META-ANALYSES

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Journal of Professional Nursing

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Empathic and listening styles of first year undergraduate nursing students: A cross-sectional study Lisa McKennaa,⁎, Ted Brownb, Brett Williamsc, Rosalind Laud

a School of Nursing and Midwifery, La Trobe University Bundoora, Victoria 3086, Australia b Department of Occupational Therapy, Monash University, Peninsula Campus, McMahons Road, Frankston, Victoria, Australia. c Department of Paramedicine, Monash University, Peninsula Campus, McMahons Road, Frankston, Victoria, Australia d School of Nursing and Midwifery, Faculty of Health, Deakin University, Burwood, Victoria 3125, Australia

A R T I C L E I N F O

Keywords: Care Communication Listening Empathy Education Nursing student

A B S T R A C T

Background: Effective communication and empathy are fundamental to nurse-patient relationships and good nursing practice. Although the importance of listening is widely accepted in the nursing practice, little research exists regarding the empathic and listening styles of undergraduate nursing students. Purpose: This study investigated empathic and listening styles of first year nursing students. Method: A cross- sectional study of 135 first year Bachelor of Nursing (BN) students from one Australian university completed paper-based versions of the revised Listening Styles Profile (LSP) and Active-Empathic Listening Scale (AELS). Results: Participants reported strong preference for ‘people’ listening style and ‘responding’ empathic listening process. No statistically significant differences were found between male and female students. People-oriented LSP was strongly correlated with the three stages of AELS, Content-oriented LSP was strongly correlated with Processing and with Responding AELS and Action-oriented LSP was strongly correlated with Processing AELS. Conclusion: It is not only important that communication skills training exists in the nursing curriculum but ensuring that knowledge learnt in the classroom is transferred to the clinical setting. Nurses must consistently implement active listening techniques and effective communication skills with all patients.

Introduction

Communication is an integral component of the nurse-patient re- lationship and central to provision of high-quality nursing care and incorporated across international standards for Registered Nurse edu- cation. In the United Kingdom, the Nursing and Midwifery Council (NMC) (2018) Standards for Pre-Registration Nursing Programmes re- quire courses to prepare Registered Nurses with competence in pro- fessional communication and ability to advise, instruct and support people requiring care. In Australia, courses leading to nursing regis- tration must facilitate development of students' effective communica- tion and ability to establish therapeutic relationships (Nursing and Midwifery Board of Australia, 2016). Essential IX in the American Association of Colleges of Nursing (2008) ‘The Essentials of Bacca- laureate Education for Professional Nursing Practice’ recognizes the role of baccalaureate programs in preparing graduates to communicate effectively and compassionately (p.31). Effective communication be- tween healthcare professionals and patients has been linked to quality

care (Seccareccia et al., 2014; Van Ess Coeling and Cukr, 2000), patient satisfaction (Beach, 2010; Wanzer et al., 2004), adherence to prescribed treatments (Harmon et al., 2006; Zolnierek and DiMatteo, 2009), and overall better health outcomes (Beach, 2010; Wittink et al., 2016).

Background

An important aspect of communication is effective listening. According to Kagan (2008), a common complaint from patients is not feeling listened to. Effective communication includes active listening which has been defined as “a way of listening and responding to an- other person, which improves mutual understanding” (Mineyama et al., 2007). Effective listening, as a quality of effective communication has been promoted by the nursing profession as a way of demonstrating care to patients and their families (Kourkouta and Papathanasiou, 2014). For listening to be therapeutic for the patients, nurses must be non-judgmental, respectful and able to show empathy and compassion (McKenna et al., 2020; Shipley, 2010). Kagan (2008) explored the

https://doi.org/10.1016/j.profnurs.2020.08.013 Received 30 May 2020; Received in revised form 18 August 2020; Accepted 20 August 2020

⁎ Corresponding author. E-mail addresses: [email protected] (L. McKenna), [email protected] (T. Brown), [email protected] (B. Williams),

[email protected] (R. Lau).

Journal of Professional Nursing 36 (2020) 611–615

Available online 21 August 2020 8755-7223/ Crown Copyright © 2020 Published by Elsevier Inc. All rights reserved.

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concept of being listened to in ten adults in the United States and found that feeling listened to, was significant to health and quality of life, resulting in feelings of being acknowledged, respected and empowered. Koskinen and Lindström (2014) argue that by listening to patients, nurses can affirm patients' suffering and give them strength to cope. Hence, listening is an important part of nursing practice as it is in- trinsically linked to quality of life. For the purposes of this study, we view active, effective listening as engaged and empathic, and ac- knowledging and responding to the individual.

It has been recognized that people have different styles of listening. Watson et al. (1995) proposed the construct of listening style as a set of characteristic or habitual approaches to listening and identified four distinct listening orientations: people, action, content and time. People- oriented listeners are concerned about others' feelings. Action-oriented listeners prefer presentations that are precise and free of errors and are inpatient when listening to a disorganised presentation. Content-or- iented listeners are concerned with facts and details. Time-oriented listeners are conscious of time and prefer interactions with others to be brief (Watson et al., 1995). This construct underpinned one of the measures employed in this current study.

Communication involves not only the transmission of information, but also the transmission of feelings (Akor and Udensi, 2013). McKinnon (2018) employed grounded theory in a UK study with nurses, concluding that empathy was ‘a tool with which to ascertain the cog- nitive and emotional perspective of others’ (p.3882). Another concept described in relation to listening is that of Active-Empathic Listening (AEL) (Bodie et al., 2013) combining the interrelated concepts of em- pathy and communication. AEL involves the active and emotional in- volvement of a listener that can take place during an interaction and consists of three stages: Sensing, Processing and Responding (Bodie, 2011). The Sensing stage involves hearing the actual words of the speaker. The Processing stage refers to acts such as understanding, in- terpreting, evaluating and remembering conversational content. The Responding stage is characterized by asking questions or paraphrasing, as well as using nonverbal signals such as head nods or facial expres- sions to indicate active attention. Empathy is a necessary prerequisite for optimal nursing practice and leads to positive patient outcomes (Hojat, 2007).

Nurses need to be able to listen communicate effectively and em- pathetically with patients, their peers and other healthcare profes- sionals. Although limited, recent research has sought to examine nur- sing students' empathy, communication skills and associated factors. In a US study by Haley et al. (2017) of 53 nursing students, active listening and self-awareness were found to be associated with empathy, while empathy was significantly associated with patient-centered care. Ear- lier, McKenna et al. (2012) found that overall undergraduate nursing students displayed acceptable levels of empathy, but their attitudes varied across different patient groups.

Nursing students' listening and communication styles have also been explored in other studies. An Australian study found that nursing stu- dents at one university displayed strong preference for ‘People’ listening style and ‘Friendly’ communicator style (McKenna et al., 2014) That study found no differences between students in different year levels or by gender. Other researchers have sought to evaluate the effect of music education activities on developing students' listening skills, specifically to enhance auscultation skills (Collins et al., 2014; Pellico et al., 2012). Hence, limited research exists on the empathic and listening styles of undergraduate nursing students. Consequently, this study aimed to in- vestigate empathic and listening styles of first year Bachelor of Nursing students. Secondly, we sought to explore whether gender played a role.

Methods

Design

A cross-sectional survey design was used to answer the research

questions:

1. What are first-year undergraduate nursing students' empathic and listening styles?

2. Is there a gender difference in students' empathic and listening styles?

Participants

All first-year students enrolled in the Bachelor of Nursing program at one university in Melbourne, Australia were invited to participate in the study. This group was selected on entry to the program as we wanted to explore what characteristics students entered with. They were commencing a communication skills course and findings were being used to inform subsequent teaching of that course. Prior to data collection commencing, ethical approval was obtained from the uni- versity ethics committee.

Instruments

Approval was obtained from the authors to employ the instruments prior to conducting the study.

Listening style profile (24 item LSP-R) The 24-item LSP-R is an instrument designed to assess four styles of

listening: People, Content, Action and Time and are rated on a seven- point rating scale (1 = strongly disagree to 7 = strongly agree). The higher the score, the higher the participant's preference for that parti- cular style. It is a revised version of LSP-16 which had low reliability estimates. Reported Cronbach's alpha for each of the four constructs were: People (α = 0.63), Action (α = 0.59), Content (α = 0.72) and Time (α = 0.67) (Bodie and Villaume, 2003). The 24-item LSP-R de- monstrated better internal consistency than the LSP-16 (Gearhart et al., 2014). That instrument reportedly possesses high internal consistency as measured by Cronbach's alpha for each of the four constructs: People (α = 0.88), Action (α = 0.93), Content (α = 0.88) and Time (α = 0.91) (Gearhart et al., 2014).

Active-empathic listening scale (AELS) The AELS is an instrument designed to assess three stages of em-

pathic listening process: Sensing, Processing and Responding. It consists of 11 items rated on a seven-point Likert scale (1 = Never true to 7 = Always true). The higher the score, the higher the participant's preference is for that process. The instrument has been reported to possess sufficient internal consistency on Cronbach's alpha for each of the three stages: Sensing (α = 0.73), Processing (α = 0.66), Responding (α = 0.78) and Total (α = 0.86) (Bodie, 2011). Test-retest was found to be modest (rsending = 0.77, rprocessing = 0.73, rre- sponding = 0.79, rtotal = 0.70) (18).

Procedure

At the end of a scheduled lecture, students were invited to partici- pate by a research member not directly involved in the students' teaching. Students were provided with an explanatory statement in- forming them of the study and what it was seeking to achieve and were informed that their participation was voluntary and that their anon- ymity would be maintained. Furthermore, they would not be identifi- able in reporting of the findings as data would be collated and reported group wide. In they agreed to participate, students were then given a set of questionnaires containing the Listening Style Profile - Revised (24- item LSP-R) and Active-Empathic Listening Scale (AELS), along with a short list of demographic questions. Participants' consent was con- sidered to be implied by completion and submission of the ques- tionnaires. Completed surveys were returned to a member of the re- search team not directly engaged in their academic program.

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Data analysis

Statistical analyses for all instruments were performed using SPSS version 21.0 (SPSS Inc., Chicago, IL, USA). Descriptive analyses were performed on the demographic profiles, 24 items LSP-R and AELS. Mann-Whitney test was employed to examine differences in listening style preferences between genders. Results were considered statistically significant where the p value was < 0.05.

Results

Demographics

A total of 135 (out of a possible 160) first year nursing students enrolled in the particular course participated in the study, representing a response rate of 84.4%. This student cohort was chosen as they were new to the course, had no previous clinical placements and were be- ginning a professional communication skills course, alongside a clinical skills course, and we sought to establish an entry-level baseline on which to base teaching and learning. These participants were pre- dominately full-time students, females (77.0%) and 19 years of age or under (57.8%). Full details of participant demographics are presented in Table 1.

Listening style profile

For the LSP-24, students showed the most preference for the People listening style and the least preference for Action listening style. Full details of the LSP-24 are presented in Table 2. Students scored highest on the individual item “When listening to others, it is important to understand the feelings of the speaker” (M 6.27, SD 0.706) and the lowest on the item “I get frustrated when people get off topic during a conversation” (M 4.20, SD 1.59). No statistically significant differences were found between females and males across all listening style types: People (p = 0.94), Content (p = 0.85), Time (p = 0.09) and Action (p = 0.15).

Empathic listening process

For the AELS, participants showed most preference for the Responding empathic listening process and least preference for Processing. Full details of the AELS are presented in Table 3. Students scored highest on the individual item “I show others that I am listening by my body language (e.g. nodding head)” (M 6.04, SD 0.97) and lowest on the individual item “I am sensitive to what others are not saying” (M 4.84, SD 1.23). No statistically significant differences were identified between females and males across the three stages of the

empathic listening process: Sensing (p = 0.82), Processing (p = 0.90) and Responding (p = 0.34).

Correlation between LSP and AELS

People-oriented LSP was strongly correlated with the three stages of AELS; Sensing (p = 0.002), Processing (p = 0.001) and Responding (p ≤0.001). Content-oriented LSP was strongly correlated with Processing (p ≤0.001) and with Responding (p = 0.019). Action-or- iented LSP was strongly correlated with Processing (p ≤0.001). Full details of the correlations between LSP and AELS are presented in Table 4.

Discussion

This study provides insight into understanding ways by which un- dergraduate nursing students approach empathic listening and com- munication. Effective communication, underpinned by empathy and sound listening, between nurses and patients is essential for the delivery of quality nursing care and ensuring patient dignity (Koskinen and Lindström, 2014). Results obtained from the 24-item LSP-R showed that nursing students in our study preferred the People listening style, which is described as being characterized by concern for the person to whom one is listening (Bodie and Villaume, 2003). This is an important ele- ment for nurses because nursing involves constant interaction with people. People-oriented LSP was strongly correlated with the three stages of active empathic listening indicating that nursing students scoring high on People-oriented LSP tended towards displaying a dis- position to be empathetic when interacting with the patients, which is important in nursing. Hence, this is a reassuring finding. Empathy, as a vital component of communication in health care, has been supported

Table 1 Students' demographic profile

Demographic Number Percentage

Enrolment status Full time 130 96.3 Part time 3 2.2 Others 2 1.5

Gender Female 104 77.0 Male 31 23.0

Age (year) 19 or under 78 57.8 20–24 45 33.3 25–29 6 4.4 30–34 3 2.2 35–39 2 1.5 40 and above 1 0.7

Table 2 Listening style preferences (24-item Listening Style Profile-R) (n = 135)

Listening style Mean SD Median Range IQR25a IQR75b

People (relational) 34.95 4.21 35.00 23.00 32.00 38.00 Content (analytical) 33.28 6.14 34.00 35.00 30.00 37.00 Time (task) 28.00 7.27 28.00 33.00 22.00 34.00 Action (critical) 27.16 6.96 27.00 35.00 24.00 31.00

a Interquartile range 25%. b Interquartile range 75%.

Table 3 Listening style preferences (Active-Empathic Listening Scale) (n = 135)

Listening process Mean SD Median Range IQR25a IQR75b

Sensing 21.15 3.08 21.00 22.00 19.00 23.00 Processing 17.24 2.39 17.00 10.00 16.00 19.00 Responding 23.04 2.89 24.00 13.00 21.00 25.00

a Interquartile range 25%. b Interquartile range 75%.

Table 4 Correlations between Listening Style Profile (LSP-R) and Active Empathic Listening Scale (AELS)

People Content Time Action

Sensing 0.265⁎⁎ 0.121 −0.019 0.153 p = 0.002 p = 0.161 p = 0.824 p = 0.077

Processing 0.284⁎⁎ 0.318⁎⁎ −0.003 0.309⁎⁎

p = 0.001 p ≤0.001 p = 0.975 p ≤0.001 Responding 0.341⁎⁎ 0.202⁎ 0.004 0.148

p ≤0.001 p = 0.019 p = 0.966 p = 0.087

⁎⁎ p < 0.01. ⁎ P < 0.05.

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by several studies (Hojat et al., 2011; Neumanna et al., 2007). The nursing students showed moderate preference for ‘content’ lis-

tening style, focusing on what is said. This is an important aspect of nursing because in order for nurses to provide quality nursing care, they need to have detail information from the patients. There was a strong correlation between content-oriented LSP with empathic processing and responsiveness indicating that nurses scoring high on content-or- iented LSP are more likely to express an understanding of the patient's situation, asking questions and head nodding indicating active atten- tion. There is good evidence that health care professionals can enable patients' towards complete recovery from trauma through verbal and non-verbal communication (Benbenishty and Hannink, 2015).

The results of the current study support previous findings from a previous Australian study of first year (n = 81), second year (n = 29) and third year (n = 91) undergraduate Bachelor of Nursing students (McKenna et al., 2014). In that study, the authors sought to determine students' preferred listening styles possessed by nursing students and whether those styles altered as their course progressed. They found students preferred the People listening style and no differences were identified between participants in different year levels of the under- graduate nursing course.

In the current study, no statistically differences were found between male and female students with regard to their listening styles pre- ferences. Hence, the findings did not support those from the study by Johnston et al. (2012) investigating the role of gender on listening styles. Those researchers examined the four listening styles as a func- tion of a person's gender across 1722 students in an introductory communication course and found that female participants tended to have a People-oriented listening style and male participants had an Action, Content, or Time-oriented listening style. In that study, the authors suggested that the differences in males and females listening styles were due to gender role self-perception. Females tended to per- ceived themselves as caring, helpful, affectional and having a desire to be with others. In contrast, males tended to perceived themselves as assertive, mastery and having a desire to control (Johnston et al., 2012).

Empathy is a vitally important component of the nurse-patient re- lationship and when verbalized by a nurse to a patient can offer support and comfort at times of anxiety and distress (Bramhall, 2014; Koskinen and Lindström, 2014). The highest individual item score for the stu- dents on LSP has indicated that it is important to understand the emotions of the person one is communicating with. In the current study, AELS results showed that the most important stage of empathic lis- tening process for the nursing students was Responding, involving questioning and clarifications to indicate that the person was being listened to. It is important to patients that the nurses are attentive to what they are saying verbally and non-verbally. The highest individual item score for the students on AELS has indicated that nonverbal communication is important because it can give additional information over and above verbal communication. According to Bodie (2011), it is important to speakers that listeners are attentive to them because it connotes an appreciation or interest in them. Hence, engagement in communication will enhance positive speaker/listener interaction.

McCabe (2003) carried out a qualitative study exploring patients' experiences of how nurses communicated, with one of the emerging themes being that of empathy. McCabe reported that it appeared im- portant to the patients that nurses communicated their understanding of their situation and alleviated their anxiety when they knew that someone understood how they were feeling. No statistically significant differences were found between male and female participants in their stages of empathic listening process in our study. This did not support the findings of Pence and James (2015) who found American female undergraduate students enrolled in communication courses showed significantly higher Responding ability than male students. In that study, the authors suggested that the differences may have been related to differences in personality.

Based upon the benefits of active listening and effective commu- nication skill sets for patients, nurses must consistently implement ac- tive listening techniques and effective communication skills among for all patients for who they deliver care. Many nurses reportedly have recognized gaps in their communication skills and have inadequate preparation for this aspect of their work during their preparatory education (Fallowfield et al., 2001; Wilkinson et al., 2002). A qualita- tive study found that nurses commonly did not provide sufficient in- formation for patients, and many patients commented that nurses were more concerned about getting their required work completed than with interacting with them (McCabe, 2003). Hence, it is not only essential to integrate communication skills into the undergraduate nursing curri- culum but also to ensure that these skills are being transferred into the workplace. The findings of this study suggest that active listening with empathy is not necessarily inherent in new students and that this needs to be specifically focused on in communication skills education. They will serve to inform the development of educational strategies to en- hance student development in these important areas.

Limitations and future research

There were limitations to the study. The response rate could not be established because attendance was not recorded at the end of the lecture. In addition, self-report measures were used so, caution is re- commended in interpreting the findings as there are commonly differ- ences between how people perceive themselves and how they actually behave. This study was conducted at one university. Therefore, caution is recommended in generalizing these results to other nursing students at other institutions as differences in curriculum may potentially have a profound impact on the students' listening or communication styles. Larger studies across multiple universities are needed. Furthermore, only first year students were included in the current study, and more research is needed to examine whether empathic listening alters as one progresses through the nursing course. However, the findings are useful in that they have provided preliminary insights into the ways in which undergraduate nursing students approach listening and communica- tion. It is recommended that this study be replicated with a bigger sample of students from several universities. It is also suggested that research be conducted to examine the listening styles and empathetic behaviors of nursing students from the beginning of their courses to the end, and potentially beyond into registered nurse practice.

Implications for education

These findings suggest there is a need for educators to understand that students enter nursing courses with different listening and empathy styles and seek to assist students to develop effective communication skills. Hence, there is a need to develop and implement specific edu- cational strategies. There is also a need for more research into optimal teaching and learning approaches for facilitating development of these skills.

Conclusion

Active listening and communication skills are fundamental elements in providing quality nursing care, an important element in a nurse and patient relationships, as well as enhancing patient dignity. This study has provided an initial exploration into the existence of these skills with first year undergraduate nursing students. It is not only essential to integrate listening and communication skills into the existing nursing curriculum but also to ensure that the skills are transferred into the workplace by registered nurses. Nurses must consistently implement active listening techniques and effective communication skills across all of their interactions with patients and their families. More work is needed to continue to build our understandings of these constructs, and development of strategies to enable these to be improved for the

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benefits of those whom nurses care.

CRediT authorship contribution statement

All authors meet the authorship criteria and all authors are in agreement with the content of the manuscript. All authors have ap- proved the final manuscript.

Conception and design of the study, data acquisition, analysis and interpretation: LM, TB, BW, RL.

Drafting and/or revising the manuscript for intellectual content: LM, TB, BW, RL.

Final approval of the final version: LM, TB, BW, RL.

Declaration of competing interest

The authors have no conflict of interest to disclose.

Acknowledgments

The authors thank the students who participated in the study.

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