Integrative review of soft skills the desirable traits and skills in nursing practise


 Aim: To explore the value of soft skills in nursing practice.Background: While hard skills refer to the technical ability and the factual knowledge needed to do a job, soft skills allow you to more effectively use your technical abilities and knowledge pleasingly. These two skills are complementary but soft skills are a prerequisite in every profession where human interaction and teamwork are needed to succeed. This integrative review examined the literature on soft skills within the nursing domain and made suggestions.Methods: An integrative literature review was carried using four electronic databases. These databases were Cumulative Index to Nursing & Allied Health Literature (CINAHL), PubMed, Medline on EBSCOhost and Google Scholar using keywords: soft skills, non-technical skills, nursing skills, nursing art and aesthetics. No dates were considered during the search of the literature. Full texts of relevant studies were retrieved after screening the titles and abstracts. Critical appraisal was undertaken, and the findings of the relevant studies were analysed using thematic analysis. Results: Seventeen studies were included, and the findings suggest an urgent need for softs skills in the nursing domain. Five themes: denotation of soft skills in nursing; benefits of soft skills in nursing; need for soft skills in nursing; inculcating soft skills into nursing practice; and links between hard and soft skills emerged. Also, the findings show that soft skills are the cognitive and social capabilities that complete the technical skills of the nurse in the health care industry.Conclusions: Soft skills have become the oxygen needed to resuscitate the seemingly dying nursing care quality. Regulatory bodies should see the call to incorporate soft skills into the nursing curriculum as an urgent resuscitative call that needs attention.


Introduction
Soft skills are intrapersonal traits and interpersonal skills 1 , that an individual possesses that makes him a preferred service provider. As intra-and inter-personal (socio-emotional) skills, it is essential for personal development, social participation and workplace success 2 . Soft skills also known as non-technical skills are gradually emerging as a required trait needed in today's job market. While soft skills are self-developed, interactive, communication, human and transferable skills, hard skills are academic skills, experience and level of expertise an individual acquires. According to Wats and Wats (2009), hard skills contribute to only 15% of one's success in maintaining a job while the remaining 85% is made by soft skills 3 . The opinion on soft skills has changed considerably during the last decades in many societies. Whereas in the past the mastering of hard skills was rated first and soft skills considered as "nice to have", the perception is different today 4 . Soft skills have become an important skill in nursing because, as educating nurses takes years to complete, the client who makes the nurses' job cycle complete is still concerned about the soft skill of the nurse.
According to Laari and Dube 5 , the quality of nursing care rendered is prominently reducing and the amount of time spent with patients listening to and explaining issues concerning their conditions is progressively fading. The therapeutic touch and the listening ear of the nurse are no longer accessible to the patient. One should be worried about these if one still holds the opinion of nursing being not only empirics but aesthetics as argued by Barbara Carper 6 . With the advent of globalisation and technological upheaval in the health care industry, the future nurse requires basic training in several sectors. This will include the development of soft skills which is a requirement for therapeutic nurse-patient relationships 7,8 .
Considering soft skills in nursing is a need, complaints from patients and clients about the reactions they receive from health care providers, especially nurses in the healthcare environment is deafening 9 . Nursing appears to be losing its grasps on quality nursing care as aesthetics are giving way to only empirics as argued by Carper and Peplau 6,10 .
From patients own perspective of quality, open communication and information flow are seen to prominently feature in their definition of quality care. Regarding nursing care, patients prefer individuals with good interpersonal communication skills such as listening carefully and attentively and explaining complex technical information clearly 11 . Patients also insist that to reduce vulnerability and anxiety, there is a need to have friendly health care providers. Also, courtesy and emotional support are important to patients as well as sensitivity and kindness including compassion and sympathy health care providers show to them 11 .
A review by Vogus,McClelland 12 indicate that patients are both more fulfilled and rate their care more highly when they experience care providers and support staff who treat them with courtesy and take their problems seriously. The findings further indicate that caring for the whole person includes the care provider's behaviours that attend to the physical symptoms as well as provide emotional support 12 .
Being friendly, courteous and giving emotional support are traits that are arguably somewhat innate even though these traits can be inculcated during training. However, it appears there is a missing link in healthcare education and this need to be sorted to satisfy clients and patients in the healthcare environment. Globally, nurses are castigated about how they treat patients under their care. Although nurses have for more than a decade in a row worn the most trusted professionals in countries such as the USA 13 , there are still pockets of studies indicating most nurses describing themselves as being authoritative in their interpersonal style and less facilitative in discharging their duties 7,14 . This exposes the need to train future nurses in intrapersonal reorientation skills on how they handle their patients because soft skills are core to a nurse-patient relationship. Even though the debate on whether soft skills can be assessed takes a central position in many healthcare educations 2 , it is without a doubt that soft skills training would facilitate the bringing of a new epoch in nursing practice globally 5 . Soft skills can be mentioned as the aesthetics; the art of nursing, the innate creative facet that brings nursing into the lamplights as a caring noble profession 6 .
With the changing educational trends, versatility in educational courses, availability of masses of qualified nursing personnel globally, the competition for job acquisition and job sustainability is becoming tougher. To get an edge over the competitors, students are left with no choice but to add values to their hard skills with soft skills to exhibit their true potential to make them the preferred candidates 3 .
Some employers prefer to hire, retain and promote persons who are dependable, resourceful, ethical, self-directed, having effective communication, willing to work and learn and having a positive attitude. These employer preferences are undoubtedly components of soft skills, the attributes of which nursing must imbibe. There is increasing consumer demand for quality healthcare in the health industries globally 15 . Soft skills are some of the hardest skills one will ever learn. It is less recognized with little respect in our training institutions but can make or break one's career and unfortunately, most individuals learn them the hard way 16 . The devaluation of soft skills is a global setback. According to Schulz (2008), it has taken the German Engineering Association to recommend that at least 20% of courses of the engineering curricula should be soft skills because employers prefer to take in job candidates who will be productive from a very early stage on. Nurse educators have a special responsibility regarding soft skills because during students' school and university years the educators have a major responsibility to impart the development of soft skills on their students 4 . From the above soft skills are seen as relevant in the job market in several sectors including the health care sector. If the job market and the employers desire soft skills in their employees in various sectors, what is the state of the literature regarding the extent to which soft skills in nursing facilitate aesthetics, the art of nursing? to improve the creativities of nurses that will bring patient and clients satisfaction.

Methods
The methods are based on the five stages of Whittemore and Knafl 17 , which are problem identification, literature search, data evaluation, data analysis and presentation.
Problem identification Page 5/19 The research problem originated from a study by Laari and Dube 5 . In their article Nursing students' perceptions of soft skills training in Ghana, they identified that majority of their respondents agreed that training nurses in soft skills would facilitate the way they care for their patients. This review was guided by the question: The inclusion criteria for electronic records included were primary sources and peerreviewed reports on soft skills. The review included no date ranges for the literature to capture enough data from the databases. To ensure the integrity of the findings, peerreviewed articles were targeted. This is because these articles already have a level of scrutiny. However, the review also added a search of grey literature and extended consultation with experts to identify relevant sources essential for this review. The process of the integrative review is presented in figure 1.

Data evaluation
Records were evaluated for their authenticity, methodological quality and informational value. Structured data extraction and quality appraisal checklist were utilized on each record for information extraction based on the Critical Appraisal Skills programme Checklist. Initially, records were selected based on their titles and abstracts of the selected titles were analysed to assess their importance to the study question. Only abstracts relevant to soft skills training in nursing were used for a full-text review. Full-text records that did not meet the appraisal process were excluded from the review. Relevant bibliographies from the identified records were also reviewed.

Data analysis
Using thematic analysis, data were extracted and coded into a manageable framework. The data was displayed to convert extracted data from individual sources into a framework that is built around particular subgroups or variables.
This extracted data was compared item by item to identify similarity for categorisation. An iterative process of examining the data displayed to facilitate the difference of patterns, themes and the relationship that existed within them using a comparative method. Conclusions were then drawn from the data. In ensuring the reliability of the review, the articles and the appraisal forms were independently reviewed by three other colleagues. Findings from these colleagues were compared for agreement in a discussion.

Results
After removing duplicates, a total of 754 records were obtained from the electronic databases searched. Title and abstract screening excluded 710 studies. Forty-four (44) studies went through the full article screening. Out of the 44 that were selected for the full articles screening, only 17 were included in this study. Twenty-seven (27) were excluded from the study because those studies did not address soft skills in nursing. Figure 1 shows the PRISMA flowchart showing the literature search and selection of studies.
The settings of these 17 included studies (shown in Table 1) were Portugal (n=3) with two studies each reported in Indonesia, Australia, the United Kingdom and the United States of America. Ghana, Egypt, Cyprus, Singapore, Sri Lanka, and Finland reporting one study each. The studies retrieved spanned from 2012 to 2020.
Five themes emerged from the review, namely; denotation of soft skills in nursing, benefits of soft skills in nursing, need for soft skills in nursing, inculcating soft skills into nursing practice and links between hard and soft skills.  22 reported that formal training for effective communication has historically been largely ignored yet the clinical environment in which healthcare takes place is becoming a progressively more complex 'socio-technical system, and the intrinsic limitations of human performance mean that communication must be a significant facet of healthcare education. This is because caregiving mostly would involve interpersonal interactions including communicating with family members and offering comfort to patients 25 .
Further, some studies reported soft skills in nursing as the art of nursing which is interconnected with knowledge and experience. Nursing is defined as both an art and a science 33 . The science part is clear, as it seems the primary emphasis has always been on the scientific aspects with little consideration given to the art 33 . Soft skills allowed nurses to use subjective data, and past experiences and knowledge that aided them in the recognition of patient's needs and provided multiple data source opportunity for the nurse to care 21 . Large, Aldridge 21 reported that art in nursing helped the nurses to identify when to disregard normal vital signs and took actions using subjective data. Nurses are central to making decisions leading to appropriate interventions following patient assessment, and the art and the experience of the nurse allowed him/her to act beyond medical direction 21 . Sills 33 crowns this section with reports that nursing is not only series of skills and techniques but a process that assimilates elements of the soul, mind and imagination. And soft skills lies in the sensitive spirit and creative imagination, the very foundation of nursing care 33 .
Soft skills are also reported as the ability of a nurse to work in a team successfully.
Successful teamwork was reported as the link between the internal environment of the nurse and the professional world 26 . Effective teams were seen as social entities that use shared knowledge, skills, attitudes, goals, and monitoring of their own and others' performance to achieve high-quality teamwork 22 . Morrell, Eukel, Santurri 24 reported that healthcare teams are often unpredictable, such that a group of competent individual professionals can combine to create an incompetent team. Teamwork in healthcare is further complicated by the fact that some individuals who have probably not previously worked with each other and might not even be familiar with each other have to collaborate. This is for the benefit of the patient in this complex and dynamic clinical environment, working together as a team and being open to other's ideas and thoughts and, using them as resources call for soft skills 24 . The development of soft skills facilitated efficient performance and a high level of harmonious human interactions in the workplace 26 .

Benefits of soft skills in nursing
Several benefits were reported from soft skills. The review findings reported that soft skills are needed for success because these skills are important tools for performing at work and people with strong non-technical skills are mostly those who are successful in their career 18 . It was also noted that it enhances career progression. Laari, Dube 5 reported that 89% of their respondents strongly agreed that the acquisition of soft skills can make a career, while the absence of soft skills can break a career. These authors also reported the students interviewed contend that soft skills were necessary skills which the nursing profession needs.
Soft skills are beneficial at the workplace as they facilitate communication, create enthusiasm, enhances attitude, teamwork, networking, problem-solving and critical thinking, and promote professionalism 24 . Since soft skills and emotional intelligence are not innate abilities and could be developed, employers who achieved a higher level of productivity in organizations were those who ensured the development of soft skills of their employees 26 . Another benefit of soft skills reported was its ability to enhance the development of self-confidence. Students interacting with Virtual Patients (VP) to inculcate soft skills reportedly developed confidence in their abilities to respond and manage practice situations. As one of the students noted, 'I feel more confident in how to handle situations now. I feel a lot more prepared in handling a patient 27 .
Additionally, soft skills improve the performances and confidence of students. Pires, Monteiro, Pereira, Stocker, Chaló, Melo 31 reported a significant improvement in performance, confidence, and self-efficacy of nursing students, and that soft skill was an added value, as it helped students to better adjust to the complex clinical context and ultimately contributed to the safety and well-being of patients 31 . Similarly, improving these skills is becoming a strategic priority within healthcare institutions at the international level 32 .
Need for soft skills in nursing As soft skills are important tools for performing at work and people with strong soft skills are mostly those who are successful in their career 18 , teaching soft skills in the classroom will help enhance the care rendered to clients. Laari, Dube 5 reported that their participants perceived soft skills training as an impetus for nursing staff to give better care to their clients. The study results further indicate that there is a need for nursing students to be educated in soft skills and that this will enhance their job performance in the clinical environment and improve the way they communicate with their clients. Soft skills were seen as a required tool to effectively recognize patient needs 21 . Maria, Rania 23 reported that managers and nurses understand the contribution and need of soft skills in performing nursing work as such both agreed on its significance and its contribution.
Patients and family members rated the soft skills of reliability and responsiveness to be highly important for nursing care. All nine service items such as reliability, promptness in helping, communication, willingness to help, sensitivity to others' feelings, courtesy, confidence in speech, going the extra mile to care and grooming standards were rated highly 25 . Ng reported of a patient commenting that the nurse 'sat by me and held my hands when I felt weakest and in pain" and that among 56 positive comments from patients and families, only two mentioned hard skills. Patients, however, complained in absence of soft skills in nursing with a patient commenting that 'when my mother requested for water, the nurse just ignored my mother'. The study reported that soft skills are very important and could outweigh hard skills and in contrast to the very few comments on hard skills, the comments on soft skills were often descriptive and emotional and it portrayed the human-centred of how nursing care was perceived 25 .
In the same vein, Pathiratne 26 reported that poor soft skills contributed to up to 80% of healthcare errors and the development of soft skills would facilitate performance efficiency and also a high level of harmonious human interactions in the workplace.

Inculcating soft skills into nursing practice
A number of the study findings 5,19,23,29,32 recommended the integration of soft skills into the nursing care process of undergraduate nursing curriculum as it would enhance nursing practice 18 , because formal education that an individual acquires within a certain period was reported that it strengthens the soft skills with continuous exposures 19 . Hariti, Rejeki 19 reported that nurses' soft skills were influenced by the difficulties faced during learning and these skills were improved with an increase in experiences. The years of service also contributed to the development of soft skills of the on-duty nurses 19 . Laari, Dube 5 reported further that the educational curriculum should include soft skills modules, and it should be assessed practically before registration for practice 5 , because soft skills were perceived to be required to effectively recognize and help patients meet their health needs 21 . Therefore, integrating soft skills into the nursing curriculum to enhance the care standards should be prominent and explicit and not situational and incidental. Besides knowledge acquisition and technical competency, the nursing curriculum could explicitly incorporate more soft skills to enhance the care standard 25 . Also, Peltonen, Peltonen, Salanterä, Hoppu, Elomaa, Pappila, Hevonoja, Hurme, Perkonoja, Elomaa 29 reporting on soft and hard skills emphasized that premium should be placed on both soft and hard skills in health professional education and in-service training 29 . Developing a tool to measure nontechnical skills, Pires, Monteiro, Pereira, Stocker, Chaló, Melo 31 reported that soft skill should be incorporated in both undergraduates and postgraduates training curricula as it will ascertain needs and improve care in healthcare contexts 31 . With regards to patient's safety soft skills were seen by undergraduates nursing students as beneficial to patient safety goals, improves clinical performance and hence a consideration on its incorporation into the curriculum ought to be prioritized 32 .
links between hard and soft skills Some authors reported a link between hard and soft skills 18,28,29,31 Elmohmady, Abo Gad, Ramadan, Hamdy 18 reported a significant correlation between observed nurses' all stages of the nursing care process and all domains of soft skills, their results revealed a significant positive relation between nurses' soft skills and all nurses' characteristics data. This relationship had the highest mean score for decision-making skills followed by communication competence skills, and team dynamic skills. While the lowest mean score was for leadership behaviour skills. Peddle, Mckenna, Bearman, Nestel 28 on the other hand reported that some students identified how hard and soft skills complement each other and the important role each plays in professional practice and patient safety 28 . An association between hard and soft skills performance in real-life inhospital ALS situations suggested that the resuscitation teams that showed a good soft skills performance also performed hard skills aspects of ALS better. In contrast, the resuscitation teams with poorer soft skills showed inferior hard skills performance during ALS 29 . Similarly, Pires, Monteiro, Pereira, Stocker, Chaló, Melo 31 , reported a significant and positive relationship, which suggests that the higher their soft skills competency in one dimension, the higher it will also be in the other dimension, and vice-versa 31 .

Discussion
Based on our results soft skills are seemly relegated in nursing science despite its importance to the healthcare consumers. The relegation of soft skills in nursing is an issue most professionals have not paid attention to correct. This has greatly impacted negatively on caring skills, communications skills, the leadership nature and the art of nursing among others in nursing. The current literature has identified a 'paediatric attention' as nursing scholars sacrifice art on the altar for science. This review identified that soft skills are crucial with regards to the roles of nurses as professionals. This is revealed in the denotation of soft skills in nursing. A spectrum of words and phrases used to describe soft skills in nursing denotes its significance. As some authors described soft skills as the caring in nursing and cognitive brain of nursing others saw it as the key to effective communication skills, the hinge to key leadership qualities, skills that are necessary for interpersonal collaboration in the health care environment. Sills 33 , argues that with all these important contributions that soft skills which Florence Nightingale called "the finest of the art", conveys the scientific community over the years have created perceptions that suggest soft skills are of a lesser value at workplace. The suggestion of soft skills being of lesser value appears to be contributing to ineffective communication skills development, which is a subset of soft skills. As such a study reported some nurses experienced some difficulties in communicating subtle changes of the patient to other professional colleagues 21,34  Benefits and need for soft skills in nursing are flawless from the findings. Patients in rating procedures and services that nurses render to them, out of 56 items only two were included that is classified as hard skills 25 . Patients saw it very necessary to report that a nurse sat by her during her pain holding her hand. As it will require no technical or hard skills to hold a patient's hand during pain, it, however, takes a nurse with soft skills to be this empathetic. Empathy according to Peddle, Mckenna, Bearman, Nestel 28 is key in nursing and is developed as a subset of soft skills. As technology generates its influence on individuals and organisations, the gap between humans continues to stretch and it is not enough for a nurse to only have an excellent Intelligent Quotient (IQ) 35 .
The recommendation to add soft skills to either the undergraduate or the postgraduate nursing programmes traversed through many authors 5,18,25,29,31,32,38 . Most of these authors recommended the integration of soft skills in both undergraduates and postgraduates due to its significance in the nursing domain. The primary focus of the nursing curriculum has always been on the scientific aspects of skills and procedures, nursing needs more than technical skills; it carries out interactions with diverse groups of individuals and families and therefore requires training that will start with this interaction in mind 39 . Inculcating these all-important skills into the future nurse might not be a bed of roses as some authors suggest of difficulty in assessing these skills because of it innate nature 26 . Others 30 argue that it is important and that several instruments have been developed to be used in various domains of soft skills to meet the need for assessment.
Peddle, Mckenna, Bearman, Nestel 28 supported Pires et al that it can and should be assessed. They have gone further to suggest with evidence on how soft skills can to taught and assessed stating that virtual patients are the answer since with a virtual patient a mistake can be made and corrected without harm to the client who receives the care.

Conclusion
There are two ways of performing every professional activity and these are hard and soft skills 40 . One may have all the technical expertise needed in a particular discipline, but if one is not able to effectively communicate, get along with others, adapt and manage one's time appropriately, hard skills acquired will take him/her nowhere. Globally, the impact of technology is felt heavily on the healthcare industry. One thing is assured that technology cannot completely replace the nursing touch and the human subtle smile that comes with a soothing fragrance. The world is gone high-tech, and jobs are being confiscated by robots with an unprecedented speed. Software's can diagnose and suggest drugs when one key-in signs and symptoms, this might soon reduce the functions of those who do this. Nursing is at a threshold of losing some functions such as serving bedpans and lifting of patients to robots.
The only role that can never be taken away is the handshake, the hug, the pat on the back and the hello that comes with a smile, indicating I hold you in high esteem in my heart. It is the transformative art and acts; it is the heart of nursing and the desire of the patient and is called soft skills.

Declarations
Author contributions LL conceptualised the study and prepared the draft and OAB and CMB did a critical review. These three authors contributed to the development of the background and planned output of the research as well as the design of the study. LL contributed to the development of the methods relating to the review and synthesis of data including the sifting and data extraction process and prepared the manuscript. OAB and CMB reviewed it. All the authors contributed to the reviewed draft version of the manuscript and approved the final version.

40.
Riggio RE, Tan SJ. Leader interpersonal and influence skills: The soft skills of leadership. Routledge; 2013. Figure 1