It is crucial for head nurses to have excellent interpersonal skills. There is ample evidence showing the importance of interpersonal skills in achieving an organization's goals. One study indicated the vital role of head nurses is providing continuous support and direction for their staff in implementing infection prevention and control programs1. Another study showed that a close rapport between head nurses and their staff could improve their working performance2. In fact, support and motivation from head nurses would encourage better discipline of their staff members in developing their knowledge and abilities3. Accordingly, interpersonal skills encompass the characteristics needed by head nurses at every activity level, including providing guidance, being a role model, and evaluating the work performance of nurses.

The ability of head nurses to understand nurses’ behaviors requires a theoretical approach to nursing. The application of Peplau's theory, which is highly pertinent to interpersonal relationships, could help patients to cooperatively engage in their own nursing care4. In addition, Peplau's theory about interpersonal relation could be applied to change particular behaviors, including improving the cognitive, affective, and psychomotor abilities of the staff or patients4.

Peplau's theory of interpersonal relations could be applied by head nurses to guide, motivate, and supervise their staffs. The application of Peplau's theory would benefit head nurses while providing supervision by playing the roles of a speaker/information resource, teacher, counselor, guardian, stranger, and leader5. These roles could help head nurses improve their interpersonal skills which are aimed at developing favorable behaviors6.

In order to change nursing staff behaviors, it is important for head nurses to cultivate interpersonal skills. Capacity building is one of the keys for assuring that head nurses can gain these skills. Training, as one of the capacity building activities, could help head nurses to ameliorate their knowledge and abilities in leadership and interpersonal relationships in accordance with organizational needs7. Furthermore, training could raise head nurses’ awareness and change their knowledge from the state of not knowing to the state of knowing8.

To date, most forms of training have tended to be tedious and not very interactive. Traditional training methods put the responsibility of learning entirely on the teacher; hence, only a one-way communication is developed9. Also, the training focuses on knowledge enhancement instead of balancing the focus on both improving the knowledge and improving psychomotor abilities10.

Training with active learning methods could effectively improve both the knowledge and psychomotor abilities of head nurses in interpersonal relationships. The use of active learning methods would be helpful for head nurses in integrating reflective and critical thinking based on evidencebased nursing11. Moreover, the mixture of reflective and active learning methods could assist head nurses in finding possible solutions to meet the needs of their staff members and deal with their shortcomings12.

Training with active learning methods is essential to improve the application of Peplau's theory of interpersonal relations. This study had the potential to enhance the head nurses’ interpersonal knowledge and skills by initiating training with active learning methods. The module/materials generated in this study could be the resource for improving the interpersonal skills of head nurses in any health-care facility. Furthermore, the study provided meaningful information about the effects of Peplau's theoretical approach of active learning on the improvement of head nurses’ interpersonal skills.

This study used a quasi-experimental design of a single group pretest and post-test without control group, and it aimed to examine the effects of Peplau's theoretical approach of active learning to strengthen the interpersonal roles of head nurses. The study was conducted at the Bunda General Hospital of Jakarta, Indonesia because the hospital has a clear organizational structure and established standards for the head nurses. The study was conducted from December 2015 to May 2016. The sample population was the head room nurses at one private hospital in Jakarta. There were two sample targets, 25 head nurses and 30 activities of head nurses, and two instruments, a questionnaire to explore respondents’ knowledge related to interpersonal relationship and an observation sheet. A total sample of 25 head nurses was admitted to the study using the following inclusion criteria: head nurses who agreed to participate in the program and who also agreed to implement the interpersonal roles.

The data were obtained using the accidental sampling technique on 30 observations, both before and after the strengthening program. The variables were the knowledge and skills of head nurses in implementing Peplau's interpersonal roles, including the variables of such roles as leader, stranger, guardian, counselor, speaker, and teacher.

The strengthening program using active learning in this study was carried out in three phases: orientation, identification, and implementation and strengthening (resolution). The orientation phase was done through the needs assessment and the signing of the informed consent. During this initial stage, the researchers would also develop a module for trainings. The second phase was done using a cognitive pretest of 16 multiple-choice questions. Training programs conducted by the researchers using active learning of case-based learning, Gibbs self-reflection, and self-directed learning were used. A module of interpersonal skills was distributed to participants prior to the training. Lastly, the strengthening (resolution) phase consisted of assessing the competence of the head nurses using the observation sheet and arranging the follow-up plans.

The framework of the study is illustrated in Figure 1.

Figure 1.

Framework of the study.

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The data were collected by the researchers before and after the strengthening program. An observation sheet tested for its content validity by nursing experts was the instrument used. A univariate analysis was performed for the characteristics of the head nurses with a central tendency method. Meanwhile, the knowledge and skills of the nurses were examined using statistical analysis by means of a paired t-test. Prior to its onset, this study was approved by the committee of ethics of the Faculty of Nursing, Universitas Indonesia.

The results of the study presented the interrelationships of head nurses’ knowledge and skills in interpersonal roles before and after participating in the strengthening programs using Peplau's theoretical approach of active learning.

The mean value of head nurses’ knowledge after the strengthening programs was 7.45 higher than that prior to the training. The analysis, furthermore, showed that the increase was significant (P=.003) (Table 1).

Nevertheless, increases of mean values were found in all interpersonal skills after the strengthening program (third observation), and, despite that results, the scores were apt to remain stable or decline in the last observation. The mean score of skills in playing the role of leader was 43 before the strengthening program (first observation), increased to 60 after the program (third observation), and increased again to 85 in the last observation. Meanwhile, the mean score of skills in playing the role of stranger was 68 before the program, increased to 81 after the implementation, and dropped to 75 in the last observation (Figure 2).

Figure 2.

Mean values of head nurses’ skills in the interpersonal relationships (n=30).

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Surprisingly, the findings demonstrated significant increases in the mean values of the head nurses’ skills in playing the role of leader (P=.006), guardian (P=.014), and teacher/speaker (P=.015). However, there were no significant increases in the mean values of the head nurses’ skills in playing the roles of counselor (P=0.092) and stranger (P=.182) (Figure 3).

Figure 3.

The ability of interpersonal role the head space with the Peplau theoretical approach.

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On average, the knowledge of the head nurses increased after the strengthening programs of the interpersonal roles using Peplau's theoretical approach. The increased knowledge of the head nurses is a process of active learning using self-directed learning, Gibbs self-reflection, and case-based learning techniques.

Active learning would facilitate the processes of knowledge discovery, problem-solving, and analysis, as well as providing a demonstration of learning experiences13. In health-care facilities, active learning activities to promote manpower development might include participation, repetition, transfer, feedback, reflection, and case studies14. Small group discussions assisted by facilitators to address specific issues and identify possible solutions are often used. In active learning, discussions would provide opportunities to learn new behaviors, while the delivery of the material would help learners understand the particular roles to be performed15.

The strengthening programs in the study employed Gibbs self-reflection and self-directed learning methods. These methods were performed by the head nurses sharing their experiences in implementing the standard operating procedures (SOPs) of the personal protective equipment (PPE) in their units. The steps helpful describing the events and feelings, evaluating, analyzing, concluding, and planning future actions. These learning methods would be helpful for the head nurses to better understand the challenges found in the workplace and improve self-control16. Moreover, one study stated that the Gibbs learning cycle is a systematically structured process involving emotions and thoughts17 that provides insights useful to build the intended behaviors.

The findings of this study demonstrated that the active teaching and learning process using Gibbs self-reflection, case-based learning, and self-directed learning significantly increased the mean scores of head nurses’ knowledge and skills in the interpersonal roles. The results were consistent with those reported in other studies. As an evaluation method, the Gibbs reflective learning approach effectively increased the knowledge of the head nurses. Likewise, a study in Jordan showed that the integration of practice and evaluation helped the respondents in acquiring new knowledge18.

In addition to resulting in knowledge improvement, the strengthening programs using active learning methods improved the head nurses’ skills in playing the roles of leader, guardian, and teacher. This result was consistent with one study which proved that self-directed learning during the first clinical practice of Saudi nursing and medical students in hospitals significantly improved their patient safety competences, discussing the problems faced while doing demonstrations, and drawing the possible solutions for future challenges. In the same study, the self-directed learning included reviewing journals, demonstrating clinical skills with peers19. Another study in China showed that self-direct-ed learning helped new nurses learn independently while aiming at developing their abilities in analyzing issues found in hospitals20.

To better understand the interpersonal competences, the strengthening program highlighted the importance of interactions, eye contact, and information exchange between head nurses and their coworkers/subordinates during work and between the head nurses and the training instructors during the training. These activities could promote selfconfidence and improve communication skills. In addition, the activities could enhance the personal and professional growth of the head nurses21.