Exploring Nurse's Communicative Role in Nurse-Patient Relations: A Qualitative Study.

Introduction: Recognition the nurses' communicative roles can influence quality of patient's care. Therefore, this study was aimed to explore nurse's role in nurse-patient relations.
Methods: This study was a qualitative research in which collected data was analyzed by content analysis method. The participants were 23 nurses, patients and their families in medical and surgical wards of a referral hospital in Tehran, Iran. Data were collected by semi-structured interview and observation.
Results: Data analysis was led to the emergence of a main conceptual category: The patient's need-based communication. This category was derived from two categories: 1) Identifying the patient's needs; and 2) Communicative behavior in the face of the patient's needs. "Identifying the patient's needs" was related to "type of the patient's problem", "patients' inquiring about their health status" and "monitoring the patient's health status". "Communicative behavior in the face of the patient's needs" was composed of four subcategories: "caring attention", "informal education of the patient", "inducing calmness to the patient", and "obtaining the trust of the patient".
Conclusion: The nurse's role in relationship with patients is designed according to patients' needs. Therefore, if the patients' needs in clinical settings are defined and clarified appropriately, the nurse-patient relations will be enhanced and thereby the quality of care will be improved.

Introduction

Communication plays a vital role in professional disciplines such as nursing. Usually, establishing an effective communication with patients is an essential aspect of nursing care.[1] Nurses, through communication skills, can recognize the patient’s healthcare needs, as a meaningful communication with patients enable nurses aspire to enhance a thorough knowledge of individual patients and their personal characteristics.[2] In fact, positive nurse-patient relationship includes a wide range of behaviors in multiple domains of nursing practice and it is an essential factor in high quality nursing care.[3] Therefore, enhancing the communication role of nurses leads to their having a positive opinion of their job and patients.[4]

Implementation of research on nurse-patient communication is necessary for improving professional nursing knowledge. In this regards, various studies have been performed on various aspects of nurse-patient communication. Bridges et al., concluded that supportive organizational settings influenced the emotional engagement of nurses with patients.[2] Kim et al., conducted a study to explore enabling factors for nurses in communication effectively with patients. They concluded that the manager should consider a set of clinic-based strategies for improving the nurse-patient relationship beyond the conventional communication skills.[5] Moore believed effective nursing care required a meaningful communication with the patient and a continued assessment of the patient’s needs.[6] Also, it seems that nurses and patients are engaged in a reciprocal process that influences both parties. For this reason, reflection on nursing skills in this process can lead to the identification of the difficulties and the recognition of possible solutions.[7] Thus, a perception to cultural aspects of communication can help nurses in nursing practice.[8]

There are few studies about nurse-patient communication in Iran. In addition, the majorities of these studies have focused on communication barriers. Shafipour et al., in a qualitative study on nurse-patient communication, found that job dissatisfaction, routine-centered care and lack of trust to nurses from patients’ views were the major barriers for achieving effective communication.[9] Also, other factors such as heavy nursing workload, hard nursing tasks, nurses’ fatigue, little time to speak with patients, fast rate of nurses’ speech, a lack of welfare facilities for nurses and some problems with the patients such as weak memory and auditory and visual disorders were considered as a barrier for communication between nurses and patients.[1,8] Norouzinia et al., concluded that difference in conversional languages between patients and nurse, overload of works and emergency situation of patients were the most barriers in nurse-patient communication.[10] Also, Azimian et al., believed routine-based culture is one of barriers in establishing nurses’ relationship.[11]

A review of literature shows that nurse-patient communication is influenced by conditions that arise in clinical settings.

However, the important point is that few studies have focused on nurses' communicative role with patients. Therefore, a deep understanding of these circumstances and nurses’ roles in their communication with patients can help healthcare policymakers to plan strategies for enhancing high quality nursing care. Therefore, this study aimed to explore the communicative role of nurses in their relationship with patients according to lived experiences of Iranian nurses and patients.

Materials and methods

This study was a qualitative research. The researchers’ purpose in this study was to investigate experiences that grounded in nurses and patient’s relations with the main research question: “What are the skills and roles of nurses in relationship with patients?” Therefore, because of there was no previous studies dealing with the nurses’ roles during communication with patients, a qualitative content analysis approach was used. According to this qualitative approach, the content of the data was analyzed in order to categorize the concept.

The study was performed on eleven Iranian nurses and twelve patients of medical and surgical wards in a referral university hospital that it was publicly funded and located in urban area in Tehran, Iran. The participants were chosen with a purposeful sampling method to gather relevant and in-depth data. All participants were speaking in Persian language and did not have any illness that would hinder verbal communication. The nurses had a bachelor’s degree in nursing.

Professional’s work experiences of nurses were between 18 months to 28 years. Two of the nurses were head nurses and worked on morning shifts and the other nurses worked on rotating work shifts. The patients spoke in Persian language too and aged from 35 to 60. Also, patients were hospitalized because of medical or surgical problems and didn’t have any mental and cognitive disorders.

Data collection methods were interviews and observation. First author of the study conducted the interviews and observations. Place of interviewing and observation was in hospital where the research was taking place. The interviews were recorded by digital MP3 recorder. After recording, the interviews were transcribed verbatim. Each interview lasted on average 30 to 90 minutes. Interviews with nurses were conducted in nurses’ room in each unit.

Interviews with patients were conducted beside patient's units in hospital. In addition, to improve the depth of understanding of the context of communication between nurses and patients as well as to verify the data gathered through interviews, 10 unstructured observation sessions were performed by a participant observer approach lasting 15 to 180 minutes. Then, each observation session was transcribed verbatim.

The first two interviews were started with head nurses as key informants. These participants had the most work experience among all the nurses and worked in different nursing units. Then, according to data analysis and constant comparison of the data, the interviews continued with other nurses and patients. The primary interview was started with general questions that had no direct reference to the relationship between nurse and patient such as “Can you explain about your actions during caring of patients?” that asked from nurses; or “Can you talk about nurses’ care in relation to yourself?” that asked from patients.

However, after transcription and analysis data, according to emerged data, interviews were changed and conducted in semi-structured form. In semi-structured interview, the questions were focused on the type of patients’ needs; concerns of patient during hospitalization; nurses’ behaviors during caring of patients; nurses’ actions during relationship with patients and so on. Also, researcher used probing questions such as aha, or can you explain more about your idea and please repeat it again to clarify the participants’ opinions.

The analysis process was divided into three phases of preparing, organizing and reporting the analyzing process and the results.[12] In the preparation phase, researchers read transcribed interview from beginning to end several times.

Then, the unit of analysis was selected. In the organization phase, the primary concepts (codes) were derived from the data. Then according to properties, dimensions and similarities of each concept, they were grouped into two abstract higher order categories.

Finally, in the reporting phase, the influencing conditions on nurses’ skills in communication with patients were explored and a main conceptual category was derived from two categories that were formed in organizing phase.

To enhance the rigor of the study, researchers used many methods including rechecking and re-interviewing the participants about the derived concepts to make sense of the data. The researchers also peer-checked the analysis process with two other faculty members trained in qualitative research. In addition, to create maximum variation, the participants were selected according to their professional experiences, work shifts, hospitalization time and ages.

This study was part of a PhD dissertation that approved by the vice chancellor of research and technology of Tehran University of Medical Sciences (research contract number: 250/5005). The aim of the study was explained to the all participants in detail. In addition, the following points were emphasized for the participants: the voluntary nature of the participation, the right to privacy, the anonymity and confidentiality of informants and the right to withdraw from the study at any time without any penalty. Also, informed consent was obtained dynamically and continuously from participants before each observation session.

Results

Data analysis was led to emergence of a main conceptual category: “The patient's need-based communication”. In fact, patient’s needs directed the communicative roles of nurses. This conceptual category was derived from two categories, 1) Identifying the patient’s needs and 2) communicative behaviors in the face of the patient’s needs. The category of “how to identify the patient’s needs” was composed of three subcategories: the type of the patient’s problem, patients’ inquiring about their health status, and monitoring the health status of the patient. The category of “communicative behavior in the face of the patient’s need” was also composed of four subcategories: caring attention, informal education of the patient, inducing calmness to the patient and obtaining the trust of patient. In the following, each category with its subcategories will be described (Table 1).

Table 1

Summary of main conceptual category, categories, sub-categories and open codes

Main them	Categories	Subcategories	Open codes
The patient's need-based communication	Identifying the patient’s needs	The type of the patient’s problem	● Acute physical problems
			● Patients concerns about treatment process and related costs
			● Emotional concerns
		Patients’ inquiring about their health status	●Asking about diagnostic tests, procedures, prognosis, medications and treatment modes
			●Asking about discharge time
		Monitoring the health status of the patient	● How to run monitoring
			● The content of monitoring
			● The run-time of monitoring
	Communicative behaviors in the face of the patient’s needs	Caring attention	● Doing task optimally
			● Accessibility of nurse to patients
			● Answering to patients’ request
		Informal education of the patient	● Explanation about medication,
			● medical and nursing interventions
			● Patients preparation for diagnostic procedures
			● Discharge preparation
		Inducing calmness to the patient	● Respect to patients
			● Nurses’ patience to patients’ requests
			● Sympathy with patients
			● Listening to patients’ concerns
		Obtaining the trust of patient	● Understanding the patients’ conditions
			● Accepting the patients

Identifying the patient’s needs

Knowing the patient’s needs was the first role that nurses needed before encountering with patients. For this reason, this category implied the “type of patients’ needs”, “patients’ inquiring about their health status”, and “monitoring the health status of the patient”.

Physical and emotional problems were the most important needs of the‏ patients. One nurse expressed “Most patients’ problems are related to their disease such as nausea and vomiting or pain” (Participant 9). Regarding the content of relationship with nurses, one patient said, “When I had pain, I asked nurses to give me an analgesic” (Participant 8). The major emotional problems of the patients were related to their concerns about the costs of the treatment, time of discharge from the hospital and consequences of the disease and their health status. One nurse in medical unit said, “All patients are concerned about the costs and their recovery” (Participant 15).

Another nurse expressed, “Here (in this ward) the main problem is the cost of the surgery and the time of discharging from the hospital” (Participant 6). One patient in medical ward said, “I was expecting to recover and be discharged from the hospital” (Participant 10).

Patients’ inquiries about their health status were another factor that helps nurses to identify the patients’ needs. The commonest inquiries were about the diagnosis of disease, evaluation procedures, treatment modes and prognosis of disease. One of surgical ward’s nurse expressed “In our ward, because most patients have malignant illnesses, they tend to have information about the prognosis, success of treatment and metastasis of the disease to their other organs” (Participant 6). In one of observational sessions in surgical wards, the researcher observed the following relationship between a nurse and a patient:

Patient: Why the result of my biopsy is not ready?

Nurse: I do not know. Let me asked the lab’s technician.

Monitoring of the patients’ health status was another skill used by nurses for knowing about the patients’ needs. Monitoring of patients’ needs was accomplished by following these steps: how to run monitoring, the content of monitoring and the run-time of monitoring.

Nurses monitor the patients using their documents, asking those questions, and observing their health status. Using documents related to patients such as nursing and physicians’ reports were the commonest method for nurses to get informed about the patients, as all of nurses in both medical and surgical wards were expressed: “Initially, we collect information about the patients by reviewing history and reports in their files, and then we practically help them”. Nurses monitored patients’ status by asking question and observing them. For examples, one of nurses in surgical ward was expressed: “I ask patients about their pain and other problems such as nausea, dizziness and so on” (Participant 2).

The content of monitoring pertained to acute and short-term problems of patients. “Because of work overload, we cannot ask patients about long term problems and their other supportive resources” (Participant 3). Alternatively, one patient said, “The nurse asked me about my current disease” (Participant 19).

Nurses monitor the patients’ status as they change shifts. “When I change shifts and take over the patients from the previous shift, I get informed about their conditions” (Participant 5). Another nurse in surgical ward was expressed, “We do not have enough time for interviewing all patients. Usually, during nursing practice such as medication administration, dressing, bed making and so on, we learn about other demands or problems of patients” (Participant 21).

Communicative behavior in the face of the patient’s needs

Communicative behavior of nurses was another skill in their encounters with patients. This category was derived from four subcategories: “caring attention”, “informal education of the patient”, “inducing calmness to the patient”, and “obtaining the trust of the patient”. The nurses’ caring attention was accomplished by applying maximum efforts to respond patient’s needs and requests. Most of the patients believed that nurses performed their tasks optimally. “Nurses did all tasks such as giving my medicines, controlling vital signs, bed making, and injecting intravenous infusions in a timely manner; In fact, nurses were doing their tasks to the fullest” (Participant 7). Another patient in one of surgical wards was expressed, “All my requests were done by the nurses as soon as possible” (Participant 8).

Enhancing the knowledge of patients and their families about the disease and the treatment process was another communicative behavior performed by nurses. Nurses performed patient education informally during caring procedures.

Patient education focused on giving explanations in relation to the process of disease, medication, diagnostic evaluation, patient preparation for procedures and others caring recommendations.

One patient expressed “nurses answered all my questions about the disease and treatment” (Participant 22). “Most of patients’ questions are related to their medication and I explain the mechanism, side effects and route of administration” (Participant 8). Discharge education was performed informally too.

One of nurses in medical ward was expressed: “I educate the patients when they are being discharged from the hospital. Our education focuses on medication at home, follow-up care and diet” (Participant 18).

Nurses induced calmness to the patients by expressing intimacy, showing a respectful behavior and confronting the patients’ needs patiently. In this regard, on of medical ward’s patients was expressed: “They (nurses) are so kind and listen to my requests patiently” (Participant 20). Also, a nurse in surgical ward was expressed: “Usually before surgery, patients are very stressful. The night before surgery, I speak with them and listen to their concerns about surgery and the operating room. I explain about measurements in the operating room and post-operation care such as range of mobilization, attached tubes and catheters and so on” (Participant 6).

Polite and respectful behavior was another factor that induced calmness to patients. A patient in medical ward was expressed: “The nurses’ behavior is very good. They respectfully interact with me and ask me about my problems such as headaches and so on” (Participant 12). Another patient in surgical ward was expressed: “They (nurses) performed their tasks and behaved very politely” (Participant 7). Expressing sympathy with patients was another method of inducing calmness. One of nurses in surgical ward was express: “Some conditions such as amputation and mastectomy is influenced the patients’ mood. I speak with them about their conditions and spend more time with them. In addition, I listen to their concerns and tell them how to live with their new conditions” (Participant 21).

Obtaining the trust of patients was another behavior that performed by nurses. Trust in patients is created by understanding the patients’ conditions and accepting them as individuals with unique needs. One of head nurses was expressed: “When you percept the patient’s condition and accept him or her as someone of your family, the patient listen to your advice and perform them” (Participant 5). Trust in patients was associated with satisfaction from the nursing personnel, compliance and following the treatment and caring modes.

Since the most nurses’ endeavors were directed to patients’ actual needs and they met these needs on time, the satisfaction of patients from the nursing care was very high. In addition, when nurses understood the patients’ conditions, they won the patients’ trust. A patient in medical ward was expressed: “Here (in this ward), nurses are very patient and sensitive to my problems and requests. They answer my requests fast and on time” (Participant 20). One of nurses was expressed: “When I understand the patients, they follow my recommendations and participate better in their care” (Participant 23).

Discussion

The aim of this study was to provide insight into nurses’ roles during communication with patients. The findings of this study present new insights into nurse–patient communication. The findings showed that communicative roles of nurses were formed according to patient’s needs. These roles were included identifying the patient’s needs and communicative behavior in the face of patient’s needs that were applied by nurses. In other words, after identifying the patients’ needs, nurses tried to enhance the quality of care with communicative behaviors such as caring attention, informal education of the patient, inducing calmness to the patient and winning the trust of patient. Jahromi and Ramezanali concluded that therapeutic communication with patients need to achieve care that is effective and responsive to their needs.[1]

In Tay et al., study the results shown that the patients’ demands and needs to communication could promote the communication between registered nurses and patients.[13] Also, Granados Gamez concluded that the nurse-patient relationship creates the activity of caring.[14] So, policy makers must pay additional attention to eliminate inhibiting factors of nurse–patient communication process.[15]

According to findings of this study, communicative roles of nurses were categorized according to two concepts: identifying patients’ needs and nurses’ behavior to patients. Nurses’ attention was focused more on the acute problems of patients. Shattell expressed that nurses paid more attention to patients with more needs.[16] In a study that aimed to understand nurses' communication with patients, the researchers found that in emergency conditions, nurses gave priority to physical care rather than the patient’s anxiety.[17]

In this study nurse were aware of patients’ needs by self-expression of patient. In fact, nurses communicated with patients in informal form and interacted with patients according to their’ requests about their problems. Results of Chan et al., study showed that in informal communication, communication was initiated by the patients. Therefore, nurses answered to them in task-oriented form such as treatment and procedural techniques.[18] Taylor concluded that nurses use different sources such as nursing notes, patient’s file and history taking to recognize the patient’s needs.[19] In addition, self-expression by patient was another means of making nursing students aware of the physical condition of the patient.[20]

Communicative behavior of nurses was summarized in caring attention, informal education, inducing calmness, and obtaining the trust of patients. In a study by Skea et al., interacting warmly with patients and attending to their care needs were the properties of valuable and worthy care of patients.[3] Also, nurses are responsible for providing important information to the patient.[21]

Morrow and Conner-Garcia believe that helping the patients to understand how to take their medication and organizing information for them about medication information were recommendations for nurse-patient communication about medication.[22] In fact, providing the biomedical and psychosocial information to the patient is a positive implication of nurse-patient communication.[23]

In this study, nurses enhanced the patient’s information by informal education. O'Hagan et al., expressed that providing and clarifying information for patient and listening to them are the characteristics of effective communication in nursing care.[24] de Leeuw et al., also concluded that nurses were more attentive to informational questions of patients than to address emotional cues.[25] Pytel et al., found that providing information about diagnostic tests and modes of treatment were the most important needs of patients and families.[26]

In this study, nurses’ active listening and respectful and polite behavior were led to patients’ calmness and trust. Mottram expressed that some nurses’ behaviors such as adequate explanation, timely satisfaction of patient’s requests, intimacy and a friendly interaction with the patient are characteristics of therapeutic communication in nursing care.[27] In Finch’s study, patients expected a professional, respectful, intimate, and professional behavior from nurses.[28] Nestel and Kidd believed that listening actively, speaking clearly and behaving respectfully were verbal and nonverbal skills crucial to effective communication.[29] In general, the meaning of nursing care from the patients’ perspective can be summarized as respect and safety for the patient.[30]

Conclusion

The findings of this study were characterized in multiple roles that nurses were used in relationship with patients. It seems the patient’s needs have an important role in forming the nurse’s communicative roles in clinical settings. Therefore, if the patients need in clinical settings are appropriately defined and clarified, the nurse-patient communication will be enhanced and thereby the quality of care will be improved.

The findings of this study can be used as a guideline for stakeholders and nursing policy makers to formulate appropriate strategies to enhance the quality of nursing care and communication process.

This study was performed with a qualitative approach and the findings were limited to the field of study. Therefore, researchers suggest more studies on this topic in other clinical settings.

Acknowledgments

The authors thank all patients and nurses who participated in this study

Ethical issues

None to be declared.

Conflict of interest

The authors declare no conflict of interest in this study‏.