INTRODUCTION

Communication plays a key role in nursing and in fact is the basic work of nurses in patient care [1]. The main task of the nurse is caring for patients, and it is reflected in the relationship between patient and nurse in its clearest way [2]. Patients also view interaction with nurses as the basis of their treatment [3]. One thing that has been overlooked in the nursing profession or is less discussed is how to communicate with children [4]. Nurse-patient relationship is more prominent, especially when the patient is a child, because the childhood is one of the most important stages of development [5]. Bad relationship can hinder a patient's recovery and may even make him permanently deprived of life or health; on the contrary, the optimal relationship can be more effective than drug therapy in patient’s recovery [6,7]. Mendes et al. emphasized the importance of nurse - patient communication not only as an essential part of nursing care but also considered it as a treatment per se [8]. Although communicating effectively with all patients is essential, such a relationship is crucial for sick children [9]. Children are one of resources and capitals of the country. Honest communication, respect for values ​​and sensitivity to the existingdifferences are necessary for optimal care of patients, especially children [10]. Statistics show that about 30 percent of children are hospitalized at least once during their childhood. About 5 percent of them have been hospitalized several times [11]. Hospitalization can never be without influence in children's lives.Unclear consequences of the disease, special treatment for the child and the child's fear and observation of the child’s pain increase stress in children and families and influence their performance and planning for the future [12]. When enough time is spent to communicate properly and effectively with the client, it will have many positive consequences. Studies have shown that the time spent on communication with patients by nurses is very short and dialogue of nurses with patients is too superficial and patients are dissatisfied that nurses do not listen them [13]. In this regard, a study was conducted in order to investigate communication skills of nursing students in different wards of the hospital and it was shown that students lacked adequate skills in this regard and communicate with patients only when proving services and more effective training of the students was emphasized [14]. On the other hand, studies assert lack of communication skills inhealth service providers stem from inadequate training and at the same time, result from absence of understanding the importance of key role for communication skills with clients [15]. Communication skills can be trained and learnt and even short-term educational courses will have significant impact on promoting communication skills. Individuals can use various communication approaches in order to meet wide range of needs and different situations of patients by learning communication skills [16]. Findings by Kruijver et al. also suggested necessity of training nurses for effective communication with patients [17]. Studies indicate that training and utilizing communication skills by nurses not only causes behavioral changes in them but also leads to emergence of positive changes in clinical conditions [18]. Thus, educating interpersonal communication skill to nurses is recognized as one of the main ways for promoting care quality, because it causes change in their behavior and attitude toward usefulness of these skills, promoting their job satisfaction and change in clinical situation and patient satisfaction [19, 20]. Small group discussion is one of the most useful and reliable educational methods. This is the best method for changing attitude. Participation in discussion is interesting and it is one of the best ways for creating creative thinking and critical thinking and finding one’s weaknesses and developing behavioral changes in individuals [21,22]. Since clinical nurses are all adults, they do not tend to have passive role in educational classes in traditional style and they tend to create learning situations themselves. Using group discussion is regarded as an efficient educational method in increasing competency of nurses in clinical judgment and their diagnostic reasoning. Being time-consuming and lack of participation of shy people in discussion and distracting the subject are among limitations and disadvantages of this method [23,24]. In Iran, due to lack of time or lack of skill of instructors, group discussion method has been less used practically in nursing education [25].

Lower number of individuals in small group discussion method compared to group discussion method allows higher participation in discussion and more opportunity for expressing their ideas as well as more focus and discussion on the subject, which is one of the advantages of this method over group discussion method.

Considering importance of promoting communication skills of nurses and its obvious advantages, and on the other hand, gap in its application in clinical care, which education may fill this gap, it seems necessary to investigate impact of implementing various educational practices on communication skills of nurses, because each of these methods has their own advantages and limitations. Current study aims at answering this question: if education using small group discussion method influence skill communication of nurse with the child.

METHODS

It is a clinical trial with two groups and pretest-posttest plan, which was conducted on the first semester of 2015 with approval from ethics committee of Mashhad University of Medical Sciences and observing ethical codes. Research population included all nurses working in wards of Sheikh Hospital, who were employed in these wards during the research period. The main inclusion criteria included tendency to participation in study, having nursing degree (at least BA), and having at least one month of working experience in pediatric ward and exclusion criteria included non-participation in study and absence in one of educational classes. Sample size was estimated as 34 per group after conducting pilot study and considering attrition. But at the end 8 ones were excluded due to non-participation in the classes and reluctance to continue. Finally, the number of nurses in each group decreased to 30, and overall 60 ones were studied. Cluster sampling method was used in emergency, surgery, hematology, and nephrology wards of Dr.Sheykh Hospital. That is, after specifying the number of nurses needed from each ward based on the total number of nurses working in the respective ward, nurses were included in the study as available, and then they were assigned in case and control group randomly. Data collection tool included research sample selection form, demographic data form, and Calgary-Cambridge checklist for communication skill evaluation. Calgary-Cambridge checklist was modified in this work for investigation child communication skills. Author made checklist included evaluation of communication skills containing 30 items which measured verbal and non-verbal communication skill of nurses in relationship with age school children (6-12 years old). Validity of the research tools was examined and confirmed by content analysis method. Reliability of Calgary-Cambridge communication skill evaluation checklist was calculated using Chronbach alpha method. Chronbach alpha coefficient was calculated as 0.84.

After providing written introduction letter to nursing office of the hospital and coordination with the respective authorities, research samples were selected using research sample selection form, and verbal explanation was given to them regarding goals and method. In case of their consent for participation in the study, they completed informed consent form. Then, researcher referred to the wards in appropriate time (active hours of each ward), observed, and recorded the way of communication of nurses with children based on the modified checklist of Calgary-Cambridge communication skill evaluation. Work of each nurse was observed and evaluated in three times. After controlling work of nurses based on their working plan samples were divided into 8-10 member groups and educational session in the form of one-day workshop of children communication skills education was held for each group by the researcher and clinical psychologist in the intervention group. That is, educational sessions of small group discussion were held inAmphitheater lounge lobby of Sheikh Hospital. In this place, arrangement of chairs is in round form which was in line with the research goals. Nurses were asked to write their name and name of ward of their service at the beginning after entering the class. Also, consent form and package of the educational workshop was given to the nurses at the beginning of the class. Sessions were held in the form of groups with 8-10 members. In this educational program, which lasted 6 hours, firstly general principles of communication were explained for the participants in the form of short lecture along with presenting slides. Then, pre-specified material were given in the form of three group discussions. First group discussion was about principles of effective communication with the child, second group discussion was related to techniques and factors helping effective communication with children, and third group discussion was allocated to obstacles of communication in special situations and problems. Each group discussion was implemented in this way that firstly the participants were asked to express their information and ideas about the subject of discussion, then when nurses were expressing their ideas, clinical psychologist emphasized correct cases expressed by the nurses and retold new cases too. The leader guided and directed participation of individuals in discussion and prevented from distraction. At the end of each discussion and after providing all materials to nurses, they were asked to express their working experiences regarding observing or not observing discussed cases, and state their results and then conclusion of the ideas was taken by the researcher. In order to prevent from distortion of research results, nurses were asked to avoid from disseminating information. In the control group, no educational program was held and research samples were observed. Three weeks after holding educational workshop, communication skill of nurses was examined and recorded based on the existing tool simultaneous with the case group. Collected data were analyzed using SPSS software, version 16, and descriptive statistical methods including mean, SD, and frequency distribution and statistical tests including chi square, Fisher exact test, and Mann-Whitney test with confidence coefficient as 95 percent.

RESULTS

Results obtained from statistical analysis showed that mean age of nurses in control group was 29.0 ± 7.1 and 29.0 ± 4.7 in case group. Most research samples in both case (29) and control (30) groups had BA degree. Mean and SD of nursing working experience of research samples was 37.6 ± 39.1 in control group and 34.0±23.1 in case group. Level of interest in working with children was high in 41.7 % (25) of participants. That is, interest in working with children was high in 40.0 % (12) and 43.3 % (13) of nurses in case and control groups, respectively. Both groups were matched based on Mann-Whitney test, chi-square and Fisher exact tests in terms of above variables and background and confounding variables included marital status, employment status, location of work, work shift, work experience in pediatrics, interest in nursing profession, satisfaction with work environment and experience of participation in communication skills training courses with children prior to intervention (p > 0.05) (Table 1).

Table 1. Frequency distribution of nurses under study in terms of demographic variables in case and control groups

P* = P values reported by Fisher exact test

Results of independent t test indicated that there is no statistical significant difference before intervention in mean and SD of verbal communication skills of nurses in two groups (P = 0.495). But after intervention, mean and SD of these skills in test group was significantly higher (P < 0.001). in inter group comparison results obtained from pairwise t test indicated that mean score of communication skills after intervention was significantly higher compared to before intervention in case group (P < 0.001), but no change in mean score of communication skill was observed in control group after intervention (P = 0.055) (Table 2).

Table 2. Mean and SD of verbal communication skill score of nurses before and after intervention in case and control groups

In investigation of non-verbal communication skill, independent t test results showed that mean and SD of non-verbal communication skills of nurses had no significant difference statistically before and after intervention in both groups (P = 0.307). But mean and SD was statistically and significantly higher in case group after intervention (P < 0.001) (Table 3).

Table 3. Mean and SD of non-verbal communication skill score of nurses before and after intervention in case and control groups

In measurement of nurses’ satisfaction with the educational method, 27 ones (71.0%) were satisfied with the implemented educational method.

DISCUSSION

Current study was conducted aiming at investigating impact of education using small group discussion on communication skills of nurse with the child, and obtained results indicated that (verbal and non-verbal) communication skills of nurses in case group using small group discussion were significantly increased after intervention, but communication skill increase in control group was not significant.

In the current study, case and control groups were not significantly different in terms of demographic and confounding variables. Results showed that education using small group discussions promotes (verbal and non-verbal) communication skills of nurses which is consistent with findings by Feingold, Bourgeois, and Barrass.

Feingold et al. considered education using small group discussion as cause for increasing interpersonal interactions and increasing attempt for answering the questions [26]. Bourgeois et al. worked on doctoral curriculum in medicine faculty of California University and found that teaching method using small group discussion increases effectiveness of interactions with patients, medical measures, observation of ethical principles, and participatory approaches [27]. Barrassin a guide study for effective learning, stated that teaching and learning through group discussion apart from the educational aspects and having enough time to analyze the important points in the discussions, has undeniable effect in terms of social culture and communication and improves communication skills and creates self-confidence [28].

Current study showed that education of communication skills using small group discussion method leads to performance change in nurses, which is consistent with findings by Rossiter and Hill and Shirazi. Rossiter showed that when lecture method is provided along with group discussion, more and quicker change is obtained in attitudes of students [29]. Hill compared lecturing and discussion methods and showed that in the discussion, mental abilities (skills), changes in values, attitudes and interests of students is more than lecture method [30].In a study by Shirazi et al. (2010) entitled studying effect of self-care program education through group discussion on knowledge and practice of diabetic adolescent girls referred to Iranian Diabetes Association, it was shown that self-care program education rough group discussion has been effectiveto improve knowledge and practice of diabetic adolescent girls [31]. Since group discussion method is one of the effective methods for changing attitude and performance, group discussion method was also identified as an effective way for promoting knowledge and performance in the current research.

In the current research, communication skill of nurses was promoted in the form of holding workshop, which is consistent with findings by Karimi. Karimi et al. (2012) in their work promoted communication skill of nurses with holding one-day workshop, which is consistent with findings in the current work [32], which can be due to similarity of methodology.

Also in the current work nurses viewed small group discussion method as an effective method for educating communication skills which is consistent with findings by Pal and Baghcheghi. The study by Pal et al. on evaluation of group discussion impact on learning on 182 social medicine students showed that group discussion had higher impact compared to conference on learning, and different forms of discussion in small groups were evaluated as positive experiences by students, and it is regarded as an understandable means for deep interaction of learning and teaching [33]. Baghcheghi et al. also reported that nursing students considered group discussion method in learning as more enjoyable, effective compared to lecture method, which caused interest in training environment [34]. The reason for consistency of results can be associated to participation and cooperation, which is created during group discussion and can cause satisfaction of individuals with the educational method.

Managheb et al. (2011) in a semi-experimental study entitled “impact of role play and group discussion on the knowledge and attitude of interns of Jahrom Medical School about breaking bad news” found that both methods promoted knowledge and attitude of interns, but role playing method caused more knowledge and attitude promotion in interns compared to group discussion method [35]. These findings were not consistent with current work’s findings. The reason for less effectiveness of group discussion method in this work can be due to comparison of this method with a novel educational method like role-play.

One of the features of role-play method is that it reduces importance of instructor’s role and encourages equal learning and listening. According to created reactions in identical groups, new ideas can be taken and directions are provided for development and change [36], but group discussion method requires skilled, experienced, patient, and expert individuals so that they can handle the discussion and acquire interaction and idea sharing skills through cooperation with others [37, 38].

One of the relative limitations of current research is dissemination of information by nurses in both groups, which nurses were asked to prevent from disseminating information at the beginning of the plan.

Results of this study in addition to emphasis on importance of educational intervention for promoting children communication skills, also improved communication skills of nurses with children and their performance in relation with children. Thus, this method can be used as an effective educational method for promoting children communication skills in bedside. But, since there are various educational methods for attitude change in individuals, there is need for more and deeper studies in this regards and it is suggested that impact of different educational methods on child- nurse communication skill is measured so that education of children communication skills can be implemented by the most effective method for nurses working in pediatric hospitals in justification sessions before and in service period.

ACKNOWLEDGMENTS:

The researchers would like to thank authorities of Dr. Sheikh Hospital and nurses participating in the research.

Research committee approval and financial support:

This article refers to approved research project in vice presidency research and Research Ethics Committee of Mashhad Medical Science University (research code: 931109).

 Conflict of interest: The authors declared no conflict of interest.