided into topics, as presented in Table 2.

Topic Characteristics
Beginnings and origin of the concept Conceptually, interpersonal skills in nursing began to be addressed by the Tuning Project (14). It defined it as individual abilities to express one's feelings and to be critical and self-critical, social skills related to interpersonal skills, ability to work in a team or to express social and ethical commitment, and abilities that tend to facilitate social interaction processes in nursing (15).

Communication skills in nursing
The most outstanding nurses' skills, strategies, and gestures to communicate effectively include empathy, negotiation skills; use of socio-culturally appropriate information; good intonation, volume, and rhythm of the voice, body language, and facial expression. According to these authors, all these aspects may be trainable (16)(17)(18). Regarding nursing education, some studies started from the positive teacher-student experience; that is, when they understand each other, students' anxiety levels are reduced in practice settings (19,20). Then, the relationship modifies the student's behavior (21).

Empathy and emotional intelligence
Interpersonal skills in nursing comprises emotional skills (emotion expression and control, anxiety management, among others) (22) and cognitive skills (interpreting the situation, perceiving others correctly), which enable nurses to observe, interpret, and integrate a situation, and take an empathic position (5). Sociodemographic, labor, and academic variables seem to be related to emotional intelligence and empathy (23). For senior nursing students, proper empathy, respect, and assertiveness levels are associated with good performance during clinical practices (24,25). Then, student's education requires not only instrumental skills, but also affective skills (26,27).

Negotiated decision-making in nursing care
Some authors determined in their studies that situational aspects for both patient and nurse may condition the quality of the established relationship, participation in care, and communication (28)(29)(30).
Research on end-of-life care found that nurses seek consensus and emotional support during decision-making, which gives peace of mind to the person, the family, and the nurse (29).

Concept from nursing theories
Peplau affirms that nursing care is an interpersonal therapeutic process carried out through a relationship between the individual and the nurse (31,32). For Paterson and Zderad, nursing is an intersubjective-transactional relationship between a nurse and a patient, where they share experiences that lead to intersubjectivity, characterized by real presence and authentic sharing (33,34). Then, humane practice becomes the purpose of interpersonal skills in nursing.

Source: Own elaboration
Finally, the literature review shows no clearly defined concept of interpersonal skills in nursing to work with for research and practice. What is clear is that interpersonal skills delimit knowledge, abilities, attitudes, and values applied to interpersonal relationships that nurses establish with care recipients and integrated into practical situations of care to ensure human care provision.

Concept attributes
The concept attributes allow us to approach a definition and recognize its characteristics. Interpersonal skills in nursing are made up of the knowledge, abilities, attitudes, and values expressed by nurses in recognition of the other person, in an authentic encounter that provides the interaction with therapeutic properties and positive effects for mutual growth (35) and favors the development of negotiation capacity and shared decision-making (36).
The development of interpersonal skills in nursing is mediated by attributes of interpersonal relationship such as trust, empathy, emotional intelligence, assertive communication, respect, openness towards others experiences, flexibility, social maturity, being in touch with one's and others' feelings, understanding, and negotiated decision-making (37). Interpersonal skills are also influenced by the nurse's experience and other interpersonal relationships, such as those involved in teamwork and work settings (36,38).
Findings from the literature are supported by the experts' opinions about the subject. They consider interpersonal skills related to the formation of the self in nursing, the ability to reflect on interactions, nurses' previous and personal experiences, and communication as the cross-cutting factors of interpersonal relationships. Voices of the experts and topics discussed are shown in Table 3.

Topics Voices of the experts
Formation of the self in nursing: That "self" includes professional and personal values, ethical principles, emotion management, and comprehension of the other person's experience and meaning of health.
"If I don't work on all these aspects of the self, not just what has to do with values, but also, for example, what has to do with self-assurance, how will I tune up confidence and sureness in a student who is going to lead health care teams and decisionmaking processes in nursing care?" (Expert 02) Communication as a basis for interpersonal relationships: Conveying an idea in which verbal and non-verbal expressions bear meanings for both parties to understand and help each other grow. 12 Table 4. Critical attributes and surrogate terms of the concept

Critical attributes Definition
Expression of the self of nursing and its bioethical values, in which the relationship has a therapeutic or pedagogical aim (according to the role of nursing) that produces positive results.
The self of nursing is abstract; however, it essentially provides care as an interpersonal relationship (4), in which the connection and interest in others' needs and vulnerable situations make nurses use their sensitivity, trust, active listening, and respect as a means of understanding and benefiting other people. The self of nursing identifies with the essence of care that is the interpersonal relationship, which allows understanding the human health experience; in this dynamic, the need to identify and control emotions emerges, especially because experiences such as pain or death are difficult to handle when caring behaviors are marked by empathy and ethical principles of caring (39,40). Consequently, the critical and reflective analysis of these situations helps the nurse understand the conceptions of health and care of people and the contexts in which care occurs, actively participating in decision-making. These characteristics enable us to recognize interpersonal skills in nursing.
In summary, interpersonal skills describe nurses' abilities to be open to others and their own experiences in the caring process. It involves knowing how to listen and communicate assertively, regulate emotions, be empathetic, respect and understand situations, help make negotiated decisions, and show a humane practice (41,42). Besides, there are settings for teamwork that also affect the way interpersonal relationships are established.

Case construction
Subsequently, once exclusive characteristics of the concept are evident, the next step is taken, which is, at first sight, something simple but requires analytical thinking: case construction. The cases are constructed to illustrate what the concept is and is not, as follows:

Model case
An emergency nurse is caring for an older adult dying on a gurney in the hall, accompanied by his relative. The nurse decides to approach them because when she started her shift, she noted the patient's condition and the sad expression of his relative, so she greets them amicably and warmly, introduces herself, and asks them what they need. The patient's relative breaks into tears, and the nurse comforts him with a purposeful touch. The patient's relative tells her that he does not understand what is going on with his father and does not know if he is suffering exposed to the sight of everyone. The nurse listens to the patient's relative, answers his questions, and helps him say goodbye to his father. Then, understanding the situation and noting that there are no beds available in the inpatient unit, the nurse moves the patient to a more private area with an exclusive space for him and the relatives who wish to be there with him. The nurse informs the psychologist about the situation, and they together support the process of death and mourning, giving peacefulness to the family and dignity to the father's death.

Borderline case
An emergency nurse is caring for an older adult going through the dying process in the hall, accompanied by his relative. The nurse decides to approach them as she does with all her patients on each shift, greeting them and asking them what they need. The patients' relative breaks into tears, and she keeps silent and leaves for a moment. Then, she returns and informs the patient's relative that as there are no beds available in the inpatient unit, she will locate the patient in a more private place so that his family can say goodbye to him. Then, understanding the situation, the nurse informs the psychologist about the situation and, they together support the process of death and mourning.

Related case
An emergency nurse is caring for an older adult going through the dying process in the hall, accompanied by his relative. The nurse decides to approach them because she feels empathy, as she had liveda similar situation with her grandfather. She greets and asks them what they need, the patient's relative breaks into tears, and the nurse begins to talk to them about how important it is to say goodbye and be grateful for everything they shared and lived together. The nurse then informs the patient's relative that there are no beds available in the inpatient unit, but she will locate the patient in a more private place. There, the patient's relative expresses his feelings; the nurse listens to him and asks for support from the psychologist to support the process of death and mourning.

Contrary case
An emergency nurse is caring for an older adult going through the dying process in the hall, accompanied by his relative. The nurse approaches to give the patient the medications and notes that the patient's relative is sad; so, she decides to avoid the situation and only informs them that she is giving medications that relieve pain.
The patient's relative asks her to please relocate them. She moves the patient to a more private area and tells them again that there are no beds available. She informs the treating physician and says that it is his job to support them in this process of death and mourning.
Comparing the model case versus the contrary case, Table 5 presents a specific analysis that makes explicit the differences between them.

Identification of antecedents and consequences
Antecedents are those aspects present before competence achievement, and consequences are those aspects that result from such competence.
As antecedents, nurses ought to have theoretical knowledge of interpersonal relationships, which is acquired during their professional training and from previous experiences such as the school and family education they received, especially values, morals, and ethics. Additionally, self-criticism and reflection on practical action should be strengthened to think and rethink the experiences derived from established relationships (43,44).
Regarding the consequences of developing interpersonal skills, nurses will follow a humane practice, be genuinely present in the care they provide, be guided by bioethical principles, and efficiently work in teams (45,46).

Empirical referents: Methods and measurement instruments
Few validated instruments are available to measure interpersonal skills in English and Spanish versions. Some scales that may mea-sure specific attributes or address interpersonal aspects are shown in Table 6. Research perspectives to approach this phenomenon show that experiences and the process of developing interpersonal skills in nursing have been researched from the qualitative point of view. Quantitatively, researchers have come close to describing the characteristics and relating each attribute to this concept.

Caring Interpersonal Relationships
Nursing Care Interpersonal Relationship Questionnaire (49). It is based on Imogene King's Conceptual Model.

Attributes of Care Subjectivity
Caring Assessment Scale Tool (CAT-V). It is based on the Theory of Transpersonal Human Caring.
Source: Own elaboration

Implications for research, practice, and education
Having conceptual clarity of the term interpersonal skills in nursing guides both the being and the duties of nursing professionals. Evidence shows a growing need to include it within the training practices of students (51) since interpersonal skills has become essential to provide care recipients with authentic and humane care. Despite being often intangible, interpersonal skills are perceptible to those who are receiving care.
However, approaching more factual knowledge, it is expected that the attributes derived from this analysis will guide future translational research through interventions that favor the development of these skills in nursing professionals and psychometric research to create specific scales for its measurement. The real impact will be on the patient cared for and their families by having nurses that make them visible and participants in their care.

Conclusions
After the literature review and the consultations with subject experts, we can affirm that interpersonal skills in nursing are the knowledge, abilities, attitudes, and values that nurses can express comprehensively during the interpersonal relationships they es-tablish with others, whether care recipients, family members, communities, colleagues, or other professionals. These skills are characterized by respect, openness to others' experiences, emotion management, commitment to others, empathy, negotiated and shared decision making, teamwork, and application of bioethical principles. Their purpose is to develop a humane nursing practice in which positive results are obtained therapeutically or pedagogically depending on the role played by the nursing profession.
Hopefully, this concept analysis will guide future research on measurement and assessment of interpersonal skills and the effect of educational programs that include interpersonal skills. Despite the different global settings in which nurses work today, interpersonal skills concern each country and each role nurses play.