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Reflecting on the communication process in health care. Part 1: clinical practice—breaking bad news

Beverley Anderson

Macmillan Uro-oncology Clinical Nurse Specialist, Epsom and St Helier NHS Trust

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This is the first of a two-part article on the communication process in health care. The interactive process of effective communication is crucial to enabling healthcare organisations to deliver compassionate, high-quality nursing care to patients, in facilitating interactions between the organisation and its employees and between team members. Poor communication can generate negativity; for instance, misperception and misinterpretation of the messages relayed can result in poor understanding, patient dissatisfaction and lead to complaints. Reflection is a highly beneficial tool. In nursing, it enables nurses to examine their practice, identify problems or concerns, and take appropriate action to initiate improvements. This two-part article examines the role of a uro-oncology clinical nurse specialist (UCNS). Ongoing observations and reflections on the UCNS's practice had identified some pertinent issues in the communication process, specifically those relating to clinical practice and the management of practice-related issues and complaints. Part 1 examines the inherent problems in the communication process, with explanation of their pertinence to delivering optimal health care to patients, as demonstrated in four case studies related to breaking bad news to patients and one scenario related to communicating in teams. Part 2 will focus on the management of complaints.

In health care, effective communication is crucial to enabling the delivery of compassionate, high-quality nursing care to patients ( Bramhall, 2014 ) and in facilitating effective interactions between an organisation and its employees ( Barber, 2016 ; Ali, 2017 ). Poor communication can have serious consequences for patients ( Pincock, 2004 ; Barber, 2016 ; Ali, 2017 ). Misperception or misinterpretation of the messages relayed can result in misunderstanding, increased anxiety, patient dissatisfaction and lead to complaints ( McClain, 2012 ; Ali, 2017 ; Bumb et al, 2017 ; Evans, 2017 ; Doyle, 2019 ), which, as evidence has shown, necessitates efficient management to ensure positive outcomes for all stakeholders—patients, health professionals and the healthcare organisation ( Barber, 2016 ; Ali, 2017 ; Evans, 2017 ; Doyle, 2019 ). Complaints and their management will be discussed in Part 2.

Reflection is a highly beneficial tool ( Oelofsen, 2012 ), one that has played a key role in the author's ongoing examination of her practice. In this context, reflection enables a personal insight into the communication process and highlights the inherent challenges of communication and their pertinence to patient care and clinical practice outcomes ( Bramhall, 2014 ). The author, a uro-oncology clinical nurse specialist (UCNS), is required to ensure that appropriate reassurance and support is given to patients following the receipt of a urological cancer diagnosis ( Macmillan Cancer Support, 2014 ; Hemming, 2017 ). Support consists of effective communication, which is vital to ensuring patients are fully informed and understand their condition, prognosis and treatment and, accordingly, can make the appropriate choices and decisions for their relevant needs ( McClain, 2012 ; Ali, 2017 ; Evans, 2017 ; Hemming, 2017 ; Doyle, 2019 ).

Reflection is a process of exploring and examining ourselves, our perspectives, attributes, experiences, and actions and interactions, which helps us gain insight and see how to move forward ( Gillett et al, 2009:164 ). Reflection is a cycle ( Figure 1 ; Gibbs, 1988 ), which, in nursing, enables the individual to consciously think about an activity or incident, and consider what was positive or challenging and, if appropriate, plan how a similar activity might be enhanced, improved or done differently in the future ( Royal College of Nursing (RCN), 2019 ).

Reflective practice

Reflective practice is the ability to reflect on one's actions and experiences so as to engage in a process of continuous learning ( Oelofsen, 2012 ), while enhancing clinical knowledge and expertise ( Caldwell and Grobbel, 2013 ). A key rationale for reflective practice is that experience alone does not necessarily lead to learning—as depicted by Gibbs' reflective cycle (1988) . Deliberate reflection on experience, emotions, actions and responses is essential to informing the individual's existing knowledge base and in ensuring a higher level of understanding ( Paterson and Chapman, 2013 ). Reflection on practice is a key skill for nurses—it enables them to identify problems and concerns in work situations and in so doing, to make sense of them and to make contextually appropriate changes if they are required ( Oelofsen, 2012 ).

Throughout her nursing career, reflection has been an integral part of the author's ongoing examinations of her practice. The process has enabled numerous opportunities to identify the positive and negative aspects of practice and, accordingly, devise strategies to improve both patient and practice outcomes. Reflection has also been a significant part author's professional development, increasing her nursing knowledge, insight and awareness and, as a result, the author is an intuitive practitioner, who is able to deliver optimal care to her patients.

Communication

Figure 2 provides a visual image of communication—it is both an expressive, message-sending, and a receptive, message-receiving, process ( Berlo, 1960 ; McClain, 2012 ; Evans, 2017 ). This model was originally designed to improve technical communication, but has been widely applied in different fields ( Berlo, 1960 ). Communication is the sharing of information, thoughts and feelings between people through speaking, writing or body language, via phone, email and social media ( Bramhall, 2014 ; Barber, 2016 ; Doyle, 2019 ). Effective communication extends the concept to require that transmitted content is received and understood by someone in the way it was intended.

The process is more than just exchanging information. It is about the components/elements of the communication process, ie understanding the emotion and intentions behind the information—the tone of voice, as well as the actual words spoken, hearing, listening, perception, honesty, and ensuring that the messages relayed are correctly interpreted and understood ( Bramhall, 2014 ; Barber, 2016 ; Evans, 2017 ; Doyle, 2019 ). It is about considering emotions, such as shock, anger, fear, anxiety and distress ( Bumb et al, 2017 ; Evans, 2017 ). Language and conceptual barriers may also negatively impact on the efficacy of the communication being relayed.

Challenges of effective communication

The following sections explain the challenges involved in communication—namely, conveying a cancer diagnosis or related bad news.

Tone of voice and words spoken

According to Barber (2016) , when interacting with patients, especially communicating ‘bad news’ to them, both the tone of voice and the actual words spoken are important. The evidence has shown that an empathetic and sensitive tone is conducive to providing appropriate reassurance and in aiding understanding ( McClain, 2012 ; Evans, 2017 ; Hemming, 2017 ). However, an apathetic and insensitive tone will likely evoke fear, anxiety and distress ( Pincock, 2004 ; Ali, 2017 ; Doyle, 2019 ). In terms of the words used, the use of jargon, or highly technical language and words that imply sarcasm and disrespect, can negatively impact on feelings and self-confidence ( Doyle, 2019 ).

Hearing what is being conveyed is an important aspect of effective communication. When interacting with patients it is vital to consider potential barriers such as language (ie, is the subject highly technical or is English not the patient's first language) and emotions (ie shock, anger, fear, anxiety, distress) ( Bumb et al, 2017 ; Evans, 2017 ). A patient may fail to hear crucial information because he or she is distressed during an interaction, or may be unable to fully understand the information being relayed ( Bumb et al, 2017 ). Good communication involves ascertaining what has been heard and understood by the patient, allowing them to express their feelings and concerns, and ensuring these are validated ( Evans, 2017 ).

Listening to the patient

Listening is a deliberate act that requires a conscious commitment from the listener ( Shipley, 2010 ). The key attributes of listening include empathy, silence, attention to both verbal and non-verbal communication, and the ability to be non-judgemental and accepting ( Shipley, 2010 ). Listening is an essential component of effective communication and a crucial element of nursing care ( Shipley, 2010 ; Evans, 2017 ; Doyle, 2019 ). In health care, an inability to fully listen to and appreciate what the patient is saying could result in them feeling that their concerns are not being taken seriously. As observed by the author in practice, effective listening is essential to understanding the patient's concerns.

Perception, interpretation, understanding

Relevant and well-prepared information is key to the patient's perception and interpretation of the messages relayed ( McClain, 2012 ). It is vital to aiding their understanding and to informing their personal choices and decisions. If a patient were to misinterpret the information received, this could likely result in a misunderstanding of the messages being relayed and, consequently, lead to an inability to make clear, informed decisions about their life choices ( McClain, 2012 ; Bramhall, 2014 ).

Fully informing the patient and treating them with honesty, respect and dignity

In making decisions about their life/care, a patient is entitled to all information relevant to their individual situation and needs (including those about the actual and potential risks of treatment and their likely disease trajectory) ( McClain, 2012 ). Information equals empowerment—making a decision based on full information about a prognosis, for example, gives people choices and enables them to put their affairs in order ( Evans, 2017 ). Being honest with a patient not only shows respect for them, their feelings and concerns, it also contributes to preserving the individual's dignity ( Ali, 2017 ; Evans, 2017 ; Doyle, 2019 ). However, as observed in practice, a reluctance on the health professional's part to be totally open and honest with a patient can result in confusion and unnecessary emotional distress.

When reflecting on the efficacy of the communication being relayed, it is important for health professionals to acknowledge the challenges and consider how they may actually or potentially impact on the messages being relayed ( McClain, 2012 ; Ali, 2017 ; Evans, 2017 ; Doyle, 2019 ).

Communication and the uro-oncology clinical nurse specialist

It is devastating for a patient to receive the news that they have cancer ( Bumb et al, 2017 ). Providing a patient with a cancer diagnosis—the ‘breaking of bad news’, defined as any information that adversely and seriously affects an individual's view of his or her future ( Schildmann et al 2005 )—is equally devastating for the professional ( Bumb et al, 2017 ; Hemming, 2017 ). It is thus imperative to ensure the appropriate support is forthcoming following receipt of bad news ( Evans, 2017 ).

Integral to the delivery of bad news is the cancer CNS, in this context, the UCNS, who is acknowledged to be in the ideal position to observe the delivery of bad news (usually by a senior doctor in the urology clinic), and its receipt by patients ( Macmillan Cancer Support, 2014 ; Hemming, 2017 ), and to offer appropriate support afterwards ( Evans, 2017 ). Support includes allocating appropriate time with the patient, and their family, after the clinic appointment to ensure they have understood the discussion regarding the diagnosis, prognosis and treatment options ( Evans, 2017 ; Hemming, 2017 ). In this instance, effective communication, as well as the time required, is usually tailored to each individual patient, allowing trust to be built ( Bumb et al, 2017 ; Evans, 2017 ; Hemming, 2017 ).

In the performance of her role, the UCNS is fully aware of the importance placed on delivering bad news well. She has seen first hand how bad news given in a less than optimal manner can impact on the patient's emotions and their subsequent ability to deal with the results. Hence, her role in ensuring that the appropriate support is forthcoming following the delivery of bad news is imperative. It is important to understand that the delivery of bad news is a delicate task—one that necessitates sensitivity and an appreciation of the subsequent impact of the news on the individual concerned. It should also be acknowledged that while the receipt of bad news is, understandably, difficult for the patient, its delivery is also extremely challenging for the health professional ( Bumb et al, 2017 ).

Communicating bad news

The primary functions of effective communication in this instance are to enhance the patient's experience and to motivate them to take control of their situation ( McClain, 2012 ; Ali, 2017 ; Evans, 2017 ; Doyle, 2019 ).

Telling a patient that they have a life-threatening illness such as cancer, or that their prognosis is poor and no further treatment is available to them, is a difficult and uncomfortable task for the health professional ( Bumb et al, 2017 ). It is a task that must be done well nonetheless ( Schildmann, 2005 ). Doing it well is reliant on a number of factors:

• Ensuring communicated information is sensitively delivered ( Hanratty et al 2012 ) to counter the ensuing shock following the patient's receipt of the bad news ( McClain, 2012 )
• Providing information that is clear, concise and tailored to meeting the individual's needs ( Hemming, 2017 )
• Acknowledging and respecting the patient's feelings, concerns and wishes ( Evans 2017 ).

This approach to care is important to empower patients to make the right choices and decisions regarding their life/care, and gives them the chance to ‘put their affairs in order’ ( McClain, 2012 ; Ali, 2017 ; Evans, 2017 ).

Choices and decision-making

Case studies 1 and 2 show the importance of honesty, respect, listening and affording dignity to patients by health professionals, in this case senior doctors and the UCNS. The issue of choice and decision-making is highlighted. It is important to note that, while emphasis is placed on patients receiving all the pertinent information regarding their individual diagnosis and needs ( McClain 2012 ), despite receipt of this information, a patient may still be unable to make a definite decision regarding their care. A patient may even elect not to have any proposed treatment, a decision that some health professionals find difficult to accept, but one that must be respected nevertheless ( Ali, 2017 ; Evans, 2017 ; Hemming, 2017 ).

Case study 1. Giving a poor prognosis and accepting the patient's decision

Jane Green, aged 48, received a devastating cancer diagnosis, with an extremely poor prognosis. It was evident that the news was not what she expected. She had been convinced that she had irritable bowel syndrome and, hence, a cancer diagnosis was quite a shock. Nevertheless, she had, surprisingly, raised a smile with the witty retort: ‘Cancer, you bastard—how dare you get me.’ Mrs Green had been married to her second husband for 3 years. Sadly, her first husband, with whom she had two daughters, aged 17 and 21, had died from a heart attack at the age of 52. His sudden death was hugely upsetting for his daughters; consequently, Mrs Green's relationship with her girls (as she lovingly referred to them) was extremely close. The legacy of having two parents who had died young was not one Mrs Green wished to pass on to her daughters. Her main concern, therefore, was to minimise the inevitable distress that would ensue, following her own imminent death.

In the relatively short time that Mrs Green had to digest the enormity and implications of her diagnosis, she had been adamant that she did not wish to have any life-prolonging interventions, particularly if they could not guarantee a reasonable extension of her life, and whose effects would impact on the time she had left. This decision was driven by previously having observed her mother-in-law's experience of cancer: its management with chemotherapy and the resultant effect on her body and her eventual, painful demise. Mrs Green's memory of this experience was still vivid, and had heightened her fears and anxieties, and reinforced her wish not to undergo similar treatment.

Mrs Green requested a full and honest discussion and explanation from the consultant urologist and the UCNS regarding the diagnosis and its implications. This included the estimated prognosis, treatment interventions and the relevant risks and benefits—specifically, their likely impact on her quality of life. In providing Mrs Green with this information, the consultant and the UCNS had ensured information was clear and concise, empathetic and sensitive to her needs ( Shipley, 2010 ; Hanratty, et al, 2012 ; Evans, 2017 ; Hemming, 2017 ) and, importantly, that her request for honesty was respected. Not disclosing the entire truth can ‘inadvertently create a false sense of hope for a cure and perceptions of a longer life expectancy’ ( Bumb et al, 2017:574 ). Being honest had empowered Mrs Green to come to terms with both the diagnosis and prognosis, to consider the options as well as the risks and benefits. She had a choice between quantity of life and quality of life. Mrs Green elected for quality of life and, accordingly, made decisions that she felt were in her own, and her family's, best interests.

Despite receiving pertinent information and sound advice on why a patient should agree to treatment intervention, they may still elect not to have any treatment ( Ali, 2017 ; Evans, 2017 ; Hemming, 2017 ). This decision, as observed by the UCNS in practice, is difficult for some health professionals to accept. In Mrs Green's case, accepting her decision not to have any treatment was extremely difficult for both the consultant and the UCNS. In an attempt to try to change Mrs Green's mind, the consultant asked the UCNS to speak to her. The UCNS was aware that the consultant's difficulty to accept the decision was compounded by Mrs Green's age (48) and a desire to give her more time. However, the UCNS had listened closely to Mrs Green's wishes and, in view of her disclosure regarding the experience of her mother-in-law's death, her first husband's untimely death, her fear of upsetting her daughters and her evident determination to keep control of her situation, the UCNS felt compelled to respect her decision.

Following the consultant's request, the UCNS spoke to Mrs Green but, on hearing what she had to say regarding her decision not to have more treatment, concluded that she had to respect Mrs Green's decision. She also clarified whether Mrs Green were willing to continue communication with her GP and ensured that the GP was fully updated regarding current events. Mrs Green had thanked the staff for all their support, but did not wish to continue follow-up with the service. The GP assured the UCNS that she would keep a close eye on Mrs Green and her family.

Case study 2. Giving an honest account of disease progression

The following case study explains how a reluctance by health professionals to be totally honest with a patient had inadvertently hampered the individual's ability to make informed decisions regarding his life choices.

Mr Brown, aged 87, had been previously diagnosed and treated for cancer. On his referral to the urology clinic, his disease had progressed to the metastatic stage, which had limited his management options to palliative care.

Since we have established that delivering bad news to a patient is a difficult task ( Bumb et al, 2017 ), it is not surprising that some health professionals fail to be totally honest with the patient for fear of upsetting them. During the consultation, it transpired that Mr Brown had other serious illnesses and was being managed by other clinicians. Seemingly, previous communications with these clinicians had left Mr Brown and his family unenlightened about his prognosis and his future prospects. In hindsight, the family would have appreciated total honesty sooner, since this would have allowed them to make realistic decisions.

After fully assessing Mr Brown's case (and in light of this disclosure) the doctor decided to be totally honest with Mr Brown and his family regarding his current situation and the choices available to him. Explanations were empathetic and sensitive to Mr Brown's and his family's feelings ( Hanratty et al, 2012 ; Evans, 2017 ). While the news was not entirely unexpected, Mr Brown and his family appreciated the consultant's candour. In this instance, the consultant had respected Mr Brown's entitlement to total honesty. By receiving all the facts, and the appropriate reassurance and support from the UCNS, Mr Brown could now consider his options and, with his family's support, proceed to put his affairs in order.

Management and treatment of cancer

The management and treatment of cancer is determined by several factors. These include: the grade and stage of the individual's disease—whether the disease is low-grade/low-risk, intermediate-grade/intermediate-risk, or high-grade/high-risk. For some low-grade/low-risk disease, the recommended treatment of choice is surgery alone. However, in certain cases, further review of the staging and histology might reveal features of cancer within the sample that are at a high-risk of local recurrence, necessitating additional treatment intervention, ie chemotherapy or radiotherapy, to minimise this threat.

Following the primary treatment intervention (ie surgery), for low-risk/low-grade disease, the risk of local recurrence is usually low, as is the need for additional treatment intervention (chemotherapy or radiotherapy). Nonetheless, local recurrence is still a possibility. A failure to make the patient aware of this possibility creates a lack of trust and a false sense of hope ( Bumb et al, 2017 ), and evokes unnecessary emotional distress for the patient, their families and carers ( McClain, 2012 ).

As previously explained, the term ‘fully informed’ relates to a patient's entitlement to all information relevant to their situation and needs (including those about the actual and potential risks) ( McClain 2012 ). Informed knowledge is power, thus honesty is imperative ( Evans, 2017 ). The following case studies highlight the consequence of failing to fully inform patients about risks and diagnosis.

Case study 3. Consequences of not being fully informed

Mr White, aged 36, had been diagnosed with a low-grade/low-risk cancer. After the initial diagnosis was explained, Mr White was explicitly told by the doctor that after surgery he would not require any additional treatment. However, a subsequent review of his staging and histology revealed features of cancer within the sample that were at a high risk of local recurrence. Therefore the decision was made to offer Mr White additional treatment with radiotherapy to reduce the risk of recurrence down the line. Understandably, this news and the ensuing emotional impact—fear, anxiety and distress—was significant for Mr White. The author contends that, to avoid inciting these emotions, Mr White should have been fully informed, at the initial diagnosis, of the potential risks that further treatment might be necessary, no matter how unlikely these risks were perceived to be. Having observed the emotional impact on Mr White, and other similar cases in local practice, the author proposed that, when delivering a cancer diagnosis, consideration must be given not only to the physical, but also the emotional/psychological impact of the diagnosis on the individuals concerned and all risks, even those deemed small, discussed.

The following case study illustrates how a lack of honesty can lead to misinterpretation and misunderstanding of the messages relayed ( McClain, 2012 ; Bramhall, 2014 ) and, accordingly, raises questions regarding the patient's care.

Case study 4. Consequences of ‘sugar-coating’ a diagnosis

Mrs Black, aged 78, had been diagnosed with a low-grade/low-risk bladder cancer, for which the recommended treatment is a course of six doses of intravesical chemotherapy (mitomycin). In providing Mrs Black with the diagnosis, the doctor had failed to clarify that the term ‘bladder polyp/wort’ in fact meant cancer. It is evident to the UCNS that the doctor's intention was to reduce the impact of the news for Mrs Black. However, if a cancer diagnosis is not clearly explained at the outset ( Evans, 2017 ), then, as the UCNS's personal observations in practice have shown, the offer of subsequent cancer treatments will raise questions. In a follow-up meeting with the UCNS, Mrs Black queried why she was having a cancer treatment, when a cancer diagnosis had not been clearly given ( Bumb et al, 2017 ). In this instance, Mrs Black's query placed the UCNS in an uncomfortable position, but one in which she ultimately had to be honest in her response.

Despite the physician's good intentions, a lack of honesty or in this case ‘sugar-coating’ the truth was an infringement of Mrs Black's right to receive full and honest information regarding her diagnosis and treatments and impacted her ability to make clear decisions regarding her care ( McClain, 2012 ; Ali, 2017 ; Bumb et al, 2017 ).

Scenario: communicating in teams

In the UCNS's experience, effective communication is crucial when communicating in teams. The UCNS's observations in practice evoked reflection on past experiences of poor communication and its ensuing impact on her feelings, including hurt and, to some extent, a degree of anger.

Seemingly, poor communication is ingrained in all areas of practice and is highly evident in teams ( Doyle, 2019 ). The ability to communicate effectively is essential to team cohesiveness. One of the chief requirement is to facilitate an environment in which individuals can grow and excel, thus good/effective communication is vital. As previously stated, the tone of voice and actual words spoken are important ( Bramhall, 2014 ; Evans, 2017 ; Doyle, 2019 ). A tone that is respectful and conducive to elevating the individual's self-esteem and morale, ultimately increases self-worth and confidence. Conversely, a patronising attitude—a tone of voice and words spoken that imply sarcasm and disrespect—can, and often does, result in hurt feelings and a significant loss of confidence ( Doyle, 2019 ). Some senior professionals clearly believe in a hierarchy of entitlement to respect in the way that individuals communicate with other team members. A patronising tone of voice and words that imply sarcasm and disrespect impact significantly on individual team members' morale, self-esteem, self-worth, confidence and professional standing. This can lead to disharmony within the clinical environment. This could be communication between a consultant and a junior doctor, or a junior doctor and senior nurse, for example.

As health professionals, admittedly, we could all attest to poor communication at some point in our careers. Nevertheless, we have a responsibility to work and communicate effectively with other team members ( Ali, 2017 ; Doyle, 2019 ). The objective here is in facilitating a happy and functional team, one that demonstrates professionalism and competency in providing the care necessary to improving patients' experiences and outcomes ( Ali, 2017 ; Doyle, 2019 ). Securing improvements necessitates the health professional reflecting on their communication skills, acknowledging their limitations and initiating steps to address these ( Barber, 2016 ).

These case studies and scenario provide an insight into the UCNS's observations and reflections on her area of clinical practice and highlight the importance of effective communication. Acknowledgement of the inherent challenges within the communication process are clearly explained, with consideration given to the actual and potential impact in terms of patient, health professionals and clinical practice outcomes ( Oelofsen, 2012 ; RCN, 2019 ).

Communicating effectively is a key interpersonal skill that is fundamental to success in many aspects of life, but seemingly few people, including health professionals, have mastered the skill of truly effective communication. There are evident pitfalls that could lead to patient care being compromised as a result of poor communication between health professionals. The UCNS's role in delivering bad news and supporting patients involves ensuring that patients are adequately informed to enable them to take control of their individual situation and, accordingly, that they are able to make the appropriate choices and decisions for their respective needs. Poor communication within teams can affect patient care and staff morale, and learning how to communicate more effectively is beneficial in terms of improving staff interactions with each other. Essentially, communicating effectively is everyone's responsibility; hence, all health professionals should look at the way they interact and communicate with each other and take the necessary steps to improve this extremely important activity.

• The cancer clinical nurse specialist (CNS) role is pivotal when patients receive bad news. It is crucial not only to the individual's understanding of the diagnosis, prognosis and treatment options, but also to the provision of appropriate support following the bad news and countering the ensuing impact of the news on the patient
• Reflection is a powerful tool, one that enables nurses to examine their practice, identifying salient issues and initiate change/improvements
• Communicating effectively is a key interpersonal skill that is fundamental to success in many aspects of life—few people (in this context health professionals) have mastered the skill of truly effective communication
• Poor communication has implications for the patient, health professional and the health organisation

CPD reflective questions

• Reflection on practice is a key skill for nurses that enables them to identify salient issues and initiate actions to address these. How well do you think you reflect in practice, and does this provide the insight you seek?
• Effective communication is an important interpersonal skill. How well do you communicate with patients and colleagues in your area of practice? Reflect on any situations that you find difficult
• The issue of poor communication within teams and its impact on team members has been highlighted in this article. Have you observed poor communication within your team or within your area of practice? If so, how could this be improved?

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Effective communication between nurses and patients: an evolutionary concept analysis

Dorothy Afriyie

Student Nurse, University of West London, Brentford

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Communication can be considered as the basis of the nurse-patient relationship and is an essential element in building trust and comfort in nursing care. Effective communication is a fundamental but complex concept in nursing practice. This concept analysis aims to clarify effective communication and its impact on patient care using Rodgers's (1989) evolutionary framework of concept analysis. Effective communication between nurses and patients is presented along with surrogate terms, attributes, antecedents, consequences, related concepts and a model case. Effective communication was identified to be a multifactorial concept and defines as a mutual agreement between nurses and patients. This influences the nursing process, clinical reasoning and decision-making. Consequently, promotes high-quality nursing care, positive patient outcome and patient's and nurse's satisfaction of care.

Communication is an essential element of building trust and comfort in nursing, and it is the basis of the nurse–patient relationship ( Dithole et al, 2017 ). Communication is a complex phenomenon in nursing and is influenced by multiple factors, such as relationship, mood, time, space, culture, facial expression, gestures, personal understanding and perception ( McCarthy et al, 2013 ; Kourkouta and Papathanasiou, 2014 ). Effective communication has been linked to improved quality of care, patient satisfaction and adherence to care, leading to positive health outcomes ( Burley, 2011 ; Kelton and Davis, 2013 ; Ali, 2017 ; Skär and Söderberg, 2018 ). It is an important part of nursing practice and is associated with health promotion and prevention, health education, therapy and treatment as well as rehabilitation ( Fakhr-Movahedi et al, 2011 ). The Nursing and Midwifery Council (NMC) (2018) emphasised effective communication as one of the most important professional and ethical nursing traits. Nonetheless, communication remains a complicated phenomenon in nursing, and most patient-reported complaints in healthcare are around failed communication ( Reader et al, 2014 ). The aim of the present concept analysis is to explore and clarify the complexity of establishing effective communication between nurses and patients in practice.

Concept analysis

Concept analysis is the foundation and preparatory phase of nursing research ( Walker and Avant, 2011 ). Concept analysis aids in clarifying concepts in nursing by using simpler elements to reduce ambiguity and identify all aspects of a concept ( Nuopponen, 2010 ; Foley and Davis, 2017 ). Draper (2014) criticised concept analysis as being methodologically weak and philosophically dubious, further arguing that there is no evidence of its contribution to patient care. However, concept analysis facilitates the review of literature on a concept of interest, thereby enabling a thorough examination of the concept ( Bergdahl and Berterö, 2016 ). This helps in understanding the concept and, therefore, applying it appropriately. Correspondingly, understanding key concepts in nursing practice enables the nurse to identify strategic interventions that could benefit patients. Although McKenna (1997) argued that there is no definite meaning of a concept because they are experienced and perceived differently by people, Walker and Avant (2011) highlighted that the ability of the nurse to describe concepts in an exploratory way is an important means to demonstrate evidence base in practice. Nursing is an evidence-based practice; hence it is the responsibility of the nurse to keep up-to-date with quality evidence and demonstrate it in practice ( Thompson, 2017 ). Therefore, it is paramount for nurses to understand concept analysis and be able to analyse key concepts in nursing.

This concept analysis aims to clarify the concept of effective communication and address the gap in knowledge using Rodgers's (1989) theoretical framework. The evolutionary method of concept analysis was chosen because it adopts a systematic approach with focused phases ( Tofthagen and Fagerstrøm, 2010 ). Rodgers's (1989) method is perceived as a simultaneous task approach, which does not seek boundaries to restrict a concept and considers its application within multiple contexts ( Gallagher, 2007 ). However, the framework will be used because it facilitates an exploration and deep comprehension of a concept ( McCuster, 2015 ). Additionally, the framework offers an alternative to a positivist approach to concepts, allowing different findings depending on the situation ( Ghafouri et al, 2016 ). Moreover, the framework provides an opportunity to identify attributes and related features in a manner that minimises bias ( McCuster, 2015 ). Effective communication between patients and nurses was analysed using the seven phases of Rodgers's (1989) evolutionary method ( Box 1A ). Further, the following four questions were addressed ( Box 1B ).

Box 1A.Rodgers's method of analysis (1989)

Box 1B.Rationale for the four focused questionsThe focus questions were driven by the Rodgers's (1989) framework of concept analysis; the four questions are aimed at analysing the concept of effective communication using the seven stages of the framework in a systematic manner to engender an understanding of effective communication

• What is effective communication?
• What are the surrogate terms and related use of the concept of effective communication?
• What attributes, antecedents and consequences apply to the concept of effective communication?
• Who benefits from effective communication between nurses and patients?

Identifying the appropriate realm for data collection

As endorsed by Brown (2005) , a comprehensive review of the literature was conducted for this analysis. Explicit inclusion and exclusion criteria were used to select relevant articles, as recommended by Tofthagen and Fagerstrøm (2010) . Two electronic databases-Cumulative Index for Nursing and Allied Health (CINAHL) and MEDLINE (Ovid)-were searched using the keywords ‘effective communication’ and ‘nurses’ and ‘patients’. The inclusion criteria allowed selection of only peer-reviewed academic journals written in the English language. Studies exploring or analysing effective communication among nurses and patients with underlying communication difficulties and cognitive disabilities were excluded, because it is likely that such patients or nurses represent a special challenge in communicating. Only articles exploring effective communication and factors that influence communication between nurses and patients were considered. A total of 2086 articles were retrieved from the databases, and these articles were screened for relevance by reading the abstract. Finally, 30 articles were determined to meet the inclusion criteria for the analysis ( Figure 1 ). The articles selected were published between 1965 and 2019.

Defining effective communication

The Cambridge English dictionary defines ‘effective’ as ‘successful or achieving the results that you want’ ( Cambridge University Press, 2018 ). According to the Oxford English Dictionary, communication is ‘imparting or exchanging information by speaking, writing or using some other medium’ ( Oxford University Press, 2018 ). The Department of Health and Social Care (2010) described communication as the meaningful exchange of facts, needs, opinions, thoughts, feelings or other information between two or more people. Further, communication can be face-to-face, over the phone or by written words. McCabe and Timmins (2013) also described communication as a cyclical and dynamic process, involving transmission, receiving and interpretation of information between people using verbal or non-verbal means. Rani (2016) simply described communication as ‘sharing meaning’.

Interestingly, Hazzard et al (2013) described communication as a primary condition of human consciousness. They further explained that people always identify themselves in a communicative state. This would imply that people are always exchanging information. The authors, however, described communication as the actions taken after speaking to someone; this highlights communication as responsive. This may be the action and reaction people adopt after a communicated request or statement. Nonetheless, Gadamer (1976) , a twentieth-century philosopher, highlighted communication as what we are and not just what we do. Kourkouta and Papathanasiou (2014) defined communication as the use of speech or other means to exchange information, thoughts and feelings among people. Therefore, effective communication may be classified as exchanging information, thoughts and feelings using either verbal or non-verbal expressions to successfully produce a desired or intended result.

Effective communication between nurses and patients may be analysed from both the nurse's and the patient's perspective. McCabe (2004) identified that the patients' perspective of effective communication entails patient-centred interaction. On the other hand, O'Hagan et al (2013) found that nurses' perspective of effective communication revolves around time, task, rapport and patients' agreement on what has been communicated. Although both perspectives appear to differ, they are both driven by the expectations of the patient and nurse. A nurse may ultimately identify effective communication as the ability to engage with patients and to achieve clinical goals. Similarly, patients may be influenced by their expectation regarding their management outcome ( Schirmer et al, 2005 ). Therefore, effective communication between nurses and patients may be defined as mutual agreement and satisfaction with care (provided and received).

Surrogate terms and relevant uses

The terms most commonly serving a manifestation of effective communication include: therapeutic communication, interpersonal relationship, intercommunication, interpersonal communication and concordance. From a literature search, these terms appear frequently, highlighting their close usage with the concept of effective communication ( Fleischer et al, 2009 ; Casey and Wallis, 2011 ; Jones, 2012 ; Bloomfield and Pegram, 2015 ; Daly, 2017 ). For example, through intercommunication or interpersonal communication, a nurse can encourage a patient to participate in their care decision-making. However, a patient's acceptance to engage in shared decision-making regarding care and agree with a negotiated care plan could reflect effective communication. This act of mutual agreement through negotiation and shared decision-making suggests concordance ( Mckinnon, 2013 ; Snowden et al, 2014 ). Abdolrahimi et al (2017) pointed out that therapeutic communication is the basis for effective communication. They highlighted therapeutic communication as an important means for establishing interpersonal relationships. These concepts are different from effective communication; however, these notions express an idea of the concept of effective communication and highlight an understanding of effective communication as emphasised by Rodgers (1989) .

Daly (2017) described communication as dynamic and cyclical, because it involves a process of transmission, receiving and interpretation through verbal or non-verbal means. This reflects the complexity of communication, which involves speaking, being heard, listening, understanding or being accepted, as well as being seen and acknowledged. Hence, assessing factors that could affect communication, such as noise or interference, is always crucial for effective communication ( McCabe and Timmins, 2013 ; Webb, 2018 ). Daly (2017) explained that other skills for effective communication, which are consciousness, compassion, competence, professionalism and person-centredness, are all important concepts in nursing studies and practice. This indicates that communication is intentional in nature, so the purpose and perspective of individuals involved should be valued and respected ( Jones, 2012 ). In the case of the nurse–patient relationship, a nurse must consider a patient's perspective, background and concerns when communicating. It is important for a nurse to be competent, ethical and professional and exhibit an individualised approach in communicating with patients ( Bramhall, 2014 ; Bloomfield and Pegram, 2015 ). For example, when communicating with a patient with no medical background, medical terms should be explained further or avoided. This promotes person-centredness, which is a determinant for effective communication for patients.

A nurse must respect human rights and be professional ( NMC, 2018 ). However, it can be challenging when communicating with a patient who does not want to communicate about their health, which reflects their right to autonomy. Nonetheless, it is paramount for a nurse to identify the purpose of communication and the difficulties, so that they can mitigate them as part of their professional and ethical duties ( Royal College of Nursing, 2015 ; NMC, 2018 ). This can be done by reassuring and encouraging patients. Correspondingly, this act of communication features in Duldt et al's (1983) theory of humanistic nursing communication. This theory is reflected in Bramhall (2014) and Kourkouta and Papathanasiou's (2014) exploration on communication in nursing. The theory explains the need for comprehensive and exclusive communication among nurses and clients as well as colleagues. The focus of the theory is on interpersonal communication and emphasises the need for humanistic approaches to help improve professional communication. These approaches include empathy, deeper respect, encouragement and interpersonal relationship. For example, listening to people, providing privacy when communicating, giving patients ample time, using kind and courteous words such as ‘please’ and ‘thank you’, as well as being frank and honest when communicating. All these approaches may promote effective communication between nurses and patients ( Jevon, 2009 ; Bramhall, 2014 ; Bloomfield and Pegram, 2015 ).

Further, Miller (2002) , Burley (2011) , Casey and Wallis (2011) , Jones (2012) Bloomfield and Pegram (2015) and Daly (2017) demonstrated how effective communication is key in the assessment, planning and implementation of personalised nursing care. Holistic assessment in nursing includes history-taking, general appearance, physical examination, vital signs and documentation ( Toney-Butler and Unison-Pace, 2018 ). Patient assessment aids in identifying the communication needs of a patient in order to promote person-centred care ( Toney-Butler and Unison-Pace, 2018 ). Moreover, non-verbal cues such as general appearance or posture are vital in communication, and understanding them could help in the assessment process. General appearance such as facial expressions, dressing, hair or skin integrity may convey information that may be helpful in the nursing assessment process. Although not ideal, however, appearance can be a powerful transmitter of intentional or unintentional messages ( Ali, 2018 ). For instance, a nurse may sense neglect or abuse when a patient appears physically unkempt, with bruises or sores. This may inform the nurse on appropriate questions to ask during history-taking in order to ascertain the patient's situation and safeguard, signpost or refer them for support if necessary. Nurses' ability to identify these concerns may aid in providing the best necessary care for their patients. This promotes person-centredness, which is perceived as a means of effective communication by patients ( McCabe, 2004 ).

Effective communication promotes comprehensive history-taking. History-taking involves communicating with patients to collect subjective data and using this information to determine management plans ( Jevon, 2009 ). In history-taking, inaccurate information may be collected when communication is not effective ( Burley, 2011 ; Jones, 2012 ; Daly, 2017 ). However, it is important for nurses to establish good personal relationships with patients, so the latter can feel comfortable in sharing their complaints ( Casey and Wallis, 2011 ). It needs to be noted that, since patients are experts in their own lives, the nurse's ability to make patients feel comfortable may encourage patients to share valuable information, as well as their expectations, concerns and fears. Effective communication is important if nurses are to implement their roles effectively with regard to holistic assessment, considering the subjective experience and characteristics of their patient. Further, a well-informed collaborative assessment through effective communication may contribute to positive patient management outcomes ( Kourkouta and Papathanasiou, 2014 ). For instance, a patient may convey all necessary information to a nurse during assessment, and this may inform the nurse and patient of the necessary examination and investigations to aid in evidence-based nursing diagnosis and a collaborative management plan. The ability to establish a mutual agreement for the nursing process suggests effective communication for both parties.

Effective communication aids in planning and implementing personalised care. It helps patients to set realistic goals and choose preferred management for better outcomes. Communication is a bidirectional process in which a sender becomes a receiver and vice versa ( Kourkouta and Papathanasiou, 2014 ). Therefore, there is a need for both patients and nurses to realise that they are partners in communicating care planning and implementation ( Bloomfield and Pegram, 2015 ). This realisation may promote the patient's dignity and may also influence patients' desire to adhere to their plan when they feel involved in decision-making ( Casey and Wallis, 2011 ). Conversely, patients may be reluctant and unhappy if they feel dictated to or patronised. Most importantly, involving patients through effective communication can empower them to have full control over their health and wellbeing. This is reflected in the self-care theory proposed by Orem (1991) and the theory of self-efficacy proposed by Bandura (1977) . These theories focus on the role of the individual in initiating and sustaining change and healthy behaviours. Orem (1991) reinforced the importance of communication, as self-care is learned through communication and interpersonal relationships.

Attributes of effective communication

Certain attributes can be used to develop a definition of effective communication that is more realistically reflective of how patients and nurses use the term in healthcare settings ( Rodgers and Knafi, 2000 ). The most common attributes identified in the literature include: effective communication as ‘a building foundation for interpersonal-relationship’, ‘a determinant of promoting respect and dignity’, ‘a precedent of achieving concordance’, ‘an important tool in empowering self-care in patient’, ‘a significant tool in planning and implementing person-centred care’ and ‘a determinant of clinical reasoning and the nursing process’ ( Casey and Wallis, 2011 ; Jones, 2012 ; McCabe and Timmins, 2013 ; Bramhall, 2014 ; Bloomfield and Pegram, 2015 ; Daly, 2017 ; Webb, 2018 ; Barratt, 2019 ). These attributes make it possible to identify situations that can be categorised under the concept of effective communication.

Antecedents of effective communication

According to the literature, antecedents to effective communication include: personality trait, perceived communication competence and level of education on communication. Personality traits were linked with communication in early research. Carment et al (1965) demonstrated that people who are introverts are less likely to communicate well compared with extroverts. McCroskey and Richmond (1990) also indicated that people with low self-esteem are less willing to communicate. This is because they are more sensitive to environmental cues ( Campbell and Lavallee, 1993 ). Additionally, McCroskey and Richmond (1990) asserted that people who perceived themselves as poor communicators may be less willing to communicate. Nonetheless, people who may be very capable of communicating may not be willing to, due to low self-esteem, anxiety or fear. As a result, such people may have low communication efficacy despite having high actual competence ( McCroskey and Richmond, 1990 ). Therefore, it is important for nurses to consider these factors when communicating with patients in order to identify their communication needs and manage them accordingly ( Daly, 2017 ). Furthermore, Dithole et al (2017) and Norouzinia et al (2016) highlighted that the nurse's level of education on communication may influence the ability to communicate effectively. Thus, incorporation of targeted communication skills education in the training curriculum and on-the-job training will empower nurses to communicate effectively with their patients.

Consequences of effective communication

The consequences of effective communication can be classified into patient–nurse-related and healthcare system-related outcomes. Skär and Söderberg (2018) mentioned that effective communication ensures a good healthcare encounter for patients. In the community settings, effective communication empowers patients to talk about their concerns and expectations ( Griffiths, 2017 ). Further, effective communication promotes a pleasant and comfortable hospital experience for patients as well as their families; this can also be reflected in the community settings, where patients may report pleasant and comfortable nursing care ( Newell and Jordan, 2015 ; Barratt, 2019 ). Kourkouta and Papathanasiou (2014) and Wikström and Svidén (2011) pointed out that the success of a nurse mostly depends on how effectively they can communicate with their patient. Conversely, ineffective communication may lead to unsuccessful outcomes. For example, a patient may convey their fears, signs and symptoms to a nurse and how the nurse decodes and applies the information may influence the intervention given ( Kourkouta and Papathanasiou, 2014 ). Likewise, a nurse may convey a piece of information to a patient, but the patient's understanding of the information will determine their action. Therefore, how the message is understood determines the action taken ( Kourkouta and Papathanasiou, 2014 ). Additionally, through effective communication, a patient may be empowered to have full control over their health and wellbeing ( Newell and Jordan, 2015 ) and may not require extended care. Clearly, effective communication can lead to positive and cost-saving consequences for patients, nurses and the healthcare system.

The final phase of Rodgers's (1989) method of analysis highlights an application of the concept in an exploratory case scenario. A model case for effective communication between a nurse and a patient is given in Box 2 . This case portrays effective communication between a nurse and a patient, revealing some surrogate terms, defining attributes, antecedents and consequences of the concept. The case model highlighted Audrey's positive engagement in her care decision-making when the nurse Dani communicated effectively. Dani visited Audrey in her home, where Audrey had spatial and environmental control, but she was reluctant to engage in her own care. Audrey perceived that other nurses did not involve her in her care decision-making. This indicates ineffective communication and may be attributed to factors such as age difference, generational gap, gender and culture and ethnic differences between Audrey and the other nurses ( Tay et al, 2011 ; Norouzinia et al, 2016 ).

Box 2.Model caseAudrey, a 90-year-old housebound patient with bilateral leg ulcers was visited by Dani, a 45-year-old community staff nurse working in a diverse multicultural district nursing team. On arrival, Dani introduced herself in a suitable tone, maintaining eye contact. Audrey responded in a low tone, without maintaining eye contact. Audrey appeared to be quiet and in a low mood; Dani identified this nonverbal cue and was determined to engage Audrey in conversation. Dani knew from her experience that leg ulcer treatment can affect a person's mental health, causing low self-esteem, fear and anxiety. Dani asked how Audrey felt and if there was something she could help her with. Audrey mentioned she was fine; her carers had visited and supported her with personal care, breakfast and medication, she had been waiting for the nurse's visit. Dani asked Audrey about her ulcers and how she felt about her dressings; Audrey mentioned she was fine, but expressed concerns about the ulcers not healing. Dani reassured Audrey, explained leg ulcers to her and advised Audrey about some effective practice to promote the healing process.Dani asked Audrey ‘How best can I help you, and how do you want your care to be delivered?’. Audrey responded, ‘You are the nurse, you know better’. Dani took ample time to explain to Audrey how she understands her own body better than any other person. Dani also reassured and encouraged Audrey that her opinions mattered, as this helped empower her, promoted her dignity and informed the nurse on how to care for her. Audrey then expressed to Dani that her other nurses, who are much younger than Dani, never ask her opinion regarding the ulcer management; hence, she was not willing to speak. Audrey mentioned that those nurses came in to re-dress her ulcers and they spoke to her about the care plan, but she did not feel involved in decision-making about her care. Audrey then mentioned that she did not mean to create problems or report anyone. Dani reassured Audrey that there would be no trouble, so she should not be afraid to speak up. Audrey thought that having an honest communication about her needs and views could create problems for her or for the nurses if it seemed that she had reported them.Dani then reassured and encouraged Audrey that the situation will be addressed in a professional manner, and none of the other nurses would feel they had been reported; however, they would involve her in her care and decision-making, which is the expectation. Audrey was then comfortable, communicated in a suitable tone and maintained eye contact with Dani. She asked Dani if she could bandage her right leg first, as she tends to be in pain for a long time when the left one is dressed first. Dani gained consent from Audrey, explained the procedure and advised Audrey to stop her whenever she experienced pain. Dani also asked Audrey a bit more about her pain and her analgesia. Dani identified that Audrey's analgesia had not been reviewed for over 3 years. Dani explained to Audrey that she would be making a referral to her GP about this matter. Audrey was very pleased and indicated she was happy with how Dani had communicated with her; she felt she could trust her. Dani was also pleased, because she could provide the best care for Audrey.

Another important factor that can affect effective communication is the environmental factor. Norouzinia et al (2016) revealed that the hospital environment is a barrier to effective communication for patients. Additionally, Tay et al. (2011) indicated the possibility of unilateral communication due to the hierarchical structure of the hospital environment. Conversely, although nurses may feel quite comfortable in the hospital or inpatient setting, they might feel relatively intimidated when visiting a patient's home. Therefore, an awareness of the contextual discomfort and how it may affect communication is important and should be considered when planning for effective two-way communication between the nurse and patient during home visits. Although all these factors are important in communication, a full discussion of these is beyond the scope of this paper and should be the focus of another complete work.

In the model case described in Box 2 , the nurse acknowledged that she was privileged to be a guest in Audrey's home, and she tailored her strategy to gain Audrey's perspective. The nurse's aim was to get Audrey involved in her care decision-making since Audrey knows herself best. Additionally, Audrey's participation in the decision-making made it possible for her to receive her preferred care. This shows that effective communication is bidirectional, and both partners (nurse and patient) must work together to achieve their desired outcomes, in this case, the patient's satisfaction with care and the nurse's ability to provide the best care.

Effective communication in nursing is clearly a complex, multidimensional and multifactorial concept. Factors such as emotions, general appearance, personality trait, mood and level of education on communication may influence the practice and outcome of effective communication. However, effective communication is an ultimate determinant of success for a nurse. Effective communication was defined as a mutual agreement and satisfaction of care for both patients and nurses. It has been linked to precede the achievement of concordance in patients, and in nurses, it influences clinical reasoning and the nursing process. This aids in implementing compassionate person-centred care and, when successful, it promotes positive patient outcomes and satisfaction with nursing care. Thus, effective communication is an important concept to prioritise in nursing education and practice. For this reason, engaging nurses in communication skills and on-the-job training will empower them to communicate effectively with their patients. As endorsed by Rodgers's (1989) , the outcome of this analysis is not the endpoint of the concept but should direct the future exploration of effective communication. Therefore, a systematic study of effective communication between nurses and patients as well as a systematic review considering effective communication among nurses and patients with underlying communication difficulties, cognitive disabilities and intercultural perspectives can ultimately enhance nursing science.

• Effective communication is a key component of nursing practice
• Effective communication is intentional in nature and can be improved through direct actions taken by the nurse
• Communication is a complex phenomenon and is an essential element of building trust and comfort in nursing
• Concept analysis is the basic way of understanding complex concepts and developing different meanings and perceptions

CPD REFLECTIVE QUESTIONS

• How might concept analysis be relevant in nursing studies or practice?
• What does effective communication mean to you?
• What are some challenges nurses face in communicating effectively?
• How can an interpersonal relationship between nurses and patients influence effective communication?

• Open access
• Published: 03 September 2021

A literature-based study of patient-centered care and communication in nurse-patient interactions: barriers, facilitators, and the way forward

• Abukari Kwame 1 &
• Pammla M. Petrucka 2  

BMC Nursing volume  20 , Article number:  158 ( 2021 ) Cite this article

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Providing healthcare services that respect and meet patients’ and caregivers’ needs are essential in promoting positive care outcomes and perceptions of quality of care, thereby fulfilling a significant aspect of patient-centered care requirement. Effective communication between patients and healthcare providers is crucial for the provision of patient care and recovery. Hence, patient-centered communication is fundamental to ensuring optimal health outcomes, reflecting long-held nursing values that care must be individualized and responsive to patient health concerns, beliefs, and contextual variables. Achieving patient-centered care and communication in nurse-patient clinical interactions is complex as there are always institutional, communication, environmental, and personal/behavioural related barriers. To promote patient-centered care, healthcare professionals must identify these barriers and facitators of both patient-centered care and communication, given their interconnections in clinical interactions. A person-centered care and communication continuum (PC4 Model) is thus proposed to orient healthcare professionals to care practices, discourse contexts, and communication contents and forms that can enhance or impede the acheivement of patient-centered care in clinical practice.

Peer Review reports

Providing healthcare services that respect and meet patients’ and their caregivers’ needs are essential in promoting positive care outcomes and perceptions of quality of care, thus constituting patient-centered care. Care is “a feeling of concern for, or an interest in, a person or object which necessitates looking after them/it” [ 1 ]. The Institute of Medicine (IOM) noted that to provide patient-centered care means respecting and responding to individual patient’s care needs, preferences, and values in all clinical decisions [ 2 ]. In nursing care, patient-centered care or person-centered care must acknowledge patients’ experiences, stories, and knowledge and provide care that focuses on and respects patients’ values, preferences, and needs by engaging the patient more in the care process [ 3 ]. Healthcare providers and professionals are thus required to fully engage patients and their families in the care process in meaningful ways. The IOM, in its 2003 report on Health Professions Education , recognized the values of patient-centered care and emphasized that providing patient-centered care is the first core competency that health professionals’ education must focus on [ 4 ]. This emphasis underscored the value of delivering healthcare services according to patients’ needs and preferences.

Research has shown that effective communication between patients and healthcare providers is essential for the provision of patient care and recovery [ 5 , 6 , 7 , 8 ]. Madula et al. [ 6 ], in a study on maternal care in Malawi, noted that patients reported being happy when the nurses and midwives communicated well and treated them with warmth, empathy, and respect. However, other patients said poor communication by nurses and midwives, including verbal abuse, disrespect, or denial from asking questions, affected their perceptions of the services offered [ 6 ]. Similarly, Joolaee et al. [ 9 ] explored patients’ experiences of caring relationships in an Iranian hospital where they found that good communication between nurses and patients was regarded as “more significant than physical care” among patients.

According to Boykins [ 10 ], effective communication is a two-way dialogue between patients and care providers. In that dialogue, both parties speak and are listened to without interrupting; they ask questions for clarity, express their opinions, exchange information, and grasp entirely and understand what the others mean. Also, Henly [ 11 ] argued that effective communication is imperative in clinical interactions. He observed that health and illness affect the quality of life, thereby making health communication critical and that the “intimate and sometimes overwhelming nature of health concerns can make communicating with nurses and other healthcare providers very challenging” [ 11 ]. Furthermore, Henly [ 11 ] added that patient-centered communication is fundamental to ensuring optimal health outcomes, reflecting long-held nursing values that care must be individualized and responsive to patient health concerns. Given the prevalence of face-to-face and device-mediated communications and interactions in healthcare settings, we must explore and clarify who, what, where, when, why, and how interactions with individuals, families, and communities are receiving care and health services [ 11 ].

The value of effective communication in nurse-patient clinical interactions cannot be overemphasized, as “research has shown that communication processes are essential to more accurate patient reporting and disclosure” [ 12 ]. Respectful communication between nurses and patients can reduce uncertainty, enhance greater patient engagement in decision making, improve patient adherence to medication and treatment plans, increase social support, safety, and patient satisfaction in care [ 12 , 13 ]. Thus, effective nurse-patient clinical communication is essential to enhancing patient-centered care and positive care outcomes.

Patient-centered communication, also known as person-centered communication or client-centered communication, is defined as a process that invites and encourages patients and their families to actively participate and negotiate in decision-making about their care needs, as cited in [ 7 ]. Patient-centered communication is crucial in promoting patient-centered care and requires that patients and their caregivers engage in the care process. As McLean [ 14 ] observed, patient-centered care can be enhanced through patient-centered communication by valuing patients’ dignity and rights. Through open communication and collaboration, where information and care plans are shared among care providers, patients, and their families, care provision becomes patient-centered [ 14 ].

Given the interconnected nature of patient-centered care and communication, we must identify the barriers and enablers of patient-centered care and communication and proposed efficient ways to enhance that because patient-centered communication is essential in achieving patient-centered care. Our aim in this paper is to identify the barriers and facilitators of patient-centered care and communication and propose and present a patient-centered care and communication continuum (PC4) Model to explain how patient-centered care can be enhanced in nurse-patient clinical interactions. As Grant and Booth argued, critical reviews are often used to present, analyse, and synthesized research evidence from diverse sources, the outcome of which is a hypothesis or a model as an interpretation of existing data to enhance evidence-based practice [ 15 ]. Thus, this critical literature review study explores the questions: what are the barriers and facilitators of patient-centered care and how can patient-centered care be enhanced through effective clinical communication?

An earlier version of this study was submitted as part of author AK’s doctoral comprehensive exams in February 2021. An interdisciplinary doctoral committee recommended many of the included literature and the questions explored in this study based on the current discourse of patient-centered care advocated for in many healthcare facilities and in recognition of the universal healthcare access objective of the health sustainable development goal. Additional searches for literature were conducted between September and November 2020 using keywords such as barriers and facilitators of nurse-patient interaction, patient-centered care, patient-centered communication , and nurse-patient communication . Databases searched included CINAHL, PubMed, Medline, and Google Scholar. Included studies in this critical review were empirical research on nurse-patient interactions in different care settings published in English and open access. All relevant articles were read, and their main findings relevant to our review questions were identified and organized into themes and subthemes discussed in this paper. Other published studies were read, and together with those that addressed the review question, a model was developed regarding how to enhance patient-centered care through effective communication.

Barriers to Patient-Centered Care and Communication

Nurses constitute a significant workforce of care providers whose practices can severely impact care outcomes (both positive and negative). Nurses spend much time with patients and their caregivers. As a result, positive nurse-patient and caregiver relationships are therapeutic and constitute a core component of care [ 9 , 13 ]. In many instances, nurses serve as translators or patients’ advocates, in addition to performing their primary care duties. Although good nurse-patient relationships positively impact nurse-patient communication and interaction, studies have shown that several factors impede these relationships with significant consequences on care outcomes and quality [ 6 , 16 , 17 ]. Thus, these barriers limit nurses’ and other care providers’ efforts to provide healthcare that meets patients’ and caregivers’ needs. We categorize the barriers to patient-centered care and communication into four kinds: institutional and healthcare system-related, communication-related, environment-related, and personal and behaviour-related barriers. Although these barriers are discussed in separate subheadings, they are interlinked in complex ways during clinical practice.

Institutional and Healthcare System Related Barriers

Many barriers to providing patient-centered care and communication during nurse-patient interactions emanate from healthcare institutional practices or the healthcare system itself. Some of these factors are implicated in healthcare policy or through management styles and strategies.

Shortage of nursing staff, high workload, burnout, and limited-time constituted one complex institutional and healthcare system-level barrier to effective care delivery [ 18 , 19 ]. For instance, Loghmani et al. [ 20 ] found that staffing shortages prevented nurses from having adequate time with patients and their caregivers in an Iranian intensive care unit. Limitations in nursing staff, coupled with a high workload, led to fewer interactions between nurses, patients, and caregivers. Similarly, Anoosheh et al. [ 16 ] found that heavy nursing workload was ranked highest as a limiting factor to therapeutic communication in nurse-patient interactions in Iran.

In a study on communication barriers in two hospitals affiliated with Alborz University of Medical Sciences, Norouzinia et al. [ 21 ] found that shortage of nurses, work overload, and insufficient time to interact with patients were significant barriers to effective nurse-patient interactions. Similar factors are identified as barriers to nurse-patient communication and interactions in other studies [ 13 , 16 , 18 ]. For instance, Amoah et al. [ 16 ] reported that nursing staff shortage and high workload were barriers to patient-centered care and therapeutic communication among Ghanaian nurses and patients. Amoah and colleagues reported a patient’s statement that:

[B]ecause there are few nurses at the ward, sometimes you would want a nurse to attend to you, but he or she might be working on another patient, so in such case, the nurse cannot divide him or herself into two to attend to you both [ 16 ].

Nurses and patients and their caregivers have noted that limited time affects nurse-patient interactions, communication, and care quality. Besides, Yoo et al. [ 22 ] reported that limited visiting hours affected communications between caregivers and nurses in a tertiary hospital in Seoul, Korea. Since the caregivers had limited time to spend with patients, they had little knowledge about the intensive care unit and distrusted the nurses.

Although nursing staff shortage is a significant barrier to patient-centered care and communication that healthcare institutions and managers must know, some healthcare scholars have critique nurses’ complaints of time limitation. For instance, McCabe [ 7 ] argued that the quality of nurse-patient interactions is what matters and not the quantity of time spent with patients and their caregivers. McCabe maintained that “spending long periods with patients does not always result in positive nurse-patient relationships” [ 7 ]. He argued that implementing patient-centered care does not require additional time; hence, nurses’ perceptions of being too busy cannot excuse poor therapeutic communication during clinical interactions. Instead, nurses are encouraged to develop self-awareness, self-reflection, and a commitment to ensuring that patients receive the needed care.

Another institution-related barrier to patient-centered care and communication is the healthcare system’s emphasis on task-centered care. Care providers are more focused on completing care procedures than satisfying patients’ and caregivers’ needs and preferences. This barrier to patient-centered care and communication is acknowledged in several studies [ 7 , 14 , 20 , 22 , 23 ]. For example, McLean [ 14 ] studied dementia care in nursing homes in the United States. She found that patient-centered care and communication in one nursing home (Snow I) were severely affected when nurses, physicians, and care managers focused on completing tasks or observing care and institutional routines to the detriment of satisfying patients’ care needs. However, in the other care home (Snow II), patient-centered care was enhanced as nurses, physicians, and the care home managers focused on addressing patients’ needs and values rather than completing care routines and tasks.

Similarly, Yoo and colleagues [ 22 ] observed that nurse-patient communication was affected when the ICU nurses placed urgency on completing tasks linked directly to patients’ health (e.g., stabilizing vital signs) than communicating to addressed patients’ specific needs. This evidence shows that when nurses are more task-focused, patients and caregivers are treated as bodies and objects, on which medical and care practices must be performed to restore health. Research has shown that when nurses focus on task-oriented care, it becomes hard to provide holistic care to patients or teach and communicate with patients even when nurses are less busy [ 20 ].

Nursing managers and their management styles can affect patient-centered care and communication. Studies have revealed that the management styles that nursing managers implement can either facilitate or impede patient-centered care [ 14 , 22 ]. When nurse managers orient their nursing staff towards task-centered care practices, it affects nurse-patient interaction and communication. Moreover, when nurse managers fail to address their staff’s mental health needs and personal challenges, it influences how nurses attend to patients’ care needs. For example, nurses have indicated that nurse-patient communication is affected when nurse managers are unsupportive or unresponsive to their needs [ 20 ].

In a study exploring nursing and midwifery managers’ perspectives on obstacles to compassion giving and therapeutic care across 17 countries, Papadopoulos et al. [ 24 ] discovered that nurses and midwifery managers’ characteristics and experiences could facilitate or impede compassion and therapeutic interactions in nursing care. Negative personal attitudes, including selfishness, arrogance, self-centeredness, rudeness, lack of leadership skills, the desire for power, and feelings of superiority among nurses and midwifery managers, were obstacles to compassion building. The study further showed that managers who emphasize rules, tasks, and results do not prioritize relationship-building and see their staff as workers rather than team members [ 24 ]. Therefore, nurse managers and care administrators must monitor nurse-patient interaction and communication to address nurses’ concerns and support them, especially in resource-constrained and high patient turnover contexts [ 25 , 26 ].

Communication-Related Barriers

Effective communication is essential to providing patient-centered care. Studies have shown that poor communication between care providers and patients and their caregivers affects care outcomes and perceptions of care quality [ 7 , 16 , 27 , 28 ]. A consistent communication-related barrier in nurse-patient interaction is miscommunication, which often leads to misunderstandings between nurses, patients, and their families [ 20 ]. Other communication-related barriers include language differences between patients and healthcare providers [ 6 , 16 , 27 ], poor communication skills, and patients’ inability to communicate due to their health state, especially in ICU, dementia, or end-of-life care contexts [ 13 , 22 ]. For instance, in their maternity care study, Madula et al. [ 6 ] noted that language barriers significantly affected effective communication between nurses/midwives and expectant mothers. A patient in their study indicated that although many nurses were polite and communicated well, some nurses had challenges communicating with patients in the Chitumbuka language, which affected those nurses’ ability to interact effectively with patients [ 6 ].

Furthermore, Norouzinia et al. [ 21 ] asserted that effective communication could not be established when nurses and patients have a language difference. Moreover, the meanings of certain non-verbal communication acts (e.g., head nodding, eye gaze, touch) can invoke different interpretations across different cultures, which could impede the interactions between patients and nurses. Even in healthcare contexts where nurses and patients speak the same language, “differences in vocabulary, rate of speaking, age, background, familiarity with medical technology, education, physical capability, and experience can create a huge cultural and communication chasm” between nurses and patients [ 12 ]. In ICU and other similar care settings, nurses find it difficult to effectively communicate with patients because the mechanical ventilators made it hard for patients to talk [ 22 ].

To overcome the communication-related barriers, healthcare institutions must make it a responsibility to engage translators and interpreters to facilitate nurse-patient interactions where a language barrier exists. Moreover, nurses working in ICU and other similar settings should learn and employ alternative forms of communication to interact with patients.

Environment-Related Barriers

The environment of the care setting can impact nurse-patient communication and the resulting care. Thus, “good health care experiences start with a welcoming environment” [ 29 ]. Mastors believed that even though good medicine and the hands working to provide care and healing to the sick and wounded are essential, we must not “forget the small things: a warm smile, an ice chip, a warm blanket, a cool washcloth. A pillow flipped to the other side and a boost in bed” [ 29 ]. The environment-related barriers are obstacles within the care setting that inhibit nurse-patient interaction and communication and may include a noisy surrounding, unkept wards, and beds, difficulties in locating places, and navigating care services. Noisy surroundings, lack of privacy, improper ventilation, heating, cooling, and lighting in specific healthcare units can affect nurse-patient communication. These can prevent patients from genuinely expressing their healthcare needs to nurses, which can subsequently affect patient disclosure or make nursing diagnoses less accurate [ 13 , 18 , 21 ]. For instance, Amoah et al. [ 16 ] revealed that an unconducive care environment, including noisy surroundings and poor ward conditions, affected patients’ psychological states, impeding nurse-patient relationships and communication. Moreover, when care services are not well-coordinated, new patients and their caregivers find it hard to navigate the care system (e.g., locating offices for medical tests and consultations), which can constrain patient-centered care and communication.

Reducing the environment-related barriers will require making the care setting tidy/clean, less noisy, and coordinating care services in ways that make it easy for patients and caregivers to access. Coordinating and integrating care services, making care services accessible, and promoting physical comfort are crucial in promoting patient-centered care, according to Picker’s Eight Principles of Patient-Centered Care [ 30 ].

Personal and Behaviour Related Barriers

The kind of nurse-patient relationships established between nurses and patients and their caregivers will affect how they communicate. Since nurses and patients may have different demographic characteristics, cultural and linguistic backgrounds, beliefs, and worldviews about health and illnesses, nurses’, patients’, and caregivers’ attitudes can affect nurse-patient communication and care outcomes. For instance, differences in nurses’ and patients’ cultural backgrounds and belief systems have been identified as barriers to therapeutic communication and care [ 12 , 13 , 21 ]. Research shows that patients’ beliefs and cultural backgrounds affected their communication with nurses in Ghana [ 16 ]. These scholars found that some patients refused a blood transfusion, and Muslim patients refused female nurses to attend to them because of their religious beliefs [ 16 ]. Further, when nurses, patients, or their caregivers have misconceptions about one another due to past experiences, dissatisfaction about the care provided, or patients’ relatives and caregivers unduly interfere in the care process, nurse-patient communication and patient-centered care were affected [ 16 , 21 ].

Similarly, nurse-patient communication was affected when patients or caregivers failed to observe nurses’ recommendations or abuse nurses due to misunderstanding [ 20 ], while patients’ bad attitudes or disrespectful behaviours towards nurses can inhibit nurses’ ability to provide person-centered care [ 31 ]. The above-reviewed studies provided evidence on how patients’ and caregivers’ behaviours can affect nurses’ ability to communicate and deliver patient-centered care.

On the other hand, nurses’ behaviours can also profoundly affect communication and care outcomes in the nurse-patient dyad. When nurses disrespect, verbally abuse (e.g., shouting at or scolding), and discriminate against patients based on their social status, it affects nurse-patient communication, care outcomes, and patient disclosure [ 6 , 32 ]. For instance, Al-Kalaldeh et al. [ 18 ] believe that nurse-patient communication is challenged when nurses become reluctant to hear patients’ feelings and expressions of anxiety. When nurses ignore patients’ rights to share ideas and participate in their care planning, such denials may induce stress, discomfort, lack of trust in nurses, thereby leading to less satisfaction of care [ 18 ].

Furthermore, when nurses fail to listen to patients’ and caregivers’ concerns, coerce patients to obey their rules and instructions [ 16 , 17 , 20 ], or fail to provide patients with the needed information, nurse-patient communication and patient-centered care practices suffer. To illustrate, in Ddumba-Nyanzia et al.‘s study on communication between HIV care providers and patients, a patient remarked that: “I realized no matter how much I talked to the counselor, she was not listening. She was only hearing her point of view and nothing else, [and] I was very upset” [ 17 ]. This quote indicates how care provider attitudes can constrain care outcomes. Due to high workload, limited time, poor remunerations, and shortage of personnel, some nurses can develop feelings of despair, emotional detachment, and apathy towards their job, which can lead to low self-esteem or poor self-image, with negative consequences on nurse-patient interactions [ 13 , 18 ].

Given the significance of effective communication on care, overcoming the above personal and behaviour related barriers to patient-centered care and communication is crucial. Nurses, patients, and caregivers need to reflect on the consequences of their behaviours on the care process. Thus, overcoming these barriers begins with embracing the facilitators of patient-centered care and communication, which we turn to in the next section.

Facilitators of patient-centered care and communication

Patient-centered care and communication can be facilitated in several ways, including building solid nurse-patient relationships.

First, an essential facilitator of patient-centered care and communication is overcoming practical communication barriers in the nurse-patient dyad. Given the importance of communication in healthcare delivery, nurses, patients, caregivers, nursing managers, and healthcare administrators need to ensure that effective therapeutic communication is realized in the care process and becomes part of the care itself. Studies have shown that active listening among care providers is essential to addressing many barriers to patient-centered care and communication [ 7 , 13 ]. Although handling medical tasks promptly in the care process is crucial, the power of active listening is critical, meaningful, and therapeutic [ 22 ]. By listening to patients’ concerns, nurses can identify patients’ care needs and preferences and address their fears and frustrations.

Another facilitator of patient-centered care is by understanding patients and their unique needs [ 25 ], showing empathy and attending attitudes [ 7 , 13 ], expressing warmth and respect [ 22 ], and treating patients and caregivers with dignity and compassion as humans. For instance, McCabe [ 7 ] noted that attending, which obligates nurses to demonstrate that they are accessible and ready to listen to patients, is a patient-centered care process; a fundamental requirement for nurses to show genuineness and empathy, despite the high workload. Showing empathy, active listening, respect, and treating patients with dignity are core to nursing and care, and recognized in the Code of Ethics for Nurses [ 33 ], and further emphasized in the ongoing revision of the Code of Ethics for nurses [ 34 ].

Besides, engaging patients and caregivers in the care process through sharing information, inviting their opinion, and collaborating with them constitutes another facilitator of patient-centered care and communication. When patients and caregivers are engaged in the care process, misunderstandings and misconceptions are minimized. When information is shared, patients and caregivers learn more about their health conditions and the care needed. As McLean [ 14 ] argued, ensuring open communication between care providers and patients and their families is essential to enhancing patient-centered care. Conflicts ensue when patients or their families are denied information or involvement in the care process. As a result, the Harvard Medical School [ 30 ] identified patient engagement, information sharing, and nurse-patient collaboration during care as essential patient-centered care principles.

Finally, health policy must be oriented towards healthcare practices and management to facilitate patient-centered care and communication. These policies, at a minimum, can involve changes in management styles within healthcare institutions, where nurse managers and healthcare administrators reflect on nursing and care practices to ensure that the Code of Ethics of Nurses and patients’ rights are fully implemented. Resource constraints, staff shortages, and ethical dilemmas mainly affect care practices and decision-making. Nonetheless, if patients are placed at the center of care and treated with dignity and respect, most of the challenges and barriers of patient-centered care will diminish. Empowering practicing nurses, equipping them with interpersonal communication skills through regular in-service training, supporting them to overcome their emotional challenges, and setting boundaries during nurse-patient interactions will enhance patient-centered care practices.

In line with the above discussion, Camara et al. [ 25 ] identify three core dimensions that nurses, patients, and caregivers must observe to enhance patient-centered care: treating the patient as a person and seeing the care provider as a person and a confidant. Regarding the first dimension, care providers must welcome patients, listen to them, share information with them, seek their consent, and show them respect when providing care. The second dimension requires that the healthcare provider be seen and respected as a person, and negative perceptions about care providers must be demystified. According to Camara et al. [ 25 ], care providers must not overemphasize their identities as experts but rather establish good relationships with patients to understand patients’ personal needs and problems. Lastly, patients and caregivers must regard care providers as confidants who build and maintain patients’ trust and encourage patients’ participation in care conversations. With this dimension, patients and caregivers must know that nurses and other care providers have the patient at heart and work to meet their care needs and recovery process.

Camara et al.‘s [ 25 ] three dimensions are essential and position patients, their caregivers, and nurses as partners who must engage in dialogic communication to promote patient-centered care. As a result, effective communication, education, and increased health literacy among patients and caregivers will be crucial in that direction.

Enhancing Patient-Centered Care and Communication: A Proposed Model

Nursing care practices that promote patient-centered communication will directly enhance patient-centered care, as patients and their caregivers will actively engage in the care process. To enhance patient-centered communication, we propose person-centered care and communication continuum (PC4) as a guiding model to understand patient-centered communication, its pathways, and what communication and care practices healthcare professionals must implement to achieve person-centered care. In this PC4 Model, we emphasize the person instead of the patient because they are a person before becoming a patient. Moreover, the PC4 Model is supposed to apply to all persons associated with patient care; thus, respect for the dignity of their personhood is crucial.

Although much is written about patient-centered communication in the healthcare literature, there is a gap regarding its trajectory and what communication content enhances patient-centered communication. Also, little is known about how different clinical discourse spaces influence communication and its content during nurse-patient clinical interactions. Using evidence from Johnsson et al. [ 3 ], Murira et al. [ 23 ], and Liu et al. [ 35 ], among other studies, we outline the components of the PC4 Model and how different discourse spaces in the clinical setting and the content of communication impact patient-centered care and communication.

The proposed PC4 Model in this paper has three unbounded components based on the purpose of and how communication is performed among care providers, patients, and their caregivers. Figure  1 illustrates the PC4 Model, its features, and trajectory.

A Person-Centered Care and Communication Continuum (PC4 Model)

Task-Centered Communication

At the lowest end of the PC4 Model is task-centered communication. Here, the care provider’s role is to complete medical tasks as fast as possible with little or no communication with the patient and their caregivers. Patients and caregivers are treated as bodies or objects whose disease symptoms need to be studied, identified, recorded, treated, or cured. As Johnsson et al. [ 3 ] observed, communication content at this stage is mainly biomedically oriented, where nurses and other healthcare professionals focus on the precise medical information (e.g., history taking, medical examination, test results, medication, etc.) about the patient. With a task-centered orientation, nurses make journal entries about their patients’ disease state and ensure that treatment plans, diagnostic tests, and medical prescriptions are completed. Communication at this stage is often impersonal or rigid (see [ 23 ] for details). Care providers may address patients and their caregivers by using informal attributes (e.g., bed 12, the woman in the red shirt, card 8, etc.), thereby ignoring patients’ and caregivers’ personal and unique identities. Patients’ and caregivers’ nonverbal communication signs are mostly overlooked.

Motivations for task-centered communication can be attributed to time limitation, high workload, and staff shortage, thereby pushing nurses and other care providers to reach as many patients as possible. Moreover, the healthcare system’s orientation towards and preference for biomedically-focused care seems to favour task-centered communication [ 7 , 14 ].

Depending on the clinical discourse space under which patient-provider interactions occur, different forms of communication are employed. Clinical discourse spaces can be public (e.g., in the ward, patient bedside), private (e.g., consulting rooms, medical test labs, nurse staff station, etc.), or semi-private (e.g., along the corridor) [ 35 ]. In these clinical discourse spaces, nurse-patient communication can be uninformed (patients or caregivers are not informed about patients’ care conditions or why specific data and routines are performed). It can be non-private (others can hear what the nurse and patient are talking about) or authoritative (care providers demonstrate power and control and position themselves as experts) [ 23 ]. Finally, in task-centered communication, healthcare providers often use medical jargon or terminologies [ 3 ] since the goal of communication is not to engage the patient in the process. Usually, patients or their caregivers are not allowed to ask questions, or their questions get ignored or receive superficial, incomprehensible responses.

Process-Centered Communication

Process-centered communication is an intermediate stage on the continuum, which could slip back into the task-centered or leap forward into person-centered communication. Through process-centered communication, care providers make an effort to know patients and their caregivers as they perform care routines. Care providers ask patients or their caregivers questions to understand the care conditions but may not encourage patients or caregivers to express their thoughts about their care needs. Patients and caregivers are recognized as persons with uniques care needs but may not have the agency to influence the care process. Care providers may chit-chat with patients or their caregivers to pass the time as they record patients’ medical records or provide care. Unlike task-centered communication, there is informative and less authoritative communication between nurses and patients and their caregivers. The goal of process-centered communication could be a mixture of instrumental and relational, with less display of power and control by nurses.

Person-Centered Communication

This is the highest point of the PC4 Model, where patient-centered care is actualized. At this stage of the communication continuum, patients and caregivers are treated as unique persons with specific care needs and are seen as collaborators in the care process. As McLean [ 14 ] observed, caregiving becomes a transactional relationship between the care provider and receiver at the person-centered stage of the continuum. The care itself becomes intersubjective, a mutual relational practice, and an ongoing negotiation for care providers and receivers [ 14 ].

The content of communication at this stage of the continuum is both “personal” and “explanatory” [ 3 ]. Nurses and other healthcare providers create meaningful relationships with patients and their caregivers, understand patients’ concerns, needs, and problems, use open-ended questions to encourage patients or caregivers to express their thoughts and feelings about the care situation. Nurses and other healthcare professionals explain care routines, patients’ health conditions, and management plans in lay language to patients and caregivers through person-centered communication. Accomplishing this level includes employing alternative forms of communication to meet the needs of intensive care unit patients, deaf patients, and ventilated and intubated patients. For instance, it has been shown that “deaf people […] frequently do not have access to clear and efficient communication in the healthcare system, which deprives them of critical health information and qualified health care” [ 36 ]. Empathetic communication practices, including active listening, showing genuine interest in patients’ care, and respect and warmth, become a significant part of nursing care [ 3 , 7 , 14 , 22 ].

Different communication strategies are employed based on the care situation and context. Chit-chatting, as a form of personal communication [ 3 ], use of humor as a communication strategy [ 7 , 8 ], and even maintaining silence [ 28 ] are essential in enhancing person-centered care and communication. Both care providers and patients or their caregivers use relationship-building and -protecting humor (see [ 28 ] for details) to address difficult situations in the care process.

Implications of the PC4 Model for Nursing Practice

Given the values of effective communication in nurse-patient interactions and care outcomes, nurses and other healthcare providers must ensure that they develop therapeutic relationships with patients, their families, and caregivers to promote person-centered care and communication. Achieving that begins with knowing and reflecting on the barriers of therapeutic communication and ways to minimize them. The PC4 Model draws nurses and all healthcare providers’ attention to patient-centered care pathways and how effective communication is necessary. Healthcare professionals, including nurses, must be aware of how their communication orientation–––either oriented toward completing tasks, following care processes or toward addressing patients’ and their caregivers’ needs––can impact patient-centered care. Healthcare providers must observe the care context, patients’ unique situations, their non-verbal language and action, and whether they belong to historically marginalized groups or cultures.

Mastors [ 29 ] has offered healthcare providers some guidance to reflect on as they communicate and interact with patients and caregivers. Thus, (a) instead of asking patients, “What’s the matter?“ care providers must consider asking them, “What’s important to you?“ With this question, the patient is given a voice and empowered to contribute to their own care needs. Care providers should (b) check with patients in the waiting room to update patients whose waiting time has been longer than usual, based on the care context. They should also (c) try to remember their conversations with patients to build on them during subsequent interactions. This continuity can be enhanced by nurse managers reexamining how they deploy care providers to patients. The same nurse can be assigned to the same patients for the duration of the patient’s stay to help patients feel valued and visible [ 29 ].

Knowledge of cultural competence, sensitivity, humility, and interpersonal communication skills will help achieve and implement the PC4 Model. As Cuellar [ 37 ] argues, “[h]umility is about understanding and caring for all people [and] being empathetic.“ Cultural competence is a “dynamic process of acquiring the ability to provide effective, safe, and quality care to the patients through considering their different cultural aspects” [ 38 ]. The concept of cultural competence entails “cultural openness, awareness, desire, knowledge and sensitivity” during care [ 39 ]. It demands that care providers respect and tailor care to align with patients’ and caregivers’ values, needs, practices, and expectations, based on care and moral ethics and understanding [ 39 ]. Active listening and showing compassion as therapeutic relationship-building skills are essential, and continuous education and mentorship will be crucial to developing these skills among healthcare providers.

We invite qualitative and quantitative studies, especially on language use and communication strategies, to explore and evaluate the PC4 Model. Providing in-depth and experiential data on ways to increase its effectiveness as a tool to guide healthcare providers is highly desired. More knowledge can support healthcare providers in offering evidence-based patient-centered care in different healthcare settings and units.

Conclusions

Effective communication is an essential factor in nurse-patient interactions and a core component of nursing care. When communication in the nurse-patient dyad is patient-centered, it becomes therapeutic. It allows for trust and mutual respect in the care process, thereby promoting care practices that address patients’ and caregivers’ needs, concerns, and preferences. We have identified the barriers and facilitators of patient-centered care and communication and proposed a person-centered care and communication continuum (PC4 Model) to demonstrate how patient-centered communication intersects with patient-centered care.

Availability of data and materials

Not applicable.

Abbreviations

Intensive Care Unit

Institution of Medicine

Person-Centered Care and Communication Continuum

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Acknowledgments

We express our gratitude to the first author’s doctoral committee members for their valuable comments, suggestions, and critique of an earlier version of this paper. We are also grateful to the anonymous reviewers for the insightful comments and suggestions that have helped us improve the study’s quality.

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Abukari Kwame is a Ph.D. candidate in Interdisciplinary Studies in the College of Graduate and Postdoctoral Studies, University of Saskatchewan, interested in patients' rights in nurse-patient clinical communications and interactions in the hospital setting. He holds two Master of Philosophy degrees in Indigenous Studies and English Linguistics. Abukari's research interests include language use in social interaction, health communication, First/Second language acquisition, African traditional medical knowledge, and Indigenous and qualitative research methodologies.

Pammla M. Petrucka is a professor in Nursing and has international research experience with many of her graduate students from Africa, Asia, and the Caribbean. Pammla has published extensively in the field of nursing. Her research interests are vast, including child and maternal health, Indigenous peoples' health, global health, and vulnerable populations, with extensive experiences in qualitative research and indigenous research methodologies. Pammla is co-editor of the BMC Nursing journal and a reviewer for many other academic journals.

The authors have not received any funding for the conduct, preparation, and publication of this paper.

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Both authors conceived the topic. PMP recommended the literature, AK searched and added more sources, and drafted the paper. PMP reviewed the paper for intellectual content. Both AK and PMP read and approved the final version.

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Kwame, A., Petrucka, P.M. A literature-based study of patient-centered care and communication in nurse-patient interactions: barriers, facilitators, and the way forward. BMC Nurs 20 , 158 (2021). https://doi.org/10.1186/s12912-021-00684-2

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Importance of the Communication in Nursing Essay

Introduction, types of communication, communication models, barriers to productive communication, ways to improve communication.

In the nursing field, productive communication is an important aspect of successful activities and the key to effective patient care. In case the management of a particular medical institution promotes creating conditions for such interaction, performance increases due to the minimization of errors and the exchange of experience among colleagues. Based on the modern principles of professional communication, one can distinguish several basic strategies of building relationships in nursing teams.

In addition, there are special models that characterize the features of information transfer among the parties involved and determine the possibilities of interaction. At the stage of building such relationships, some barriers may arise, which are essential to overcome timely. Respecting colleagues’ personal dignity and following the principles of professional ethics can help maintain productive communication in the nursing environment, thereby increasing the potential success of activities.

While examining the types of nursing communication in the context of the importance of specific approaches, classic concepts may be cited. In particular, Sibiya (2018) notes that there are two key types of interaction – verbal and non-verbal, and each of them has its unique goals and purposes. Verbal communication is carried out through speaking directly and exchanging words among the parties involved. Sibiya (2018) argues that this style of interaction is an important aspect of the nursing field and healthcare sector in general. Also, in addition to interpersonal professional contacts, employees can communicate with other stakeholders, for instance, patients and their relatives. Therefore, this form of interaction is significant in the considered environment.

The non-verbal mechanism is based not on speech but on body language. As Sibiya (2018) remarks, looks, gestures, emotional movements of hands, and other elements of non-verbal communication are involved in nursing, and about 60% of all interaction is carried out in this format (p. 21). In some situations, for instance, emergency cases, this type of contact is more effective than speech due to the natural ability of a person to perceive visual information more quickly.

While taking into account the specifics of the work of junior medical employees, additional communication methods may be identified based on the profile of their activities. However, the two styles considered are the most common principles of transmitting relevant information.

The analysis of nursing communication at a deeper level can make it possible to single out specific models that form the principles of transmission and perception of information. Sibiya (2018) cites three key interaction concepts – linear, interactive, and transactional. All these strategies are subordinate to the basic principles of communication, in particular, conveying data from one party to the other one, but the features of this transfer are distinctive.

The linear model is a classic strategy when speakers direct their messages to listeners and intend to convey certain information in the most understandable form. This principle is basic and does not have any unique features and associated conditions. The interactive model is a more complex form of interaction and involves a communication mode in which recipients of information can interpret certain data individually.

An example of communication among senior and junior nurses may be given in order to convey the meaning of such relationships in the context of advice and recommendations. Finally, the transactional model is the most complex form of interaction because, for its implementation, additional factors should be taken into account, for instance, time, place, environment, and other criteria that can affect the communication process. All the three models may be utilized in nursing and help healthcare providers understand one another successfully.

Despite clear instructions that medical employees should follow during their work, the communication process can be complicated by barriers caused by concomitant circumstances and affecting relationships. Norouzinia, Aghabarari, Shiri, Karimi, and Samami (2016) consider these aspects that make it difficult to maintain effective interaction and note several key obstacles – language, cultural, and educational. In addition, in some cases, more global factors may arise, for instance, political ones, when legal conventions affect nurses’ work (Norouzinia et al., 2016). These obstacles may occur both in verbal and non-verbal communication forms, which complicates the work to eliminate them.

These obstacles can be interconnected and create increased discomfort for employees. For instance, language barriers are characteristic of a diverse cultural environment, and accusations based on personal bias may cause conflicts in the workplace. Also, Norouzinia et al. (2016) mention the religious context and note that in some countries, nurses cannot touch colleagues or patients of the opposite sex, which creates challenges for non-verbal communication. As a result, performance indicators are reduced due to the inability to maintain a productive work environment in which each employee can count on effective interaction and support. Therefore, searching for methods to improve communication in the nursing area is one of the priority tasks in case one or more of the aforementioned barriers are identified.

In order to minimize potential barriers to productive communication in nursing, it is essential for all employees to be aware of the importance of appropriate behavioral patterns. For this purpose, MacLean, Kelly, Geddes, and Della (2017) offer to use special training materials at the early stages of education so that future employees could have an idea of ​​the basics of ethical interaction. The manifestation of bias based on individual prejudices is unacceptable since any conflicts can lower patient outcomes, which is unacceptable. The dignity of each employee is to be respected in order to avoid interpersonal contradictions.

To enhance unique communication skills, for instance, non-verbal ones, the management of medical institutions should promote the exchange of experience among subordinates and encourage teamwork. In the context of intense activities that many nurses face, Sibiya (2018) recommends avoiding unclear messages in order to prevent misunderstandings and make the exchange of information more productive.

In addition, the ability to be convincing is a valuable quality that may allow earning authority among colleagues and become an example for them. To train this skill, it is necessary to follow all the aforementioned aspects of work and take into account ethical forms of interaction in a professional nursing environment. These measures can improve the quality of communication and, therefore, expand opportunities for successful collaboration.

Compliance with the principles of ethical interaction can help improve nursing communication in all its manifestations and increase patient outcomes, which is the ultimate goal of all interventions. Both verbal and non-verbal contacts are common in the medical environment in question, and appropriate models may be applied. In nursing practice, some communication barriers arise periodically due to various factors. In order to exclude them and minimize the likelihood of conflicts, rejecting bias should be a mandatory attribute of junior medical employees’ activities, and the exchange of experience may help maintain productive interaction.

MacLean, S., Kelly, M., Geddes, F., & Della, P. (2017). Use of simulated patients to develop communication skills in nursing education: An integrative review. Nurse Education Today , 48 , 90-98.

Norouzinia, R., Aghabarari, M., Shiri, M., Karimi, M., & Samami, E. (2016). Communication barriers perceived by nurses and patients. Global Journal of Health Science , 8 (6), 65-74.

Sibiya, M. N. (2018). Effective communication in nursing. In N. Ulutasdemir (Ed.), Nursing (pp. 19-36). London, UK: IntechOpen.

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