The Relationship Between Clinical Communication Skills of Pediatric Nurses and Children’s Trust in Nurses: The Mediating Role of Emotional Intelligence

Introduction

Trust is a relational phenomenon and a dynamic process.¹ In healthcare institutions, trust is described as an emotional bond that connects leaders and employees, enhancing teamwork, communication, and productivity.² Trust is the cornerstone of all therapeutic relationships,³ the foundation of effective operation in the healthcare system, and an intangible asset for improving patient prognosis and satisfaction.⁴

In theory, nurse-patient trust is defined as the confidence in nursing being appropriate, reliable, and as successful as possible.⁵ In clinical practice, both nurses and patients are participants and beneficiaries of nurse-patient trust. Establishing a strong trust relationship can help nurses collaborate closely with patients, enabling comprehensive care, promoting continuous care and treatment, and increasing patient compliance with treatment, further facilitating patient recovery. For patients, a good nurse-patient trust relationship helps them open up, share their thoughts and feelings, and feel more comfortable with nurses.⁶ Additionally, it enhances the patient’s sense of security and reduces stress caused by uncertainty.⁷ Trust crises between nurses and patients not only tend to create a vicious cycle of tension in the nurse-patient relationship but can also lead to adverse medical outcomes and potentially alter fundamental ethical and existential values in society.⁸

In pediatric inpatient units, trust between nurses and children builds a positive care atmosphere and supports a healthy work environment.⁹ This trust enhances confidence in safe, high-quality care and promotes children’s physical and emotional recovery.¹⁰ Trust in nurses is an essential need for children during hospitalization, as it plays a critical role in counteracting the vulnerability of children.¹¹ Pediatric patients’ mistrust of the hospital environment and nurses can lead to behaviors such as crying, restlessness, resistance to treatment, poor compliance, withdrawal from interpersonal relationships, observation and questioning, as well as aggression and anger during the treatment process.¹² Despite its importance, trust relationships between pediatric nurses and patients are rarely given attention, especially in pediatric clinical nursing practices, where trust in pediatric patients towards nurses is often overlooked.⁶

Research has shown that emotions play a crucial role in the relationships and communication between nurses, patients, and their families.¹³ There is a growing body of evidence indicating that emotional intelligence is an essential interpersonal skill for establishing confident and empathetic communication. Pediatric nursing is an occupation characterized by its demanding nature, involving high risks, the need for advanced technological skills, and considerable pressure. Some studies have shown that nurses working in pediatric hospitals exhibit more severe emotional reactions compared to nurses in general hospitals.¹⁴ Emotional intelligence can be defined as the ability to understand, recognize, and manage one’s own and others’ emotions, and it is the ability to handle emotional issues related to oneself and others in the workplace.¹⁵

High emotional intelligence not only promotes the development of cognitive activities but also empowers individuals to regulate their emotions, enabling them to deal with diverse forms of pressure. Consequently, it contributes to heightened levels of personal well-being, job satisfaction, and job performance. In the realm of nursing, especially pediatric nursing, emotional intelligence emerges as a significant factor that substantially influences the overall quality of nursing work.¹⁶ Importantly, emotional intelligence can directly predict clinical communication skills,¹⁷ with nurses’ communication skills improving as their emotional intelligence increases.¹⁸ Communication is considered a core principle of nursing practice.¹⁹ Research has demonstrated that approximately 70% of workplace violence incidents in pediatric hospital settings are caused by ineffective communication between healthcare professionals and patients.²⁰ Nurses with high emotional intelligence generally demonstrate superior clinical communication skills. This enables them to more accurately recognize non-verbal cues from children and emotional signals from family members, adjust their communication strategies accordingly, and thereby improve treatment adherence and patient satisfaction.⁹ Emotion serves as one of the three fundamental pillars of trust.¹¹ Trust toward strangers has been found to intensify with positive emotional states. Emotional intelligence, constituting the cognitive foundation for comprehending and regulating emotions, enables individuals with heightened emotional competence to better understand and manage both self-referential and interpersonal affective experiences. This enhanced emotional capability significantly facilitates trust establishment and relationship maintenance.^9,21 Notably, empirical evidence confirms that emotional intelligence positively predicts interpersonal trust.²² It is evident that both communication skills and emotional intelligence are predictive factors influencing trust relationships. However, there is limited research on the interplay between communication skills, emotional intelligence, and trust relationships, especially in the context of pediatric nurses and children. Therefore, investigating the relationship between emotional intelligence, clinical communication skills, and children’s trust in nurses is crucial.

This study aims to explore the relationship between the clinical communication skills of pediatric nurses and children’s trust in nurses, ultimately discovering effective ways to maintain a high-quality nurse-patient trust relationship.

Methods

Participants and Procedure

A correlational, cross-sectional, non-experimental study was conducted in a tertiary pediatric hospital in Nanjing, China. The study population consisted of two purposive samples from two research groups.

Group 1 included 390 pediatric inpatients in regular wards (Inclusion criteria: children aged 8–14 years; children without neurological or psychological abnormalities; children hospitalized for at least 5 days; consent from both the child and their parents/guardians to participate in the study; exclusion criteria: children and parents/guardians with cognitive impairments, illiteracy, or communication difficulties; critically ill children unable to complete the assessment scales).

According to a 1:1 matching principle, group 2 consisted of nurses caring for the same child for ≥3 days during the same period (inclusion criteria: registered nurses with a minimum of 1 year of work experience; actively working on the clinical frontline; no history of psychiatric illnesses or major diseases; voluntary participation in this study; exclusion criteria: rehired nurses, nurses engaged in further education, or nursing interns who were on leave for more than 3 months in the year prior to this study).

According to Kendall’s rough estimate method for sample size, considering 10–15% inefficiency, a minimum of 348 subjects were required, which is 5–10 times the number of items. The sample size needed for the structural equation model was at least 200, and for each additional variable, the sample size increased by a factor of 5–10 for the independent variable. This study had 3 variables, requiring an increase of 15–30 in the sample size, totaling at least 215. Therefore, this study required a minimum sample size of 348, and ultimately, 390 questionnaires were distributed.

Data were collected from October 2023 to March 2024. Electronic questionnaires were administered face-to-face to eligible participants, with a standardized protocol. Before filling out the questionnaire, the researcher provided clear information about the purpose of the study, how to fill out the questionnaire, confidentiality assurances, and the option to refuse or withdraw from the study at any time. All participants voluntarily signed an informed consent form.

A total of 390 pediatric questionnaires were distributed, all of which were returned. Five questionnaires were excluded due to incomplete data, obvious patterns in responses, or logical errors, resulting in 385 valid questionnaires, with an effective rate of 98.71%. Three nurses refused to participate in the study; therefore, following the initial sampling plan, additional samples were included to reach 385 valid questionnaires, resulting in a questionnaire effectiveness of 100%.

This study was approved by the Ethics Committee of the Affiliated Children’s Hospital of Nanjing Medical University (Ethics No.: 2022101979–1). All participants were informed and voluntarily signed an informed consent form. The data were analyzed anonymously.

Measures

The data collection used two versions of the self-management questionnaires. One version was administered to the children. The questionnaire was administered and collected through a network platform. Approval and cooperation were secured from the head of nursing at the surveyed hospital before distributing the questionnaire. Subsequently, the questionnaire link was sent to the clinical nurses in each department with their assistance. Additionally, compliance with the survey was encouraged through the distribution of mementos and health consultations to the children and their parents/caregivers. The second version of the questionnaire was given to the nurses. After obtaining approval from the hospital’s nursing department and consent from the study participants, the electronic questionnaires were administered face-to-face. The children’s survey comprised general information and a scale measuring the children’s trust in nurses. The nurse’s questionnaire included general information, a scale assessing clinical nurse communication skills, and a scale measuring emotional intelligence.

Sociodemographic Data

Designed by the research team through a review of the literature, the sociological data covered various aspects. For children, it encompassed age, gender, home address, method of medical expense payment, average monthly family income, general health status, number of hospital visits in the past year, and whether they were an only child, along with family income level, general health status, and number of hospital visits in the past year. For nurses, this included gender, age, years of experience, professional title, education level, marital status, reproductive status, and department.

Clinical Nurse Communication Skills Scale

Developed by Zeng Kai in 2010,²³ this scale is used to measure the clinical communication skills of nurses. It comprises six dimensions and 58 items, covering team communication, emotional perception, emotional support, basic verbal communication, basic non-verbal communication, and communication in difficult situations. It employs a Likert 5-point scoring system, where 1 to 5, respectively, indicate “very poor” to “excellent”. A higher score indicates stronger clinical communication skills. The scale demonstrates good reliability and validity, with a total Cronbach’s α coefficient of 0.978 and individual dimensions ranging from 0.973 to 0.954.

Emotional Intelligence Scale (WLEIS)

Developed by Wong Yuen-sau and Law Shing-Kwong in 2002 at Chinese University of Hong Kong,²⁴ this scale assesses emotional intelligence. It includes four dimensions and 16 items, covering self-emotion appraisal, appraisal of others’ emotions, use of emotions in oneself, and emotional self-regulation. It uses a Likert 5-point scoring system, where 1 to 5, respectively, indicate “completely inconsistent” to “completely consistent”. A higher score indicates higher emotional intelligence. The scale demonstrates good reliability and validity in the nurse population, with a total Cronbach’s α coefficient of 0.833 and individual dimensions ranging from 0.788 to 0.886.

Child Trust in Nurse Scale (CTGNS)

The Chinese version of this scale, revised and translated by the researchers, measures children’s trust in nurses.²⁵ It includes three dimensions and a total of eight items, covering reliability, honesty, and emotion. It employs a Likert 5-point scoring system, where 1 to 5, respectively, indicate “highly unlikely” to “highly likely”. A higher score indicates higher trust in the nurses. The scale demonstrates good reliability and validity, with a total Cronbach’s α coefficient of 0.822 and individual dimensions ranging from 0.752 to 0.852.

Quality Control

The electronic questionnaire system was designed to allow each ID to submit only one response. Submission was only allowed after completing all questions. During the phase of data compilation, two individuals conducted checks, verification, and data entry. Additionally, a third researcher reviewed and corrected 10% of the questionnaires as a quality control measure.

Data Analysis

Data analysis was conducted using SPSS 26.0 and AMOS 23.0 software. Quantitative data were analyzed using means and standard deviations to describe the study participants’ demographic characteristics, clinical communication skills, emotional intelligence, and children’s trust in nurses scores. Correlation analysis was employed to describe the relationships between clinical communication skills, emotional intelligence, and children’s trust in nurses. The AMOS 23.0 software was used to explore the mediating pathways between clinical communication skills, emotional intelligence, and children’s trust in nurses. Bootstrap method was used to calculate the 95% CI by repeated sampling 5,000 times. If none of the results contained 0, the mediation effect was significant. The significance level was set at α=0.05, with statistical significance considered when P<0.05.

Results

Sample Characteristics

A total of 385 nurses were included in this study, including 15 (3.9%) male nurses and 370 (96.1%) female nurses; age:31.03 ± 5.35 years, 68 (17.7%) aged 21–25 years, 108 (28.1%) aged 26–30 years, 176 (45.7%) aged 31–40 years, and 33 (8.6%) >40 years. The full distribution of the nurse participants’ socio-demographic details is displayed in Table 1. The total score of clinical communication skills was (239.27±33.25) points. Significant differences were observed in the clinical communication skills scores among nurses with different years of nursing experience, marital status, professional titles, departmental roles, and childbirth status (P<0.05). Similar to emotional intelligence, nurses with over 15 years of experience, those who were married, deputy chief nurses or above in terms of professional titles, and head nurses displayed higher clinical communication skills scores compared to their counterparts with different years of experience, marital statuses, professional titles, and departmental roles. Additionally, nurses who had given birth had higher clinical communication skills scores than those who had not. The results showed that the total score of emotional intelligence was (62.51±9.03) points, and there were statistically significant differences in emotional intelligence scores among nursing personnel with different years of nursing experience, professional titles, and departmental roles (P<0.05). Notably, nurses with over 15 years of working experience, deputy chief nurses or above in terms of professional titles, and head nurses exhibited higher emotional intelligence scores compared to those with fewer years of experience, lower professional titles, and different departmental roles.

Table 1 The Clinical Communication Skills, Emotional Intelligence, and Demographic Influences of Pediatric Nurses ()

A total of 385 children were included in this study, including 225 (58.4%) male children and 160 (41.6%) female nurses; age:10.25 ± 1.45 years, 208 (54.0%) aged 8–10 years, 177 (46.0%) aged 11–15 years. The full distribution of the pediatric participants’ socio-demographic details is displayed in Table 2. The total score of children’s trust in nurses is (28.85±6.48) points. The results indicated that there were statistically significant differences in the total trust scores of children in nurses among those with different places of residence (P<0.05). Specifically, children living in urban areas exhibited higher levels of trust in nurses compared to those living in rural areas. Furthermore, statistically significant differences in the total trust scores in the nurses of children were observed among those with different family income levels and general health status (P<0.05). Children from families with incomes below 30,000 yuan and those in good health displayed higher levels of trust in nurses compared to their counterparts with different income levels and health conditions.

Table 2 The Current Trust Level of Pediatric Patients Admitted to General Wards and Its Demographic Influences ()

Correlations Between Pediatric Nurses’ Clinical Communication Skills, Emotional Intelligence, and Children’s Trust in Nurses

The Pearson correlation analysis results indicated that the total score of nurses’ emotional intelligence was positively correlated with the total score of clinical communication skills and the total score of children’s trust in nurses (r=0.626, r=0.499, P<0.001) (Table 3), and significant positive correlations were observed between the total score of emotional intelligence among nurses and both the total score of clinical communication skills and the total score of children’s trust in nurses (r=0.626, r=0.499, P<0.001) (Table 3). Additionally, there was a significant positive correlation between the total score of clinical communication skills and the total score of children’s trust in nurses (r=0.450, P<0.001) (Table 3).

Table 3 Correlations Between Pediatric Nurses’ Clinical Communication Skills, Emotional Intelligence, and Children’s Trust in Nurses (n=385)

The Mediating Effect of Emotional Intelligence in the Relationship Between Clinical Communication Skills of Pediatric Nurses and Children’s Trust in Nurses

A structural equation model was established with clinical communication skills as the independent variable, emotional intelligence as the mediating variable, and children’s trust in nurses as the dependent variable. The model fitting was performed using the maximum likelihood method, and the original model was optimized based on the model modification indices. The final model was illustrated in Figure 1. The model demonstrated satisfactory fit indices: χ²/df=2.196, GFI=0.928, AGFI= 0.893, NFI =0. 936, IFI = 0. 954, TLI = 0. 941, CFI = 0. 954, RMSEA =0. 077, indicating a good model fit. The mediation effect was examined using the Bootstrap method with 5,000 repeated samples, and the mediation model is shown in Figure 1. The results of the study found that the confidence interval of the pathway: clinical communication skills→emotional intelligence→children’s trust in nurses did not contain 0, which indicated that the direct effect of clinical communication skills on children’s trust in nurses was still significant after the introduction of emotional intelligence, and the direct effect was 0.074, the indirect effect was 0.060. In addition, the indirect effect accounted for 44.8% of the total effect, as shown in Table 4.

Table 4 Mediation Analysis of Pediatric Nurses’ Emotional Intelligence Between Clinical Communication Skills and Children’s Trust in Nurses

Figure 1 Attributes on the latent variable path analysis between pediatric nurses’ emotional intelligence, clinical communication skills, and children’s trust in nurses.

Discussion

This study reaffirms the direct influence of pediatric nurses’ clinical communication skills on children’s trust in them, while also presenting initial evidence of the mediating role involved. The findings of this study underscore the importance of emotional intelligence levels in pediatric nurses, introducing a fresh viewpoint on enhancing children’s trust in their nurses.

A previous study confirmed a positive correlation between nurse-patient communication skills and trust.²⁶ Effective nurse-patient communication plays a crucial role in reducing patients’ physiological and psychological stress. Through communication, nurses can adjust or change patients’ cognition, beliefs, and mindset, encouraging them to actively cooperate with diagnosis and treatment as well as nursing care.²⁷ Nurses who possess strong communication skills are better equipped to manage conflicts with pediatric patients and their families effectively, mitigating tensions and reducing the risk of violence.²⁸ The study showed that nurses with stronger clinical communication skills are better at establishing trust relationships, which was verified once again.

Pediatric nurses’ emotional intelligence was significantly related to children’s trust in nurses. Rotenberg’s interpersonal trust framework theory highlights that emotion is one of the three foundations of trust, and trust in strangers increases with positive emotions.²³ Interpersonal trust is significantly positively correlated with emotional intelligence.^29,30 Nurses with high emotional intelligence exhibit strong self-awareness, effective emotional regulation, and enhanced empathy in recognizing others’ emotions. They also excel at managing interpersonal relationships and are more likely to understand others, making it easier for them to establish good trust relationships.²⁵

Emotional intelligence plays a partial mediating role in the relationship between the clinical communication skills of pediatric nurses and children’s trust in nurses. In other words, the clinical communication skills of pediatric nurses not only directly predict children’s trust in nurses but also affect children’s trust in nurses indirectly through the mediating role of emotional intelligence. One of the core competencies required for healthcare professionals in the 21st century, as highlighted by the World Health Organization, is the ability to communicate and interact effectively with patients and peers,²⁷ as Trudeau said, “Sometimes to heal, often to help, always to comfort”. Effective nurse-patient communication is an integral part of the processes of healing, helping, and comforting patients, which is also one of the key factors contributing to differences in patient satisfaction.²⁸ On the one hand, nurses with strong clinical communication skills can accurately assess patients’ needs, provide comfortable care, emotional support, and health education, and convey relevant information promptly, which facilitates the patient’s understanding of nursing work and helps establish mutual trust and cooperation. On the other hand, nurses, as the primary providers of therapeutic and caregiving services in clinical work, often face challenges and emotional stress. Emotional intelligence, as a protective factor, enables nurses to flexibly and effectively regulate their emotions, thereby contributing to alleviating negative emotional disturbances, maintaining self-balance, and building strong nurse-patient trust relationships.⁹

This study found differences in children’s trust in nurses among various socio-demographic variables. Children living in urban areas had higher trust in nurses than those living in rural areas. In rural areas, the social environment is relatively closed, with a small population and limited social circles. Rural children may face issues related to a weaker sense of social identity. Additionally, urban families often prioritize establishing and maintaining parent-child relationships, displaying greater attention to their children, and engaging in frequent and positive interactions. In contrast, in rural areas, due to reasons such as parents working away from home, there is relatively less communication between parents and children, resulting in fewer emotional connections between parents and children. This difference could make it more difficult for rural children to establish trust with others,³¹ which aligns with the findings of Gan et al.³² The higher level of trust among low-income individuals than among high-income individuals may be due to their stronger reliance on and respect for medical professionals, as they have limited sources of information and lower self-learning abilities. Previous studies also suggested that middle-income individuals tend to have a higher awareness of their individual rights and may approach interactions with nurses with a more skeptical attitude. Furthermore, children with poor health conditions exhibited lower trust in nurses, which could be related to their heightened sense of uncertainty and anxiety about their illnesses.

Elevating the trust relationship between pediatric patients and nurses can be achieved by enhancing the clinical communication skills and emotional intelligence levels of pediatric nurses. Research indicated that communication skills and emotional intelligence can be cultivated through post-training and maintained over the long term.^33,34 To enhance the clinical communication skills of pediatric nurses, nursing managers can organize forums for sharing communication and interaction experiences and incorporate communication skills training into nursing classrooms. This ensures that nurses engage in sincere, patient, and empathetic communication, as well as ensuring the accuracy, relevance, and accessibility of the content, thus guaranteeing communication quality. Furthermore, nursing managers can enhance nurses’ emotional intelligence levels by organizing lectures on emotional intelligence and offering psychological counseling courses. They can also innovate training methods, such as personalized workshops, Balint group sessions, scenario-based role-play, and group sandplay games.^35,36

Limitations

This study aimed to investigate the relationship between pediatric nurses’ clinical communication skills and children’s trust in nurses, as well as the mediating effect of emotional intelligence. However, several limitations must be acknowledged. First, the sampling method employed in this study was purposive sampling, and the study participants were limited to nurses in a specific tertiary pediatric hospital. This limitation somewhat restricts the representativeness of the sample. The subsequent research should consider more scientifically rigorous sampling methods and expand the sample range to include nurses from different levels of hospitals, various regions, and general hospitals. Second, this study was a cross-sectional study, which only analyzed the relationship between emotional intelligence, clinical communication skills, and children’s trust in nurses at a specific point in time. It did not conduct longitudinal comparisons, which weakened the strength of the causal relationship demonstration. Therefore, future research could conduct longitudinal investigations based on the characteristics of key variables to confirm the results of this study.

Conclusion

This study confirmed that emotional intelligence partially mediated the relationship between pediatric nurses’ clinical communication skills and children’s trust in nurses. Nursing managers could enhance the trust between pediatric patients and nurses by improving the emotional intelligence and clinical communication skills of pediatric nurses through training. This study provided empirical evidence for intervention strategies aimed at enhancing children’s trust in nurses.

Implications

Trust plays a crucial role in determining the quality of nursing care and patient outcomes, especially within the nurse-patient relationship. Facilitating effective communication between healthcare providers and patients is the key to fostering mutual trust. Emotional intelligence not only directly predicts nurses’ clinical communication skills but also positively influences interpersonal trust. Therefore, enhancing emotional intelligence among pediatric nurses can be seen as a strategic approach to improve their clinical communication skills and foster a harmonious nurse-patient relationship in pediatric nursing care.