Nurse Education Today (1991) lI,24-29 0 Longman Group UK Ltd 1991

Nurses’ interpersonal skills: a study of nurses’ perceptions

Phillip Burnard and Paul Morrison

Six Category Intervention Analysis was used as the framework of a study which involved asking 117 trained nurses to rate their interpersonal skills along six dimensions. The findings suggested that the nurses viewed themselves as being more skilled in offering support, information and prescription in their dealings with patients and less skilled in being catalytic, cathartic and confronting in similar circumstances. The findings in this study were similar to those of previous studies in this field. The study has implications for the development of interpersonal skills training programmes for nurses.

INTRODUCTION

There is a growing interest in nurses’ developing interpersonal skills (Muldary, 1983; Faulkner & Maquire, 1984; Aidroos, 1985; Kagan, 1985; Conboy-Hills, 1986; Fielding SC Llewelyn, 1987; Reynolds & Cormack, 1987; Burnard, 1989a; 1989b). Nurses are being encouraged to develop a range of communication, counselling, assert- iveness, facilitation and social skills. What remains unclear is how nurses view their own

interpersonal skill levels. It is asserted that such views need to be taken into account before further interpersonal skills training can be planned. This study offers a format for the self-assesment of interpersonal skills. It builds on previous research by the authors (Burnard & Morrison, 1988 Morrison & Burnard 1989).

Philip Burnard MSc RGN RMN DipN Cert Ed RNT Lecturer in Nursing Studies and Paul Morrison BA (Hans) RGN RMN PGCE Lecturer in Nursing Studies, University of Wales College of Medicine, Cardiff, Wales (Requests for offprints to PB) Manuscript accepted 23 May 1990

24

The paper identifies a theoretical framework

known as Six Category Intervention Analysis (Heron, 1989) offers an aim for the study,

describes the methodology and findings and compares the results of the study with previous

ones. It closes with a discussion of the findings and some suggestions for future research and training in the field. The present study seeks to test out the validity of our previous findings.

Six Category Intervention Analysis

Six Category Intervention Analysis (Heron, 1975; 1989) developed out of previous work by Blake and Mouton (1976). It is a device for identifying possible types of effective interper- sonal interventions between practitioners and clients. Heron’s category analysis is a theoretical analysis and the authors could find no reference to any empirical work that predated the develop- ment of the analysis nor could they find any later, published studies which used the analyses to guide research in this area. The analysis has been widely used at the Human Potential Research Project, University of Surrey (HPRP,

1987) as a tool for training people in using

communication skills. It is notable, too, that

those courses are often attended by nurse Leachers and nurse practitioners and have been recommended by the National Boards for Nurses as suitable courses for those who wish to

develop their interpersonal skills (Nicolas & Gooderham, 1982).

The categories identified in Heron’s category analysis are: prescriptive, informative, confront- ing, cathartic, catalytic and supportive. To be prescriptive is to offer advice or make sug- gestions. To be informative is to offer informa- tion or instruction. To be confronting is to

challenge the person’s behaviours, attitudes or beliefs. To be cathartic is to enable the release of

tension and strong emotion (tears, anger, fear etc.). To be catalytic is to draw out, to encourage f’urther self-exploration. To be supportive is to

validate or confirm the other person’s self- worth. Heron further subdivides the categories

under the headings authoritative categories and facilitative categories. Authoritative interven-

tions are those which enable the practitioner to maintain some degree of control over the rela- tionship and include the prescriptive, informa-

tive and confronting categories. Facilitative interventions are those that enable the locus of

control to remain with the client and include the

cathartic, catalytic and supportive categories. Table 1 identifies these categories. Heron’s

analvsis may be compared to Blake and Mouton’s (1976) original Intervention Category Analysis which comprised the following categories:

1. acceptant;

2. catalytic; 3. confrontation; 4. prescription;

5. theories and principles.

Heron’s analysis appears to have improved the internal logic of the category analysis, has removed the ‘theories and principles’ category and added other categories. It is notable, also, that Blake and Mouton’s focus of attention was interventions made in management: Heron’s concern is with interpersonal interventions. Thus the purpose of the two sorts of analysis is

Table 1 Authoritative and facilitative cateaories

Authoritative Facilitative Categories Categories

Prescriptive informative Confronting

Cathartic Catalytic Supporting

different. The point needs to be raised as 10 what

degree such analyses can appropriately be trans- ferred and modified in this way. It is notable that Blake and Mouton’s analysis was intended for use in a fairly specific context, whilst Heron’s

claims a much wider range of application for his

analysis. Heron claims that the category- analysis offers

an exhaustive range of therapeutic interven-

tions. He further claims that the interpersonallv skilled person is one who can move appro- priately and freely between Ihr various tat-

egories when using the categol-) analysis as a means of guiding therapeutic. action. Heron

suggests that no categorv is more or less impor- tant than any other category. Paradoxicall), however, he argues that catalytic interventions

form a ‘bedrock’ type of intervention that ma\

serve as the basis for effective c.c)nlnlunication and counselling. He also offers the view that

because we live in a ‘non-cathartic societv’ (Heron 1977), where the overt expression of

strong emotion is not highly valued, the cathartic category will tend to be less frrquentlv and less

skilfully used bv many practitioners. Fielding and’I,lewelvn (1987) Ilote that there

are different degrees 01‘ resistant e to the o\‘et-t expression of emotion within the I ‘li, influenced by culture. Heron goes on to make a case for the therapeutic value of cathartic release - a highly

pertinent and contentious argument but one which is beyond the remit of this paper. Other commentators may not view cathartic release as being of such importance. George Kelly, for example, in acknowledging the need to ‘look forward’ in life, rather than to look back at past experiences says ‘the only valid \\a> to live OIW’S

life is to get on with it’ (Kelly. 1969) The c-ategorv analysis is pitched at the level of

intention. That is to say that it does not pick out a

26 NURSE EDUCATION TODAY

range of specific verbal behaviours but attempts to guide the user’s intentions in making thera- peutic interventions. Thus it is in no sense a mechanical, behavioural training device but a

means of enabling the user to discriminate between a range of varied therapeutic (and, by implication, non-therapeutic) interventions.

The question remains, however, as to the degree

to which researchers can have access to the people’s intentions and whether or not people can remember their intentions, after the event!

The word ‘intervention’ is used here to describe any verbal or non-verbal statement or behaviour that the practitioner may use in the therapeutic relationship. The word ‘category’ is used here to denote a range of related interventions.

Hammond (1983), in the context of psychi-

atric nurse education noted that the category analysis could be used in two ways:

4

b)

as a means of interpreting nurse/patient interventions and as an aid to the nurse during counselling

sessions. Goodwin and Bond (1978) had called for the development of catalytic and

cathartic skills development, as per the category analysis, in health visitors.

Bond and Kilty (1983) described the application of the category analysis for use in peer support groups. Dryden (1985) had discussed the use of the analysis in teaching counselling skills to ‘non-psychologists’. The use of the category analysis in interpersonal skills training and counselling skills development had been

described elsewhere (Burnard, 1983; 1984;

Table 2 Synopsis of the six category intervention analysis

Prescriptive To offer advice, make suggestions etc. Informative To oive information, instruct, impart

knowledge etc. Confronting To challenge restrictive or compulsive

verbal or non-verbal behaviour. Cathartic To enable the release of emotion

through tears, angry sounds etc. Catalytic To be reflective, to ‘draw out’ through

the use of questions, reflections etc. Supportive To offer support, be validating,

confirming etc.

1985; 1989a; 1989b). Heron (1989) has sug-

gested that the six category approach is also useful in planning management strategies.

Previous research

We had carried out two previous studies using a ranking schedule to determine student and

trained staffs’ perceptions of their interpersonal skills (Burnard and Morrison 1988, Morrison and Burnard 1989). In the study of 93 trained

nurses’ perceptions, using the six categories, the following rank order emerged:

1. supportive; 2. informative; 3. prescriptive; 4. catalytic; 5. cathartic; 6. confronting;

In the above overall ranking, item one rep- resents the category that respondents felt most skilled in using and item six represents the category that respondents felt least skilled in

using. Our study of student nurses’ perceptions yielded a similar response and the details of the

differences between the two studies can be obtained from the reports of those studies.

The present study was designed to test the reliability of those previous studies by using a different method of collecting data, using the category analysis described here. The rating

scale used in this study also allowed greater flexibility of analysis than did the ranking

schedule. The results of this study were open to analysis using multidimensional scaling (MDS) (Kruskal &Wish, 1978; Forgas, 1979): a method

that allows the data to be viewed from a variety of perspectives and allows hidden patterns and trends to emerge from them in ways that would not be possible using more conventional meth- ods. This analysis of the data will be reported on at a later date. The present study is an extension of the two previous studies and part of a larger study on interpersonal skills in nursing.

Aims of the study

The present study built on previous work on the

iiVRSE EI)l_“(:.~~IO~ TOD.-\Y 2’i

six category approach (Burnard & Morrison,

1987; Morrison & Burnard, 1989). We were

interested in testing out the validity of the

findings in the studies discussed above. We wanted to find out whether or not there was a

consistency in the way nurses viewed their inter- personal skills in terms of Heron’s analysis. If

consistency was present we may be more con- fident in using our results to develop training methods, educational policy, assessment tech- niques and further research.

Also. as we suggested previously, prior to our research it appeared that Heron’s category analysis had not been tested empirically and little had been written about nurses’ perceptions of

their own interpersonal skills.

DESIGN OF THE STUDY

Methodology

Whilst this was essentially a quantitative survey, a

guiding principle in designing the study was that summed up by George Kelly:

‘If you want to know something about some-

one, ask them, they might just tell you’.

(Epting, 1984)

Thus our intention was to ask the nurses in our

sample to tell us how they perceived their own interpersonal skill levels, whilst the category analysis served as a framework for making sense of‘ these perceptions.

Sample characteristics

We used a convenience sample (Field & Morse

1985) of 117 trained nurses who attended counselling skills workshops run by one of the present authors (PB). These nurses were from the fields of general, psychiatric and community nursing. On the one hand, the convenience sample offers the opportunity of gathering larger amounts of data. On the other, the sample cannot be said to be representative. Any con- clusions that are drawn from a study using a convenience sample must be tentative in nature.

In view of the paucity of research in this particu-

lar domain, we felt justified in using such a

sample.

Procedure

Following a period of introduction and familiar-

isation with the category analysis, the nurses in each case were invited to take part in the study b) completing a rating scale (Table 3). Specifically. each respondent was asked to rate the six cat-

egory items to correspond with how skilled the) perceived themselves to be while talking to patients in a professional nursing setting.

Analysis

Once the rating scales had been completed, we

drew up a matrix consisting of rows and columns in which each row represented a respondent and each column represented a category of the analysis. From this matrix we were able to calculate mean rating scores for each of the

categories. From these we were able to rank order the six categories in terms of the dimen- sion ‘least skilled - most skilled’. These findings

are illustrated in Table 4.

RESULTS

Our findings were as follows. The category that was identified as the one that the respondents

felt most skilled in using was the supportive category (mean rating score 4.23. rank order 1). The informative category was in second position (mean rating score 3.94, rank order 2,. Third

Table 3 Rating Scale

Not Very skilled skilled

Prescriptive 1 2 3 4 5 Informative 1 2 3 4 5 Confronting 1 2 3 4 5 Cathartic 1 2 3 4 5 Catalytic 1 2 3 4 5 Supportive 1 2 3 4 5

28 NURSE EDUCATION TODAY

Table 4 Mean rating and rank order of the six categories

Type of intervention Category Mean rating Rank order

Authoritative Prescriptive 3.75 3 Informative 3.94 2 Confronting 2.37 6

Facilitative Cathartic 2.81 5 Catalytic 3.3 4 Supportive 4.23 1

was the prescriptive category (mean rating score 3.75, rank order 3). The catalytic category was

ranked next (mean rating score 3.3, rank order

4) followed by the carthartic category (mean rating score 2.37, rank order 5). The confront-

ing category was in last position (mean rating score 2.37, rank order 6).

This rank order mirrors exactly the rank order of our previous study of trained staffs’ perceptions of their interpersonal skills in terms of the six categories (Burnard & Morrison,

1988).

DISCUSSION

This study has further confirmed the suggestion that some nurses are more skilled in being

supportive, informative and prescriptive and less skilled in being catalytic, cathartic and con- fronting. In our previous papers (Burnard &

Morrison, 1988; Morrison & Burnard, 1989) we offer some suggestions as to why these trends may be apparent. We do not intend to rehearse these arguments again in this paper but offer the following list of some factors that may influence the findings:

The organisational culture (Sathe, 1983) in hospitals may work against the develop- ment of a facilitative style of interpersonal relationships between nurses and patients. The ‘facilitative’ approach takes time. Nurses may feel that they do not have time to spare to develop relationships that involve being catalytic, cathartic and con- fronting. Catalytic, cathartic and confronting

that may be emotionally draining. Some

nurses may a) not want to make such an

emotional investment and/or b) not be

sufficiently trained in using these methods. Nursing often involves practical activities and nurses may see the job as involving

‘getting the work done’ (Melia, 1987). This may mitigate against the use of a more

client-centred approach to working. There has been a considerable emphasis on the ‘information giving’ aspect of nursing care (Hayward, 1975; Boore, 1978; Devine

& Cook, 1983). This may account for some of the emphasis on the informative cat-

egory noted in this study. Indeed, some

nurses may view their jobs as more con- cerned with information giving than with

being catalytic or cathartic. It may be the case that many aspects of nursing practice do not require the use of

catalytic, cathartic and confronting skills. The respondents in our studies have offered a general picture of their skills. It may be that catalytic, cathartic and con- fronting skills are only rarely used or

needed. It would seem odd to argue that all six categories are equally as frequently

required as one another, given their different nature. On the other hand, the person who does not often use certain interventions may also not be very skilled in using them when she has to. This raises complicated questions about the nature and content of interpersonal skills training programmes.

Having noted all of these possible expla- nations for our findings, the issue that remains clear is the regularity with which the pattern of

approaches involve an ‘investment of self response, in terms of the six categories, has

NL’KSE EDL’C:.ATION -1.OD.41 29

recurred. Thus it would seem that for many

nurses, the rank order: supportive, informative,

prescriptive, catalytic, cathartic and confronting,

characterises their perceptions of their own interpersonal skills.

This paper has described a further study of the use of six category intervention analysis in

the exploration of nurses’ perceptions of their interpersonal skill levels. The findings of these six category analysis studies are recurring fre- quently enough to suggest that trainers in this field may need to review their interpersonal

skills training programmes to ensure that nurses are developing competences in a wider range of skills. At the moment it would appear that little

has changed on the interpersonal scene. Nurses

are still ‘nurse’ centred as opposed to ‘patient’ centred. Given the present emphasis on individ- ualised nursing care, it is possible to question

whether or not this should continue to be the

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