Knowledge, attitude and practice regarding therapeutic communication among nurses in Kandy District, Sri Lanka

Therapeutic communication is considered as a skill required for all health care workers in order to improve understanding the patient in a better manner and encouraging the patient to express feelings & ideas. It has also been accepted as a high standard of nursing care which is to be practiced at every hospital and nursing facility. As practice of therapeutic communication improves outcome of nursing care, objective of this study was to assess the level of knowledge, attitude and practice regarding therapeutic communication among nurses in teaching hospitals in the Kandy district, Sri Lanka. Specific objectives were to determine the factors affecting practice of therapeutic communication and to evaluate the self- satisfaction of therapeutic communication among participants. A cross sectional study design was employed to gather data by a structured self-administered questionnaire involving 200 nurses working in teaching hospitals in Kandy, Sri Lanka. Results were analyzed by MINITAB version 18.

setting. However, increased workload at the hospital was named a barrier by many participants.  (Sherko et al., 2013).Moreover, therapeutic communication is also considered an important factor when assessing quality of health care (Younis et al., 2015) and has been recognized as fundamental to all nursing practice (Miguel et al., 2014).

Conclusions
Further it is a requirement that the nurse and patient collaborate actively following different types of communication, such as active listening by paying attention to what the patient is saying verbally & non verbally. A nurse can help patient to express emotions by making observations. Touch is considered as one of the most powerful form of therapeutic communication and can be explained as bringing the sense of caring by holding a patient's hand, using silence allowing the patient to think & gain some insight into the situation. (Sherko et al.2013).Communication skills support in providing information & feedback, giving hope to patient and helping them to cope with anxiety during hospitalization (Shafakhah et al.,2015). Nurses could provide a higher patient satisfaction, better health outcomes, quality of treatment care & more active self -management in patients with chronic diseases when they apply therapeutic communication for their patients (Ferreira et al.,2016). On the other hand, ineffective communication could result in stress , errors in diagnosis, decrease of patient participation in care plan & information exchange and poor quality of treatment outcome (Shafakhah et al.,2015).
There has been wide discussion among health care workers regarding the quality of outcome in the patient care in hospital settings. One of the aspects which has drawn attention by various centers and researchers was to investigate knowledge, attitude and practice of effective and appropriate communication between the nurses and patients as patients spend most of their hospital stay with nurses in the clinics and wards. As positive effects of therapeutic communication have been identified, multiple research in the field have been conducted in order to find the possibilities of further improving practice of therapeutic communication by the nurses. Therefore, nurses need to be supported by high-quality and evidence based training in order to meet those challenges (Bramhall et al., 2015).
Outcome of this study would be helpful for the nurses to improve their knowledge, attitude & practice for improved quality of care & to identify the causes of failure in therapeutic communication in these hospitals. As we could not trace any peer reviewed article in the area of study in Kandy district in Sri Lanka, it is expected that the outcome of this study will provide significant information on identification of specific problem areas which need to be improved in the future. It further will support in enhancing physical as well as psychological wellbeing of the patients in the state hospitals in the region. It ultimately will uplift the quality of care at the state hospital sector in the country.

General Objective
To determine the knowledge, attitude & practice regarding therapeutic communication among nurses in Teaching Hospitals in Kandy district.

1.
To determine level of knowledge of therapeutic communication among nurses in Teaching hospitals in Kandy district.

2.
To determine level of attitude of therapeutic communication among participants.

3.
To describe the percentage of participants currently applying therapeutic communication in Teaching hospitals in Kandy district.

4.
To determine the factors affecting practice of therapeutic communication in Teaching Hospitals in Kandy district.

5.
To evaluate the self-satisfaction of therapeutic communication among participants.

Study design
The study was conducted as a survey research design to assess knowledge, attitudes and practice regarding therapeutic communication among nurses in teaching hospitals in Kandy district. A descriptive cross-sectional study was carried out with a self-administered questionnaire.

Study area/setting
The study was conducted at Teaching Hospitals in Kandy district (Teaching hospital Peradeniya, Sirimavo Bandaranaike Specialized Children's Hospital &Teaching hospital Kandy).

Study population
The study population was nurses attached to teaching hospitals in Kandy district with more than 6 months of service in the respective hospital.
Inclusion Criteria-Nurses with 6 months or more service in the respective hospital.
Exclusion Criteria-Nurses who were busy in their work.
Written consent was obtained from every participant. Data gathered was kept confidential & when publishing individual response will be not displayed. Nurses were requested to fill the questionnaire at the home & return it the next day & on voluntary basis. The information that I collected from this research project was kept confidential. Information gained were kept locked without sharing with anyone.

Sampling Technique
Convenient sampling method was used to collect the data for the study. The sample size was taken as about 200.

Study Instrument and material
Evaluation of knowledge, attitude and practice of therapeutic communication among nurses were measured using English questionnaires that are developed based on research studies. Questions were analyzed during pilot study and modified accordingly.

Data collection tools/ instruments
The data collection tool was the questionnaire which included socio-demographic background, evaluation of knowledge, attitude, practice and causes of failure in therapeutic communication.

Method of collection
Data was collected during December, 2018. A pre tested questionnaire was given to each nurse after giving brief explanation about the research. Informed written consent was obtained at the same time. Five to 10 minutes were roughly taken to complete the questionnaire for a single participant. All the possible ethical issues were addressed throughout the period of study.

Pre Test
The questionnaire was pre-tested to clarify comprehensibility & understanding of questions & to identify the time required to complete the questionnaire. Twenty-five nurses were selected at Peradeniya hospital who were not included in the proper sample.
Furthermore, their wards were not included in the sample too. The questionnaire was modified according to the comments & data analysis of the pre-test.

Ethical Consideration
Ethical clearance was obtained from the ethical review committee, Faculty of Allied Health Sciences, University of Peradeniya. Permission to conduct the study was obtained from the Directors of the teaching hospitals of Kandy district, Chief Nursing Officers of each hospital and ward sisters/ ward masters of each ward.

Statistical Analysis
MINITAB version 18 was used to analyze the data. Catching and correcting errors of the collected data was done before stepping into the data analysis. Non-numerical data was coded into a unique numerical pattern to ease the phase of data analysis. A descriptive analysis along with appropriate visual representation made on the demographics measurements and other interested variables as the first phase in the study. All the hypothesis of the study was conducted at a significant level of 0.05. Statistical tests for association and goodness of fit was used to assess the significance among the knowledge, attitude and practices. It was determined by employing Chi square test. Further analysis was conducted according to the distributional assumptions on data.

Pretest-Validation of the questionnaire.
The pilot test was carried out using twenty five nurses who were randomly selected from the teaching hospital Peradeniya and not included into the study. The questionnaire was modified according to item analysis by removing and modifying some questions in order to improve the reliability of the study. Interestingly, the current study reveals that there was a statistically significant association between educational status and the nurse's attitude that he/ she has a responsibility for improving therapeutic communication (P=0.010) ( Table : 5).
There was a statistically significant association between graduate form and the attitude that therapeutic communication improves self-satisfaction of nurses (P=0.011) ( Table: 5) .According to results, similar association was there when position & years of service were considered. There was a statistically significant association between position & years of service with attitude of therapeutic communication decreases anxiety and fear of patient (P=0.008) ( nurses were with opinion that therapeutic communication helps to succeed the nursing plans (Thanasekaran et al., 2017). A study in an Australian university had attempted assessing nursing students' listening & communication styles using paper-based versions of the listening style profile. There was only slight differences in preferences for listening and communication styles between the gender (Mckenna et al., 2014). We have identified that nurses in teaching hospitals in Kandy district consider active listening is the most important part in therapeutic communication with a patient. None of the participants stated that active listening is not important in the process. The results could be attributed to the fact that majority of participants were females.
When attitude towards therapeutic communication was considered, majority of participants agreed that therapeutic communication prevents medical errors of patients.
According to a study in western Ethiopia, most of the nurses strongly agreed to the fact that therapeutic communication improves their care (Thanasekaran et al., 2017) .The results are favorable towards our findings as prevention of medical errors of patients is one part of improving care.
Our study showed that, 59.29% nurses were always involved in applying therapeutic communication in pre-operative & post-operative care. Another study showed that majority of nurses utilized therapeutic communication & results highlighted that 52% of communication skills than students in lower semesters (Shafakhah et al., 2015). Similarly another study in Greek had confirmed that there is a statistically significant association between nurses learning at the university and those with two years training. Nurses at the University responded with higher number of correct answers about communication than others(Kounenou, Aikaterini and Georgia, 2011). As a result of the changes in the curriculum, continuing education programs, nurses in our country too have improved their skills & knowledge on patient care including facts on therapeutic communication. There was also a statistically significant association between positions & the knowledge that arguing with a patient is not suitable in therapeutic communication.
We observed a statistically significant association between number of years of service & knowledge that therapeutic communication helps to encourage expression of feelings & ideas of patients and exchange of information in verbal or non-verbal manner and nurses must protect the privacy of patient in order to achieve therapeutic communication.
Furthermore, according to our study, there was a statistically significant association between number of years in service and knowledge of therapeutic communication.
However, another study had shown that there is no statistically significant association between years of service & knowledge of therapeutic communication. We consider number of years in service is an important tool to show the level of experience of nursing practice.
In addition, there was a statistically significant association between socio-demographic variables and attitude of therapeutic communication. Our finding also showed that, there