communication in mental health nursing essay

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2.3 Therapeutic Communication

Therapeutic communication has roots going back to Florence Nightingale, who insisted on the importance of building trusting relationships with patients. She taught that therapeutic healing resulted from nurses’ presence with patients. [1] Since then, several professional nursing associations have highlighted therapeutic communication as one of the most vital elements in nursing. Therapeutic communication is a type of professional communication defined as the purposeful, interpersonal, information-transmitting process that leads to client understanding and participation. [2] Read an example of a nursing student using therapeutic communication in the following box.

Example of Nurse Using Therapeutic Listening

Ms. Z. is a nursing student (as simulated in Figure 2.1) [3] who enjoys interacting with patients. When she goes to patients’ rooms, she greets them and introduces herself and her role in a calm tone. She kindly asks patients about their problems and notices their reactions. She provides information and answers their questions. Patients perceive that she wants to help them. She treats patients professionally by respecting boundaries and listening to them in a nonjudgmental manner. She addresses communication barriers and respects patients’ cultural beliefs. She notices patients’ health literacy and ensures they understand her messages and patient education. As a result, patients trust her and feel as if she cares about them, so they feel comfortable sharing their health care needs with her. [4]

Photo showing a simulated student nurse interacting with a seated patient

Therapeutic communication is different from social interaction. Social interaction does not have a goal or purpose and includes casual sharing of information, whereas therapeutic communication has a goal or purpose for the conversation. An example of a nursing goal before using therapeutic communication is, “The client will share feelings or concerns about their treatment plan by the end of the conversation.”

Therapeutic communication includes active listening, professional touch, and a variety of therapeutic communication techniques.

Active Listening

Listening is an important part of communication. There are three main types of listening, including competitive, passive, and active listening. Competitive listening occurs when we are mostly focused on sharing our own point of view instead of listening to someone else. Passive listening occurs when we are not interested in listening to the other person, and we assume we understand what the person is communicating correctly without verifying their message. During active listening , we communicate both verbally and nonverbally that we are interested in what the other person is saying while also actively verifying our understanding with them. For example, an active listening technique is to restate what the person said and then verify our understanding is correct. This feedback process is the major difference between passive listening and active listening. [5]

Nonverbal communication is an important component of active listening. SOLER is a mnemonic for establishing good nonverbal communication with clients. SOLER stands for the following [6] :

S: S itting and squarely facing the client
O: Using o pen posture (i.e., avoid crossing arms)
L: L eaning towards the client to indicate interest in listening
E: Maintaining good e ye contact
R: Maintaining a r elaxed posture

Professional touch is a powerful way to communicate caring and empathy if done respectfully while also being aware of the client’s preferences, cultural beliefs, and personal boundaries. Nurses use professional touch when assessing, expressing concern, or comforting patients. For example, simply holding a patient’s hand during a painful procedure can effectively provide comfort.

For individuals with a history of trauma, touch can be negatively perceived, so it is important to ask permission before touching. Inform the person before engaging in medical procedures requiring touch such as, “I need to hold down your arm so I can draw blood.”

Nurses should avoid using touch with individuals who are becoming agitated or experiencing a manic or psychotic episode because it can cause escalation. It is also helpful to maintain a larger interpersonal distance when interacting with an individual who is experiencing paranoia or psychosis.

Therapeutic Communication Techniques

There are a variety of therapeutic techniques that nurses use to engage clients in verbalizing emotions, establishing goals, and discussing coping strategies. See Table 2.3a for definitions of various therapeutic communication techniques discussed in the American Nurse , the official journal of the American Nurses Association.

Table 2.3a Therapeutic Communication Techniques [7]


	Acceptance acknowledges a client’s emotions or message and affirms they have been heard. Acceptance isn’t necessarily the same thing as agreement; it can be enough to simply make eye contact and say, “I hear what you are saying.” Clients who feel their nurses are listening to them and taking them seriously are more likely to be receptive to care.	Client: “I hate taking all this medicine. It makes me feel numb.” Nurse (making eye contact): “Yes, I understand.”
	Clarification asks the client to further define what they are communicating. Similar to active listening, asking for clarification when a client says something confusing or ambiguous is important. It helps nurses ensure they understand what is actually being said and can help clients process their ideas more thoroughly.	Client: “I feel useless to everyone and everything.” Nurse: “I’m not sure I understand what you mean by useless. Can you give an example of a time you felt useless?”
	Focusing on a specific statement made by a client that seems particularly important prompts them to discuss it further. Clients don’t always have an objective perspective on their situation or past experiences, but as impartial observers, nurses can more easily pick out important topics on which to focus.	Client: “I grew up with five brothers and sisters. We didn’t have much money, so my mom was always working and never home. We had to fend for ourselves, and there was never any food in the house.” Nurse: “It sounds as if you experienced some stressful conditions growing up.”
	Exploring gathers more information about what the client is communicating.	Client: “I had to lie when I found out a dark secret about my sister.” Nurse: “If you feel comfortable doing so, tell me more about the situation and your sister’s dark secret.”
	Giving recognition acknowledges and validates the client’s positive health behaviors. Recognition acknowledges a patient’s behavior and highlights it without giving an overt compliment. A compliment can sometimes be taken as condescending, especially when it concerns a routine task like making the bed.	Nurse: “I noticed you took all of your medications.”
	Using open questions or offering general leads provides keywords to “open” the discussion while also seeking more information. Therapeutic communication is most effective when clients direct the flow of conversation and decide what to talk about. Giving patients a broad opening such as “What’s on your mind today?” or “What would you like to talk about?” is a good way to encourage clients to discuss what’s on their mind.	Client: “I’m unsure of what to do next.” Nurse: “Tell me more about your concerns.”
	Paraphrasing rephrases the client’s words and key ideas to clarify their message and encourage additional communication.	Client: “I’ve been way too busy today.” Nurse: “Participating in the support groups today has kept you busy.”
	Presenting reality restructures the client’s distorted thoughts with valid information.	Client: “I can’t go in that room; there are spiders on the walls.” Nurse: “I see no evidence of spiders on the walls.”
	Restating uses different word choices for the same content stated by the client to encourage elaboration.	Client: “The nurses hate me here.” Nurse: “You feel as though the nurses dislike you?”
	Reflecting asks clients what they think they should do, encourages them to be accountable for their own actions, and helps them come up with solutions.	Client: “Do you think I should do this new treatment or not?” Nurse: “What do you think the pros and cons are for the new treatment plan?”
	Providing silence allows quiet time for self-reflection by the client.	The nurse does not verbally respond after a client makes a statement, although they may nod or use other nonverbal communication to demonstrate active listening and validation of the client’s message.
	Observations about the appearance, demeanor, or behavior of patients can help draw attention to areas that might pose a problem for them.	Nurse: “You look tired today.” Client: “I haven’t been getting much sleep lately because of so many racing thoughts in my head at night.”
	Offering self provides support by being present. Inpatient care can be lonely and stressful at times. When nurses provide presence and spend time with their clients, it shows clients they value them and are willing to give them time and attention.	Offering to simply sit with clients for a few minutes is a powerful way to create a caring connection.
	Asking about perceptions in an encouraging, nonjudgmental way is important for clients experiencing sensory issues or hallucinations. It gives clients a prompt to explain what they’re perceiving without casting their perceptions in a negative light. It is also important to establish safety by ensuring the hallucinations are not encouraging the client to harm themselves or others.	The client looks distracted and frightened as if they see or hear something. Nurse: “It looks as though you might be hearing something. What do you hear now?” or “It looks as if you might be seeing something. What does it look like to you?”
	Encouraging comparisons helps clients reflect on previous situations in which they have coped effectively. In this manner, nurses can help clients discover solutions to their problems.	Nurse: “It must have been difficult when you went through a divorce. How did you cope with that?” Client: “I walked my dog outside a lot.” Nurse: “It sounds as though walking your dog outside helps you cope with stress and feel better?”
	Offering hope encourages a client to persevere and be resilient.	Nurse: “I remember you shared with me how well you coped with difficult situations in the past.”
	Humor can lighten the mood and contribute to feelings of togetherness, closeness, and friendliness. However, it is vital for the nurse to tailor humor to the client’s sense of humor.	Nurse: “Knock, knock.” Client: “Who’s there?” Nurse: “Orange.” Client: “Orange who?” Nurse: “Orange you glad to see me?” (Laughs with the client)
	Confronting presents reality or challenges a client’s assumptions. Nurses should only apply this technique during the working phase after they have established trust. Confrontation, when used correctly, can help clients break destructive routines or understand the state of their current situation.	Client: “I haven’t drunk much this year.” Nurse: “Yesterday you told me that every weekend you go out and drink so much you don’t know where you are when you wake up.”
	Summarizing demonstrates active listening to clients and allows the nurse to verify information. Ending a discussion with a phrase such as “Does that sound correct?” gives clients explicit permission to make corrections if they’re necessary.	Client: “I don’t like to take my medications because they make me tired, and I gain a lot of weight.” Nurse: “You haven’t been taking your medications this month because of the side effects of fatigue and weight gain. Is that correct?”

Nontherapeutic Responses

Nurses must be aware of potential barriers to communication and avoid nontherapeutic responses. Nonverbal communication such as looking at one’s watch, crossing arms across one’s chest, or not actively listening may be perceived as barriers to communication. Nontherapeutic verbal responses often block the client’s communication of feelings or ideas. See Table 2.3b for a description of nontherapeutic responses to avoid.

Table 2.3b Nontherapeutic Responses [8] , [9]


	Asking personal questions that are not relevant to the situation is not professional or appropriate. Don’t ask questions just to satisfy your curiosity.	Nontherapeutic: “Why have you and Mary never gotten married?” Therapeutic: “How would you describe your relationship with Mary?”
	Giving personal opinions takes away the decision-making from the client. Effective problem-solving must be accomplished by the client and not provided by the nurse.	Nontherapeutic: “If I were you, I would put your father in a nursing home to reduce your stress.” Therapeutic: “Let’s explore options for your father’s care.”
	Changing the subject when someone is trying to communicate with you demonstrates lack of empathy and blocks further communication. It communicates that you don’t care about what they are sharing.	Nontherapeutic: “Let’s not talk about your insurance problems; it’s time for your walk now.” Therapeutic: “After your walk, let’s look into what is going on with your insurance company.”
	Generalizations and stereotypes can threaten nurse-patient relationships.	Nontherapeutic: “Older adults are always confused.” Therapeutic: “Tell me more about your concerns about your father’s confusion.”
	When a client is seriously ill or distressed, the nurse may be tempted to offer false hope with statements that everything will be alright. These comments can discourage further expressions of a client’s feelings.	Nontherapeutic: “You’ll be fine; don’t worry.” Therapeutic: “It must be difficult not to know what will happen next. What can I do to help?”
	Sympathy focuses on the nurse’s feelings rather than the client. It demonstrates pity rather than trying to help the client cope with the situation.	Nontherapeutic: “I’m so sorry about your amputation; I can’t imagine losing my leg due to a car crash.” Therapeutic: “The loss of your leg is a major change. How do you think this will affect your life?”
	A nurse may be tempted to ask the client to explain “why” they believe, feel, or act in a certain way. However, clients and family members can interpret “why” questions as accusations and become defensive. It is best to rephrase a question to avoid using the word “why.”	Nontherapeutic: “Why are you so upset?” Therapeutic: “You seem upset. Tell me more about that.”
	Nurses should not impose their own attitudes, values, beliefs, and moral standards on others while in the professional nursing role. Judgmental messages contain terms such as “should,” “shouldn’t,” “ought to,” “good,” “bad,” “right,” or “wrong.” Agreeing or disagreeing sends the subtle message that a nurse has the right to make value judgments about the client’s decisions. Approving implies that the behavior being praised is the only acceptable one, and disapproving implies that the client must meet the nurse’s expectations or standards. Instead, the nurse should assist the client to explore their own values, beliefs, goals, and decisions.	Nontherapeutic: “You shouldn’t consider elective surgery; there are too many risks involved.” Therapeutic: “You are considering having elective surgery. Tell me more about the pros and cons of surgery.”
	When clients or family members express criticism, nurses should listen to the message. Listening does not imply agreement. To discover reasons for the client’s anger or dissatisfaction, the nurse should listen without criticizing, avoid being defensive or accusatory, and attempt to defuse anger.	Client: “Everyone is lying to me!” Nontherapeutic: “No one here would intentionally lie to you.” Therapeutic: “You believe people have been dishonest with you. Tell me more about what happened.” (After obtaining additional information, the nurse may elect to follow the chain of command at the agency and report the client’s concerns for follow-up.)
	Passive responses serve to avoid conflict or sidestep issues, whereas aggressive responses provoke confrontation. Nurses should use assertive communication.	Nontherapeutic: “It’s your fault you are feeling ill because you didn’t take your medicine.” Therapeutic: “Taking your medicine every day can prevent these symptoms from returning.”
	Arguing against client perceptions denies that they are real and valid. They imply that the other person is lying, misinformed, or uneducated. The skillful nurse can provide information or present reality in a way that avoids argument.	Nontherapeutic: “How can you say you didn’t sleep last night when I heard you snoring!” Therapeutic: “You don’t feel rested this morning? Let’s talk about ways to improve the quality of your rest.”

See the following box for a summary of tips for using therapeutic communication and avoiding common barriers to therapeutic communication.

Tips for Effective Therapeutic Communication

Establish a goal for the conversation.
Be self-aware of one’s nonverbal messages.
Observe the client’s nonverbal behaviors and actions as ‘cues’ for assessments and planning interventions.
Avoid self-disclosure of personal information and use professional boundaries. (Review boundary setting in the “ Boundaries ” section of Chapter 1.)
Be patient-centered and actively listen to what the client is expressing (e.g., provide empathy, not sympathy; show respect; gain the client’s trust; and accept the person as who they are as an individual).
Be sensitive to the values, cultural beliefs, attitudes, practices, and problem-solving strategies of the client.
Effectively use therapeutic communication techniques.
Recognize themes in a conversation (e.g., Is there a theme emerging of poor self-esteem, guilt, shame, loneliness, helplessness, hopelessness, or suicidal thoughts?).

Common Barriers to Therapeutic Communication

Using a tone of voice that is distant, condescending, or disapproving.
Using medical jargon or too many technical terms.
Asking yes/no questions instead of open-ended questions.
Continually asking “why,” causing the client to become defensive or feel challenged by your questions.
Using too many probing questions, causing the client to feel you are interrogating them, resulting in defensiveness or refusal to talk with the nurse.
Lacking awareness of one’s biases, fears, feelings, or insecurities.
Causing sensory overload in the client with a high emotional level of the content.
Giving advice.
Blurring the nurse-client relationship boundaries (e.g., assuming control of the conversation, disclosing personal information, practicing outside one’s scope of practice).

Recognizing and Addressing Escalation

When communicating therapeutically with a client, it is important to recognize if the client is escalating with increased agitation and becoming a danger to themselves, staff, or other patients. When escalation occurs, providing safety becomes the nurse’s top priority, and the focus is no longer on therapeutic communication. Read more information in the “ Crisis and Crisis Intervention ” section of the “Stress, Coping, and Crisis Intervention” chapter.

Cultural Considerations

Recall the discussion from Chapter 1 on how cultural values and beliefs can impact a client’s mental health in many ways. Every culture has a different perspective on mental health. For many cultures, there is stigma surrounding mental health. Mental health challenges may be considered a weakness and something to hide, which can make it harder for those struggling to talk openly and ask for help. Culture can also influence how people describe and feel about their symptoms. It can affect whether someone chooses to recognize and talk openly about physical symptoms, emotional symptoms, or both. Cultural factors can determine how much support someone gets from their family and community when it comes to mental health. [10]

Nurses can help clients understand the role culture plays in their mental health by encouraging therapeutic communication about their symptoms and treatment. For example, a nurse should ask, “What do you think is wrong? How would you treat your symptoms?”

Read more about providing culturally responsive care in the “ Diverse Clients ” chapter of Open RN Nursing Fundamentals .

Karimi, H., & Masoudi Alavi, N. (2015). Florence Nightingale: The mother of nursing. Nursing and Midwifery Studies, 4 (2), e29475. https://doi.org/10.17795/nmsjournal29475 ↵
Abdolrahimi, M., Ghiyasvandian, S., Zakerimoghadam, M., & Ebadi, A. (2017). Therapeutic communication in nursing students: A Walker & Avant concept analysis. Electronic Physician, 9 (8), 4968–4977. https://doi.org/10.19082/4968 ↵
“ beautiful african nurse taking care of senior patient in wheelchair ” by agilemktg1 is in the Public Domain. ↵
This work is a derivative of Human Relations by LibreTexts and is licensed under CC BY-NC-SA 4.0 ↵
Stickley, T. (2011). From SOLER to SURETY for effective non-verbal communication. Nurse Education in Practice, 11 (6), 395–398. https://doi.org/10.1016/j.nepr.2011.03.021 ↵
American Nurse. (n.d.). Therapeutic communication techniques . https://www.myamericannurse.com/therapeutic-communication-techniques/ ↵
StatPearls by Sharma & Gupta is licensed under CC BY 4.0 ↵
Mental Health First Aid USA. (2019, July 11). Four ways culture impacts mental health. National Council for Mental Wellbeing. https://www.mentalhealthfirstaid.org/2019/07/four-ways-culture-impacts-mental-health/ ↵

A type of professional communication defined as the purposeful, interpersonal, information-transmitting process that leads to client understanding and participation.

Communicating both verbally and nonverbally that we are interested in what the other person is saying while also actively verifying our understanding with them.

A mnemonic for effective nonverbal communication.

Nursing: Mental Health and Community Concepts Copyright © 2022 by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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UNLV Theses, Dissertations, Professional Papers, and Capstones

Improving therapeutic communication in mental health nursing: a quality improvement project.

Patricia A. Nill Follow

Degree Type

Dissertation

Degree Name

Doctor of Nursing Practice (DNP)

First Committee Member

Mary Bondmass

Second Committee Member

Third committee member, number of pages.

Over 46 million adults in the United States (U.S.) live with a mental illness. Locally in Nevada, the psychiatrist to patient ratio is approximately 700:1, and patients are seen primarily in the inpatient setting, if seen at all, due to the wait average of 85 hours in the hospital emergency rooms for access into mental health hospitals or specialty units of a general hospital. Moreover, costs for mental health mood disorders alone are estimated at over seven million dollars annually. The Institute of Medicine (IOM) opined the need for change in healthcare to redesign practice and clinical communication with patients in all healthcare settings; however, more is still needed in mental health. Therapeutic communication is essential to meet the patient's physical and psychological needs while establishing the nurse-patient trusting relationship. Clinical outcomes in mental health settings remain poor, with non-therapeutic communication resulting in poor patient outcomes. A leading cause of inadequate treatment includes non-therapeutic communication during pre- and post-discharge treatment.

It is not well described in the literature what role nurses play, nationally or locally, in ensuring the safe transition of mental health patients from an emergency room to a specialty unit. Mental health nurses are expected to complete clinical assessments on admitted clients, including effective therapeutic interpersonal communication techniques and psychosocial intervention skills to provide safety, trust, collaboration with rapport, respect, genuineness with the caring emphasis, and empathy. Nurses may be able to decrease adverse events within mental health settings, in part, by practicing therapeutic communication; unfortunately, evidence shows that nurses are often unprepared in mental health to incorporate therapeutic communication and relationship building among their patients. Expected knowledge of, and competence in therapeutic communication would seem to be a logical requirement for mental health nurses; however, Nevada's current practice does not require demonstrated knowledge and competency in therapeutic communication between mental health nurses and patients in hospital settings. Competency development may guide nurses to develop critical thinking skills to practice and support psychiatric patients to achieve optimal outcomes.

The lack of required knowledge and competency related to therapeutic communication is the underlying impetus for this Doctor of Nursing Practice (DNP) project. The purpose of this DNP project was to develop, implement, and evaluate an educational module for mental health nurses and staff to improve knowledge and competency in therapeutic communication with their patients. The TeamSTEPPS® Program was adapted to develop a mental health-specific educational module focused on therapeutic communication to accomplish this purpose. The educational module was implemented online due to Covid-19 Pandemic, and this intervention was evaluated using four previously validated TeamSTEPPS® instruments.

Fifty-two participants were included in this project. Results indicated a statistically significant change in knowledge and competency pre- compared to the post-intervention with the educational module. Based on the results of this project, one may conclude that implementing additional mental health education for nurses may improve their knowledge and competency related to therapeutic communications with their patients, as was demonstrated in this project.

Communication; Mental health; Outpatient; Psychiatric; Safety; Therapeutic communication

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Communication | Mental and Social Health | Nursing

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University of Nevada, Las Vegas

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Nill, Patricia A., "Improving Therapeutic Communication in Mental Health Nursing: A Quality Improvement Project" (2021). UNLV Theses, Dissertations, Professional Papers, and Capstones . 4177. http://dx.doi.org/10.34917/25374070

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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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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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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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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)

Stage 1: Identify and name the concept of interest

Stage 2: Identify surrogate terms and relevant uses of the concept

Stage 3: Identify and select an appropriate realm (sample) for data collection

Stage 4: Identify the attributes of the concept

Stage 5: Identify the references, antecedents, and consequences of the concept, if possible

Stage 6: Identify concepts that are related to the concept of interest

Stage 7: Identify a model case of the concept

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?

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Communication as an Aspect of Mental Health Nursing Care

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Mental Health: Nursing Care Essay Sample

"Mental health nursing is a multifaceted profession that requires the integration of biopsychosocial approaches, holistic assessment, planning and implementation, evidence-based communication strategies, and a deep understanding of the interplay between risk, ethics, law, and service-user perspectives."

Nursing Care, Mental Health Nursing

Introduction

Mental health nursing is a complex and dynamic field that requires a comprehensive understanding of the diverse factors that influence mental health and well-being. The biopsychosocial model, which encompasses biological, psychological, and social factors, provides a valuable framework for understanding and addressing the multifaceted nature of mental health care (Engel, 1977). In this essay, we will critically examine the biopsychosocial approach to mental health care, with a focus on the essential skills required by mental health nurses to promote biological, psychological, and social health. The discussion will be structured around the following key areas: biopsychosocial approaches, the role of mental health nurses in holistic assessment, planning and implementation, evidence-based communication strategies, and the interface between risk, ethics, law, and service-user perspectives in mental health care. Through a thorough exploration of these topics, we will establish the importance of mental health nursing skills in promoting comprehensive and effective care across a variety of settings.

Biopsychosocial Approaches: Critically Examining Mental Health Care

The biopsychosocial model, initially proposed by Engel (1977), provides a comprehensive framework for understanding mental health care by considering the interplay between biological, psychological, and social factors. This model challenges the traditional biomedical paradigm, which primarily focuses on physiological processes and tends to overlook the complexities of human experience (Ghaemi, 2009). The biopsychosocial approach acknowledges that mental health is influenced by multiple determinants, including genetic predispositions, individual experiences, and social context (Engel, 1977; White, 2005). This perspective facilitates a more nuanced understanding of mental health, recognizing that mental illness is a contested notion, influenced by various cultural, historical, and societal factors (Pilgrim & Rogers, 2005).

In recent years, the biopsychosocial model has been increasingly adopted in mental health care, as it accounts for the complex interplay of factors contributing to mental health and illness (Borrell-Carrió, Suchman, & Epstein, 2004). Epidemiological research demonstrates that mental health disorders are influenced by a multitude of determinants, including genetic predispositions, individual experiences, and social context (Kessler et al., 2005). Demographic factors, such as age, gender, and socioeconomic status, also play a significant role in shaping mental health outcomes (World Health Organization, 2001).

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By critically examining biopsychosocial approaches, mental health professionals can better understand the complex nature of mental illness and the various factors that contribute to its development and maintenance. This understanding allows for more targeted and effective interventions, as well as informing public health policies and strategies aimed at promoting mental health and well-being in diverse populations (Sartorius, 2007).

Furthermore, mental health nurses should be knowledgeable about various therapeutic approaches and interventions that can address the different aspects of the biopsychosocial model. For instance, cognitive-behavioral therapy (CBT) can help patients modify maladaptive thought patterns and behaviors, while family therapy can address social and relational issues that contribute to mental health problems (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012). Integrating these different therapeutic modalities allows mental health nurses to provide comprehensive care that addresses the full spectrum of factors impacting an individual's mental health.

In addition to integrating various therapeutic approaches, mental health nurses must also consider the role of epidemiology and demography in shaping mental health care. Epidemiological research can inform mental health nurses about the prevalence, distribution, and determinants of mental health disorders, helping them to identify vulnerable populations and implement targeted interventions (Whiteford et al., 2013). Demographic factors, such as age, gender, and socioeconomic status, also play a significant role in determining mental health outcomes and access to care (Kessler et al., 2005). By considering these factors, mental health nurses can develop a nuanced understanding of the complex interplay between individual, social, and environmental factors in mental health care.

Moreover, mental health nursing must be grounded in an understanding of mental illness as a contested notion. There are ongoing debates about the classification, diagnosis, and treatment of mental health disorders, with different perspectives emphasizing the role of biological, psychological, or social factors (Insel, 2010). By engaging with these debates and critically evaluating the evidence, mental health nurses can develop a more informed and flexible approach to mental health care, recognizing that there may be multiple valid perspectives and strategies for addressing mental health issues.

The Role of Mental Health Nurses: Holistic Assessment, Planning, and Implementation

Mental health nurses play a crucial role in providing holistic care that addresses the diverse needs of individuals experiencing mental health challenges. By adopting a biopsychosocial approach, they can assess, plan, and implement interventions that consider the interrelated aspects of patients' lives (Barker, 2018). In doing so, mental health nurses collaborate with patients, families, and interdisciplinary teams to develop and deliver comprehensive, person-centered care plans (Videbeck, 2017). This systematic approach promotes safety, effectiveness, and a positive therapeutic environment across various settings, such as inpatient units, community mental health services, and specialized clinics (Barker, 2018).

Mental health nurses are at the forefront of providing holistic care to individuals experiencing mental health challenges. Their role extends beyond merely addressing the symptoms of mental illness; they are responsible for assessing and considering the broader biopsychosocial context in which mental health issues arise (Barker, 2018).

One essential aspect of this role involves conducting comprehensive assessments that consider the biological, psychological, and social factors impacting an individual's mental health (Videbeck, 2017). This may involve obtaining a detailed medical and psychiatric history, assessing the individual's social support network, evaluating their coping strategies, and identifying any potential barriers to treatment (Barker, 2018).

Once a thorough assessment has been completed, mental health nurses work collaboratively with patients, families, and interdisciplinary teams to develop and implement person-centered care plans that address the individual's unique needs and goals (Videbeck, 2017). This may involve coordinating and delivering a range of interventions, such as psychopharmacological treatments, psychotherapy, psychoeducation, and social support services (Barker, 2018).

Mental health nurses are also responsible for continually monitoring and evaluating the effectiveness of these interventions, adjusting care plans as needed to ensure optimal outcomes (Videbeck, 2017). This ongoing process of assessment, planning, and implementation is crucial for promoting safe, effective, and collaborative care across a variety of settings (Barker, 2018).

In order to effectively implement person-centered care plans, mental health nurses should also be proficient in various therapeutic techniques and modalities. This may include the delivery of evidence-based psychotherapies, such as CBT, dialectical behavior therapy (DBT), and acceptance and commitment therapy (ACT), as well as the administration and monitoring of psychopharmacological treatments (Barker, 2018). By developing a diverse skillset and staying informed about the latest research and best practices in mental health care, mental health nurses can ensure that they are providing the highest quality care to their patients.

The implementation of mental health nursing care across various settings also requires mental health nurses to develop strong collaborative skills. Interdisciplinary teamwork is essential in mental health care, as it enables the integration of diverse perspectives and expertise to provide comprehensive and coordinated care for patients (WHO, 2009). Mental health nurses must be able to effectively communicate with other healthcare professionals, such as psychiatrists, psychologists, social workers, and occupational therapists, and actively contribute to the development and implementation of interdisciplinary care plans (Barker, 2018).

Furthermore, mental health nurses need to be proficient in working with patients in a variety of care settings, such as acute inpatient units, outpatient clinics, community mental health centers, and residential facilities (Gournay, 2003). Each setting presents unique challenges and opportunities for mental health nurses, and requires a tailored approach to assessment, planning, and intervention. By developing the skills and knowledge necessary to work effectively across different care settings, mental health nurses can ensure that they are providing the highest quality care to their patients, regardless of the context in which care is delivered.

Evidence-Based Communication Strategies: Understanding Unique Perspective

Effective communication is fundamental in mental health nursing, as it enables nurses to gain insight into the unique perspectives of patients and their experiences with mental illness (McCabe & Timmins, 2013). Evidence-based communication strategies, such as active listening, empathy, and the use of open-ended questions, foster a therapeutic alliance and facilitate collaborative care planning (Videbeck, 2017). Moreover, mental health nurses need to be culturally competent, recognizing and addressing the impact of culture, language, and beliefs on patients' experiences and communication needs (Bhui, 2013).... Read More

Barker, P. (2018). Psychiatric and Mental Health Nursing: The craft of caring. CRC Press.

Cleary, M., Horsfall, J., & O'Hara-Aarons, M. (2011). Mental health nurses' views about their roles and how they are best supported by nurse unit managers. Journal of Psychiatric and Mental Health Nursing, 18(9), 781-788.

Colom, F., & Vieta, E. (2006). A perspective on the use of psychoeducation, cognitive-behavioral therapy and interpersonal therapy for bipolar patients. Bipolar Disorders, 8(6), 636-642.

Department of Health. (2015). The Mental Health Act. UK Government.

Gournay, K. (2003). The changing face of mental health nursing. International Journal of Nursing Studies, 40(8), 797-805.

Insel, T. R. (2010). Rethinking schizophrenia. Nature, 468(7321), 187-193.

Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617-627.

Mental Health Commission of Canada. (2012). Changing directions, changing lives: The mental health strategy for Canada. Mental Health Commission of Canada.

Videbeck, S. L. (2017). Psychiatric-Mental Health Nursing. Wolters Kluwer Health.

Whiteford, H. A., Degenhardt, L., Rehm, J., Baxter, A. J., Ferrari, A. J., Erskine, H. E., ... & Vos, T. (2013). Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. The Lancet, 382(9904), 1575-1586.

World Health Organization. (2009). Improving health systems and services for mental health. World Health Organization.

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Communication in Nursing Practice: Gibbs’ Reflective Cycle Essay

To find inspiration for your paper and overcome writer’s block
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Introduction

Description, action plan, reflective conclusion.

Communication is a fundamental element in nursing practice. This element can possibly determine patients’ satisfaction and even the outcomes of their treatment (Lotfi et al., 2019). The situation described in the paper will exemplify the potential role of communication, which is why it will serve as a Gibbs Reflective Cycle nursing example. The cycle will help to assess the situation and extract lessons from it.

The model is a widely-recognized and crucial learning instrument, allowing individuals to extract lessons from life experiences. The pattern helps one to consider previous experiences, reevaluate them in the light of new knowledge, and implement the freshly obtained insight to improve future practice (Markkanen et al., 2020). The cycle is composed of six stages (description, feelings, evaluation, analysis, conclusion, and action plan), on which the reflection regarding the personal experience will be based (Markkanen et al., 2020). The paper’s principal objective is to outline a challenging situation from personal practice using Gibbs’ Reflective Cycle. The problematic situation is an encounter with a patient suffering from an infected diabetic foot ulcer and in need of amputation. Overall, the paper aims to critically analyze the situation and transform it into a learning opportunity useful in improving my future practice as a wound care specialist.

The situation concerns a 40-year-old patient with diabetes and an infected foot ulcer who was admitted to the hospital where I was working at the moment. The patient had a long history of diabetes, from which he suffered since he was ten years old. A multidisciplinary team examined the patient and established that he needed an amputation. As I approached the patient to get a consent form, I noticed that he looked upset. Given the described situation, it might be suggested that a communication dilemma here is of ethical character, in particular – it is the delivery of the bad news. By applying the model, the provided Gibbs Reflective Cycle example communication will demonstrate what actions were undertaken to resolve the mentioned dilemma.

The incident that will be analyzed is an outstanding Gibbs Reflective Cycle nursing example, which happened several years ago when I began working as a wound care nurse. A 40-year-old diabetic patient with an infected diabetic foot ulcer was admitted to the hospital. He had a long history of diabetes, suffering from the condition for three decades. A multidisciplinary team examined and communicated with the patient; it was established that he needed a below-knee amputation. The group stated their decision and left, and I had to retrieve the consent form. While retrieving the record, I perceived that the patient looked exceedingly sorrowful and depressed. Nevertheless, I did not know whether I needed to intervene in the situation and left.

Although I worked for many years in nursing before the incident, I became a certified wound care nurse relatively recently before it took place. At the moment, I saw the situation as irreparable, so I was not sure whether I should have tried to console the patient. I felt anxious and, to an extent, powerless when faced with the man’s grief. I thought that words or an empathic response would not be able to mitigate his sadness. Additionally, I was also somewhat startled that the multidisciplinary team did not handle the conversation more delicately and left rather abruptly. Overall, I did not feel confident enough to handle the situation and was unsure whether my intervention would be appropriate.

I frequently returned to the incident, trying to understand what should have been done instead. Retrospectively, I believe that it helped me to reevaluate the role of therapeutic communication in my profession. Prior to the incident, I did not perceive preoccupation with patients’ emotional well-being as my duty as a nurse. I believed that administering medications and treatment, performing tests, recording medical history, educating patients, et cetera, was all that was required of me. Nevertheless, I did not fulfill another vital function in the described situation. To understand that a holistic approach to care presupposes therapeutic communication, I had to experience the case (2). As a nurse, showing empathy and consoling patients is a critical function that is sometimes overlooked. Furthermore, the incident demonstrates a lack of cooperation between the nursing staff and the team since communication was needed to ensure that the emotional impact of amputation on the patient was alleviated.

Some medical professionals find the process of delivering bad news challenging and feel psychologically unprepared (Van Keer et al., 2019). A lack of skills in this aspect can negatively affect patients: they might undergo extra stress, have lower psychological adjustment, and have worse health outcomes (Biazar et al., 2019; Matthews et al., 2019). Furthermore, the way the news is handled can impact patients’ understanding of the situation and adherence to treatment (Galehdar et al., 2020). Given the adverse effects, multiple protocols and approaches to communicating bad news and dealing with its consequences were developed. This situation is analyzed in detail in a ‘Gibbs Reflective Cycle example essay pdf’ that focuses on these communication challenges in healthcare.

In the patient- and family-centered approach, the process occurs based on the patient’s needs as well as their cultural and religious beliefs (Hagqvist et al., 2020). Upon communicating the information, a medical professional is supposed to assess their understanding and show empathy (Hagqvist et al., 2020). In an emotion-centered approach, a medical professional is supposed to embrace the sadness of the situation and build the patient-medical professional interaction on empathy and sympathy (Hagqvist et al., 2020). Yet, the patient- and family-centered approach seems more effective since excessive empathy can be counter-productive and impede information exchange.

Managing patients’ reactions is the final and particularly vital step in communicating bad news. Nurses are commonly involved in handling emotional responses, which entails several responsibilities:

Additional emotional support should be given to those who cannot accept the information (Galehdar et al., 2020).
Nurses can find more related information and share it with patients (Rathnayake et al., 2021).
Nurses are supposed to improve the situation if bad news has been delivered poorly (Dehghani et al., 2020).

In the case of amputation, heightened emotional attention should be given to the patient, as limb loss is a life-altering procedure. Such patients commonly undergo the five stages of grief (denial, anger, bargaining, depression, and acceptance) and are prone to developing anxiety, depression, and body image issues (Madsen et al., 2023). Hence, upon delivering the news regarding amputation, it is vital to provide a patient with community resources for dealing with emotional and psychological implications.

Currently, I understand more in-depth that delivering and handling the consequences of bad news is an inescapable reality of the nursing profession. The incident allowed me to notice the aspects of my professional development that necessitate more attention and improvement. Hence, I strive to be more empathetic in my clinical practice and not undervalue the role of patient-nurse communication. I attempt to provide psychological and emotional support to patients and console them to the best of my ability and knowledge, especially if a patient has just received traumatic news. Due to the incident, I comprehended better that a patient’s emotional well-being can be dependent on my actions. I also stopped presuming that other medical professionals provide the necessary emotional support. Moreover, I understand that I am not powerless when faced with a patient’s sorrow.

Consequently, I will not neglect the importance of patient-nurse communication for patients’ health outcomes and mental well-being. I will offer hope where it is appropriate and encourage and validate patients’ emotions to help them deal with traumatic information (Font-Jimenez et al., 2019). In the future, I will use verbal and non-verbal communication clues to show that I care and, generally, be more empathetic (Font-Jimenez et al., 2019). I will not prevent my insecurities from fulfilling my nursing duties, nor will I allow the feeling of hopelessness to affect my clinical practice. Furthermore, I will rely on evidence-based approaches to handle bad news effectively and facilitate its delivery to patients.

Additionally, I will be more mindful in my nursing practice. Gibb’s reflective cycle will assist me in attaining this objective. I will continue to apply it to the situations occurring at work in order to think systematically as well as analyze and evaluate them. Furthermore, Gibb’s reflective cycle will enhance my ability to learn from my experience. The model will help me to refine my communication skills and make patient-nurse interactions more intuitive and productive (Markkanen et al., 2020).

The situation allowed me to understand the actual value of therapeutic communication in nursing. Now, I understand the need to exercise it in my clinical practice, which is a realization that I further explored in a ‘Gibbs Reflective Cycle example essay pdf.’ Learning to provide emotional support and manage the consequences of bad news is an essential quality for nurses, influencing health outcomes and satisfaction from a visit. Additionally, I become more conscious of my own emotions and the way they can prevent me from acting in a patient’s best interests. Overall, the proper tactics of delivering bad news and assisting patients in handling them became a higher priority in my clinical practice.

To conclude, this reflection featured an episode from my practice in which I analyzed a communication situation using Gibbs’ Reflective Cycle. It showed that I need to concentrate on my abilities to resolve the communication dilemma of the delivery of bad news. The above discussion also demonstrated how the implementation of an appropriate and significant evidence-based model – Gibbs’ Reflective Cycle – may result in better patient outcomes.

Biazar, G., Delpasand, K., Farzi, F., Sedighinejad, A., Mirmansouri, A., & Atrkarroushan, Z. (2019). Breaking bad news: A valid concern among clinicians . Iranian Journal of Psychiatry, 14 (3), 198–202. Web.

Dehghani, F., Barkhordari-Sharifabad, M., Sedaghati-kasbakhi, M., & Fallahzadeh, H. (2020). Effect of palliative care training on perceived self-efficacy of the nurses . BMC Palliative Care, 19 , 63. Web.

Font-Jimenez, I., Ortega-Sanz, L., Acebedo-Uridales, M. S., Aguaron-Garcia, M. J., & de Molina-Fernández, I. (2019). Nurses’ emotions on care relationship: A qualitative study . Journal of Nursing Management, 28 (8), 2247-2256. Web.

Galehdar, N., Kamran, A., Toulabi, T., & Heydari, H. (2020). Exploring nurses’ experiences of psychological distress during care of patients with COVID-19: A qualitative study . BMC Psychiatry, 20 , 489. Web.

Hagqvist, P., Oikarainen, A., Tuomikoski, A.-M., Juntunen, J., & Mikkonen, K. (2020). Clinical mentors’ experiences of their intercultural communication competence in mentoring culturally and linguistically diverse nursing students: A qualitative study . Nurse Education Today, 87 , 104348. Web.

Lotfi, M., Zamanzadeh, V., Valizadeh, L., & Khajehgoodari, M. (2019). Assessment of nurse–patient communication and patient satisfaction from nursing care . Nursing Open, 6 (3), 1189-1196. Web.

Madsen, R., Larsen, P., Carlsen, A. M. F., & Marcussen, J. (2023). Nursing care and nurses’ understandings of grief and bereavement among patients and families during cancer illness and death – A scoping review . European Journal of Oncology Nursing, 62 , 102260. Web.

Markkanen, P., Välimäki, M., Anttila, M., & Kuuskorpi, M. (2020). A reflective cycle: Understanding challenging situations in a school setting . Educational Research, 62 (1), 46-62. Web.

Matthews, T., Baken, D., Ross, K., Ogilvie, E., & Kent, L. (2019). The experiences of patients and their family members when receiving bad news about cancer: A qualitative meta-synthesis . Psycho-Oncology, 28 (12), 2286-2294. Web.

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A Model for Effective Nonverbal Communication between Nurses and Older Patients: A Grounded Theory Inquiry

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Nonverbal communication is an inevitable art to be effectively mastered by nurses. Nurse nonverbal communication has many benefits when it is effective. For instance, nonverbal communication is important to convey affective and emotional information, and demonstrate respect for and build therapeutic relationships with older patients. As the older population is growing fast worldwide, effective nonverbal communication with older patients is an essential skill for nurses and will improve patients’ satisfaction and the quality of care. Therefore, this article presents a model to guide effective nonverbal communication between nurses and older patients. A Grounded Theory approach guided the study. Data were collected between July 2018 and January 2020 through overt participant observations and individual interviews. Purposive and theoretical sampling were used to select 13 clinically experienced nurses, 4 nursing students, and 8 older adults. Data analysis encompassed open coding, axial coding, and selective coding. The results showed that effective nonverbal communication emerged as the co-phenomenon hinged within context and/or environment and is influenced by certain factors. This model, which is in support of person-centered communication and care, advocates for effective nonverbal communication between nurses and older patients.

1. Introduction

Worldwide, older adults account for 1.05 billion people, with 74.4 million in African countries with the expectation to reach 235.1 million by 2050 [ 1 ]. In sub-Saharan Africa, the burden of geriatric diseases is growing, with more older adults requiring geriatric healthcare services and frequent hospitalization with longer stays [ 2 , 3 ]. This is especially the case in sub-Saharan Africa where there are few long-term care settings [ 4 ]. With hearing deficits, changes in attention and coding of information, and restrictions in interaction, participation, and effective verbal communication [ 5 ], nurses’ effective communication with older adults emerges as an essential skill in geriatric care [ 6 ].

Communication, which is important to understand older adults’ needs and support their health and well-being [ 7 ], is defined as the process of sending and receiving messages to share knowledge, attitudes, and skills [ 8 ]. It includes both verbal and nonverbal components, since it is not just the mere transmission of information [ 9 ]. While verbal communication denotes the transmission of messages through spoken words [ 8 ], nonverbal communication describes the reaction of the face, body, or voice, including what is expressed between each other [ 10 , 11 ]. Nonverbal communication is important to convey affective and emotional information, demonstrate respect for patients, and build therapeutic relationships with patients [ 12 , 13 ]. This makes nonverbal communication unique and more important for effective communication between nurses and older patients. When nurses enhance their communication skills, it improves patients’ satisfaction as well as the quality of care [ 14 , 15 ].

Communication, as one of the important aspects of caring for patients that affects all other aspects of care, should be given special attention [ 16 ]. To date, there are few nonverbal communication models identified to help nurses to communicate effectively with patients let alone older adults. The first model is SOLER (Square, Open, Lean, Eye contact, Relax) developed in 1975 by Eagan to describe effective body language employed to make others feel listened to. It only includes proxemics (use of space) and kinesics (movements of the body), and mostly focuses on interactions during a consultation, not during hospitalization [ 17 ]. The second model is SURETY (Sit at an angle, Uncross legs and arms, Relax, Eye contact, Touch, Your intuition), which criticizes and advances the SOLER model by including the use of touch, emphasizing the importance of individual intuition, and encouraging the inclusion of therapeutic space [ 18 ]. Although it includes proxemics, kinesics, and haptics (use of touch), it has been developed to encourage the inclusion of therapeutic space and intuition in verbal communication skills’ content. None of these models were intended for nurses’ effective nonverbal communication with older patients or were derived from the participants’ views on nonverbal communication between patients and nurses. Moreover, a model with consideration of nurses’ views is more likely to be appropriate and acceptable by nurses [ 19 ], because healthcare workers’ perspectives are important in determining effective strategies [ 20 ].

As of 2018 in Cameroon, the growing older population is translating to increased healthcare demand [ 2 ]. Unlike other African countries such as Mauritius, Seychelles, and South Africa, there is no national effort to develop long-term care settings in Cameroon [ 4 ]. As a result, older adults solely utilize hospital settings when requiring medical assistance [ 21 , 22 ] where nurses communicate more often with them. Additionally, Cameroon is one of the most linguistically fragmented countries in sub-Saharan Africa, with approximately 250 indigenous languages, apart from English and French which are both considered official languages [ 23 ]. As a result, it is less likely that a nurse speaks the same vernacular as an older patient who does not speak French or English. Although communication skills training and models do not necessarily ascertain that nurses will be skilled communicators [ 24 ], they might be helpful in assisting nurses to improve their nonverbal communication with the older adult population. As some of these older adults mostly rely on nonverbal communication because of their functional impairments [ 25 ], nurses need to be equipped, more than ever, with tools to improve their communication skills. Therefore, this paper aims to present a model for effective nonverbal communication between nurses and older patients.

2. Materials and Methods

2.1. design.

The purpose of this study was to develop a model for effective nonverbal communication between nurses and older patients during hospitalization. It was for this reason that a qualitative Grounded Theory (GT) approach was followed [ 26 ]. GT was chosen because “it is a useful methodology for the study of interpersonal activities between nurses and patients and others because a social interaction is at the heart of the caring process in nursing” [ 27 ] (p. 16).

2.2. Study Settings and Context

The study took place in two public hospitals in the east and central regions of Cameroon, a low-and-middle-income country at the heart of the Gulf of Guinea in Central Africa [ 28 ]. Both hospitals are in the central level of the three-level pyramidal Cameroonian healthcare system. The first hospital was chosen because it is the only one with a geriatric unit in Cameroon. Similarly, the second was selected because it is a referral regional hospital. In both hospitals, older adults are admitted to adult wards with younger adults but are categorized according to their illness. In addition, both hospitals employ qualified nurses and nurse assistants, irrespective of registration status given that registration was not mandatory in Cameroon before 2022.

2.3. Study Participants and Sampling Methods

In keeping with GT, which aims to recruit participants with rich information on the phenomenon under investigation, purposive and later theoretical sampling were used. Firstly, 10 clinically experienced nurses who were involved in the day-to-day care of older adults admitted to the hospital, could articulate in English or French, and were willing to participate in the study were purposively sampled. Furthermore, 8 older adults who were not critically ill, could articulate in English or French, and expressed a willingness to participate in the study were also purposively sampled. Theoretical sampling included the recruitment of additional participants who cared for older patients. These were 2 middle unit managers, 4 undergraduate student nurses allocated for clinical placement in the selected hospitals, and 1 nurse assistant. We collected and analyzed data simultaneously as recommended in Grounded Theory; thereafter, we stopped recruiting and including participants when no additional information emerged from the analysis. All up, 17 nurses and 8 older patients were included in the study. Their characteristics are described in Table 1 .

Sociodemographic characteristics of the participants.

Participant	Age (Years)	Gender	Hospital	Position	Types of Nurses	Years of Experiences
P1	26–35	Female	Hospital 1	Staff nurse	Degree nurse	4
P2	46–55	Female	Hospital 2	Middle unit manager	Diploma nurse	32
P3	36–45	Female	Hospital 2	Staff nurse	Diploma nurse	23
P4	36–45	Male	Hospital 2	Staff nurse	Geriatric nurse	11
P5	46–55	Female	Hospital 2	Unit manager	Geriatric nurse	30
P6	46–55	Female	Hospital 2	Staff nurse	Diploma nurse	11
P7	36–45	Female	Hospital 2	Staff nurse	Diploma nurse	9
P8	26–35	Female	Hospital 2	Staff nurse	Geriatric nurse	3
P9	26–35	Female	Hospital 2	Staff nurse	Geriatric nurse	6
P10	26–35	Female	Hospital 2	Staff nurse	Nurse aid	14
P11	36–45	Female	Hospital 1	Staff nurse	Diploma nurse	13
P12	36–45	Female	Hospital 2	Staff nurse	Geriatric nurse	5
P13	26–35	Female	Hospital 1	Middle unit manager	Degree nurse	10
P14	18–25	Female	Hospital 1	Student nurse	Degree program	2nd year
P15	18–25	Female	Hospital 1	Student nurse	Diploma program	1st year
P16	26–35	Female	Hospital 2	Student nurse	Student nurse aid	1st year
P17	26–35	Female	Hospital 2	Student nurse	Student nurse aid	1st year
P18	78	Female	Hospital 1	N/A	N/A	N/A
P19	65	Male	Hospital 2	N/A	N/A	N/A
P20	64	Female	Hospital 2	N/A	N/A	N/A
P21	82	Female	Hospital 2	N/A	N/A	N/A
P22	67	Male	Hospital 2	N/A	N/A	N/A
P23	61	Male	Hospital 1	N/A	N/A	N/A
P24	92	Male	Hospital 2	N/A	N/A	N/A
P25	70	Female	Hospital 2	N/A	N/A	N/A

2.4. Data Collection

Data were collected between July 2018 and January 2020 through overt participant observations and individual interviews. The principal investigator commenced with a month-long observation of how nurses communicated nonverbally with older patients during different types of interactions. Such interactions were, but are not limited to, day-to-day nursing care-related tasks, social interactions, and health education interactions. The observations were recorded as field notes because no ethics permission was granted for video recording. Data from the observations guided the development of the initial interview guide which was used to conduct individual in-depth interviews with participants.

Only the nurses who were observed met the criteria to be interviewed. Therefore, the principal investigator approached them in the nursing station when they seemed free, verbally provided information about the study, and issued each with an information letter with the intention to obtain consent to be interviewed. Following this, those nurses who showed interest in participating in the study were booked for individual in-depth interview at times most convenient for them. The initial interviews captured the meaning and channels of nonverbal communication from the nurses’ perspectives. One open-ended question was asked: “How can you define nonverbal communication with older patients”? This was followed by probing questions that allowed the researcher to elicit more information, obtain more clarity, and confirm data captured during observations. Due to the constant comparative methods for data collection and analysis, interviews informed each other. Each individual interview, conducted in the participant’s preferred language, lasted between 50 min and 60 min. Subsequently, field notes were recorded during and after the interviews. Data saturation was achieved at interview 17 when no additional information emerged.

The same principles were followed to recruit and include older adults for interviews. A total of 47 older adults were referred to the study, but 13 did not meet the eligibility criteria. The remaining 34 older patients who met the inclusion criteria were individually approached at their bedside when they seemed free with no visitors nor care activities happening. The principal investigator introduced herself, explained the purpose of the study, and sought consent for participation in the study. Consent to be observed was provided by 29 older patients, of whom 8 were interviewed thereafter. Older adults who consented to participate in the study either agreed to be interviewed on the spot or preferred to make an appointment for a different time. The initial interviews with older adults captured their interpretation and understanding of nurse nonverbal communication. One open-ended question was asked: “How do you understand when a nurse communicates without saying a word?” This was also followed by probing questions for more clarity and to obtain additional information. The interviews with older adults also informed each other. Field notes were also taken during and after interviews. Data saturation was achieved at interview 8 when no additional information emerged.

2.5. Data Analysis

Data were analyzed by three researchers, who were all female and comprised a principal investigator and two academics with PhDs who have supervised graduate students following qualitative research methodology. None of the researchers worked or was working at the data collection site; therefore, they had no relationship with the participants. Data analysis encompassed open coding, axial coding, and selective coding, which seemed intertwined as the researchers moved back and forth between data collection and data analysis. The process is referred to as a constant comparative method by Strauss and Corbin [ 29 ]. This allowed the generation of increasingly focused questions, thus providing direction for subsequent interviews [ 30 ]. In addition, constant comparison was used throughout the study. The software NVIVO version 12 [ 31 ] was used to import transcripts, write memos, code conceptual categories, properties, and dimensions from the data, conduct data analysis, and refine the model.

Data were initially coded sentence-by-sentence during open coding to summarize and define emerging categories, paying special attention to the processes linking them. This was followed by axial coding, where data were reassembled and codes refined and categorized into categories and subcategories [ 32 ]. This allowed for a better understanding of the categories, with similar ones merged into higher-order categories. After creating concepts and categories from data in the open coding phase, the researchers continued to group categories and subcategories in the axial coding phase. The researchers then developed a category by specific conditions, context, and actions or interactions by which it was managed [ 33 ]. The researchers further refined a list of categories by carefully trying to merge or delete some of them after making possible connections. Categories were linked depending on their properties and dimensions. Some categories were named in words and phrased by the participants, while others were renamed by the researchers’ academic and professional knowledge and readings. These concepts are referred to as “literature-driven concepts” [ 29 ]. The researchers continued to code new data, re-examining and comparing the data until saturation was reached. Selective coding followed axial coding, which involved the process of selecting the core category “ effective nonverbal communication ”, systematically relating it to other categories, validating those relationships, and completing categories that needed further refinement and development; by following the process of reduction and comparison. The iterative nature of the data analysis process allowed the researchers to repeatedly ask questions while studying the data, in addition to using the “ waving a red flag ” technique , which allowed them to look beyond the obvious in the data [ 26 ]. The researchers were convinced that the model began to emerge as soon as the diverse properties began to integrate.

2.6. Ethical Considerations

Ethical approval (reference number HSS/2008/017D) to commence the research study was obtained from the University of KwaZulu-Natal Humanities and Social Sciences Research Ethics Committee. Permission was further obtained from the two participating hospitals. Following ethical approval requirements, before data collection, an information letter explaining the purpose and nature of the study was given to each participant. The participants were allowed to ask any questions before the voluntary signing to participate in the study, be observed, and be audio-recorded. The participants were informed that they may withdraw from the study at any time with no due penalty or repercussions. Furthermore, all participants were assured that no information provided by them would be shared with another person without their authorization. To maintain confidentiality, pseudonyms were used. Participants did not receive monetary benefits for participating in the study.

To ensure trustworthiness, the researchers used the criteria of credibility, transferability, dependability, and confirmability [ 34 ]. The credibility of the study was promoted by the researchers’ prior engagement with participants. Prolonged engagement was ensured by the establishment of relationships with participants during the study. Data analysis was audited by taking observational field notes regarding the context of the interviews, with peer debriefing conducted to confirm emerging categories and themes. Confirmability was ensured by triangulating data sources and validating audiotaped and transcribed transcripts against emerging categories and themes through constant comparison. Further, nine interviews were returned to participants who did not add much to what they originally said. Dependability was ensured by data quality checks with an expert in Grounded Theory, peer review of coding, and consultation with qualitative researchers to validate the codes and categories that emerged from the analysis. Finally, transferability was established by rich descriptions of the study context, informants, research procedures, and the provision of extracts from the interviews to enrich the findings.

3. Results and Discussion

The model was developed based on the findings from open coding, selective coding, and axial coding. Table 2 , Table 3 and Table 4 summarize the extracts from the participants and the observations, which served as a starting point to develop the model.

Extracts of the contextual conditions forming the basis for developing the model.

Context and environment	Linguistically fragmented country	(P2, middle unit manager, diploma in nursing) (tribe in Cameroon), (tribe in Cameroon) . (P1, staff nurse, degree in nursing)
	Negative stereotypes on older adults	. (P23, older man, 61 years) . (P12, staff nurse, specialization in geriatric nursing)
	Inexistent long-term care facilities	(in the hospitals), (long-term care facilities), (P11, staff nurse, diploma in nursing) . (P7, staff nurse, diploma nurse)

Extracts of the core phenomenon forming the basis for developing the model.

Core Phenomenon	Channel: Artifacts (use of objects)	. (P8, staff nurse, specialization in geriatric nursing) . (P7, staff nurse, diploma in nursing)
	Channel: Haptics	(P10, staff nurse, nurse aid) (older patients). (P17, student nurse, 1st year) (P12, staff nurse, specialization in geriatric nursing)
	Purpose: Support verbal communication	. (P1, staff nurse, degree in nursing) . (P13, middle unit manager, degree in nursing)
	Purpose: Build relationships with older patients	(P4, staff nurse, specialization in geriatric nursing) (P7, staff nurse, diploma in nursing)

Extracts of the outcomes forming the basis for developing the model.

Outcomes	Compliance with care	(P8, staff nurse, specialization in geriatric nursing) (P7, staff nurse, diploma in nursing)
	Older patients’ satisfaction	. (P18, older woman, 78 years) . (P10, staff nurse, nurse aid)
	Nurse messages go through	(nonverbal communication) (P7, staff nurse, diploma in nursing) (nurses) (P25, older woman, 70 years) . (P8, staff nurse, specialization in geriatric nursing)

Additionally, Figure 1 indicates the elements of the model in line with Strauss and Corbin’s paradigm, which include the antecedents, the contextual conditions, the core phenomenon, the actions and interaction strategies, the intervening conditions, and the outcomes.

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Object name is healthcare-10-02119-g001.jpg

Summary of findings in line with Strauss and Corbin’s paradigm.

These elements ( Figure 1 ) were used as the foundation for the development of this model. Some of these elements were extensively described in other papers by the same lead author [ 35 , 36 ]. Hence, this paper focuses on the emerged model, to enhance nonverbal communication between nurses and hospitalized older adults.

We followed the components for developing a model, which include the purposes of the model, the concepts and their definitions, the structure of the model, and the assumptions of the model, as described by Chinn and Kramer [ 37 ].

3.1. Purpose of the Model

According to Chinn and Kramer [ 37 ], the purpose of the model justifies the context and situation in which the model applies. Although communication is bidirectional, nurses are responsible for its proper conduct [ 38 ]. Therefore, this model of effective nonverbal communication between nurses and older patients, in the context of this study, provides a framework that guides nurses to effectively communicate nonverbally with older adults in hospital settings. Furthermore, in-service training for nurses who were not part of this study can be developed based on the elements provided by this model. This model can be used by curriculum developers and policymakers as a guide for nursing schools in the teaching and learning of nonverbal communication to both undergraduate and postgraduate students. Furthermore, this model answers the United Nations’ [ 39 ] call for more data on older adults from developing countries, thus contributing to the limited body of knowledge in the area of nonverbal communication in geriatric care in hospital settings [ 40 ], as compared to nonverbal communication in long-term care settings.

3.2. Basic Assumptions of the Model

The assumptions that formed the basis of effective nonverbal communication between nurses and older patients in this model are outlined below:

Effective nonverbal communication is present in every healthcare encounter between nurses and older patients because it is impossible not to communicate nonverbally [ 10 ]. In other words, whenever there is an interaction between a nurse and an older patient, nonverbal communication is inevitable even when there is no verbal content. Scholars have estimated the amount of nonverbal content in communication, in comparison to verbal content. They described that nonverbal communication accounts for 60% to 90% of total communication [ 13 ]. Thus, nonverbal communication is unavoidable. Therefore, nurses should be aware that their nonverbal communication might send conflicting messages to older patients if they do not match the verbal content. In addition, the awareness of nonverbal messages sent to others is essential, as it often provides an explanation as to why people respond to us in the way they do [ 41 ]. Hence, nonverbal communication emerges as an intentional concept, which nurses should be aware of, as it may have negative consequences to the level of care rendered.

Effective nonverbal communication with older patients is person-centered . It is worth noting that older patients are not a homogenous group, as they have different experiences [ 42 ] coupled with different nonverbal communication needs. Person-centered care assumes that healthcare workers should communicate and interact with patients in a person-centered way while paying attention to patients’ different expectations and needs through verbal and nonverbal communication [ 43 ]. Hence, an added assumption in this model is that nonverbal communication is individualized and needs-oriented. Nurses are encouraged to take into consideration older patients’ nonverbal communication needs. Despite this, authors acknowledge the beliefs of Chan et al. that initial interactions with older patients tend to be scripted and governed by established social norms [ 44 ]. In time, nurses should be able to easily bend or break these norms to align them with each older patient’s specific needs.

Effective nonverbal communication is unique, dependent on the context and the nurse rendering care . The model brings forth the assumption that clinical contexts are different, along with the types of interaction with patients and the types of illnesses. On the other hand, nurses bring to the table different backgrounds, training, and personalities. These lead to unique encounters with each one. The emphasis in this model is that unique does not mean chaotic but instead means distinct, that may or may not be automatically replicable to another encounter. Moreover, effective nonverbal communication cannot be reduced to a set of theoretical and linear principles to absolutely follow because there is no universal way to communicate. This allows room for the creativity, flexibility, intuition, and authenticity that are needed in effective communication [ 44 ]. Furthermore, as nurses grow in confidence and experience, the model assumes that they will embrace and master effective nonverbal communication in every encounter and obtain mastery over the external display of their emotions. Hence, nurses will become shapers of and accountable for effective nonverbal communication with older patients.

Effective nonverbal communication is a subjective and interactive process which may be misinterpreted or misunderstood. Indeed, there is a risk of miscommunication or misunderstanding that cannot be eliminated when using nonverbal communication [ 45 ]. In this model, we posit that nurses interpret situations based on filters and frames. Filters refer to what influences the way nurses attempt to communicate nonverbally with older patients. Such filters are, but are not limited to, nurses beliefs, past experiences, and personality traits [ 36 ]. On the other hand, frames can be defined as a nurse’s own interpretation of a situation. As an example, one participant reported that some older patients practice witchcraft in the hospital, therefore preventing nurses from getting closer to them or spending more time with them. According to the participant, this may have negative consequences on the effectiveness of nonverbal communication between nurses and older adults. As nonverbal communication is an interactive process, nurses may misunderstand and misinterpret nonverbal messages sent by older patients. Like nurses, older patients can misunderstand or misinterpret the nonverbal messages sent to them, resulting in ineffective nonverbal communication. The mismatch in the interpretation and understanding of nonverbal communication may be due to past negative experiences with nurses, critical conditions, or different cultures or religions between nurses and older adults [ 36 ]. To minimize misinterpretations and misunderstanding, the model suggests that nurses be encouraged to obtain feedback that ascertains that the older patients have understood, or not, the nonverbal messages sent by nurses. Similarly, nurses should ascertain that they have correctly captured messages sent to them by older patients for the success of nonverbal communication. This is called reaching an area of communicative communality [ 46 ].

Effective nonverbal communication is reliant on cultural and religious beliefs complicated by the multilingual nature of the context. Hence, the assumption in this model is that within effective nonverbal communication are the components of religion and culture. As an example, in some cultures or religions, eye contact with an older adult is considered rude; conversely, it can express empathy in other contexts. Another example is affective touch, which can be considered invasive in some contexts. Hence, the model posits that effective nonverbal communication is reliant on one’s culture and religion. Within the context of this study, nurses and older patients are often from religious and culturally diverse regions with language differences. Cameroon is known for being multilingual with more than 250 indigenous languages [ 23 ] in a population of more than 26 million people. Although there may be instances where both nurses and patients share the same cultural and religious beliefs, the assumption in this model is that different social circumstances, orientations, and languages may influence nonverbal communication. Nurse prudence is therefore essential when initiating nonverbal modalities that can be considered ambiguous.

3.3. Concepts and Definitions

Effective nonverbal communication is the core concept from which other concepts evolve. It is a dynamic and evolving process that takes place as the relationship with an older patient develops. The emerging concepts in this study and those described in this paper are effective nonverbal communication, context and environment, action and interaction strategies, pillars, and outcomes.

3.3.1. Core Concept

The core concept in this study is effective nonverbal communication between nurses and older patients. It refers to a variety of communicative behaviors that do not carry linguistic content, but are unique, religiously and culturally sensitive, and person-centered. In the literature, common attributes of effective communication include a significant tool in planning and implementing person-centered care, a foundation for interpersonal relationships, and a determinant of promoting respect and dignity [ 47 , 48 , 49 ]. On the other hand, inaccurate or ineffective nonverbal communication behavior will not enable older patients to understand and interpret nurse messages. Therefore, it should be accurate to avoid distortion of messages. In this model, effective nonverbal communication entails the channels and the purposes of nonverbal communication in the context of the study. However, the core concept has been extensively discussed in another manuscript [ 50 ]. Therefore, the following is a summary of the core concept.

The Channels of Effective Nonverbal Communication

The channels of effective nonverbal communication mostly include haptics, proxemics, kinesics, and vocalics. Few participants mentioned active listening, physical appearance, and artefacts.

Haptics refer to the use of touch or physical contact, which in this study includes handshake, kiss, hug, pat, and stroke.

Proxemics , the use of space and distance, are the physical proximity and distance with older patients. In this model, physical proximity refers to sitting close to older patients, including sitting on their beds. Physical proximity includes standing at the door to talk to them, sitting far from them, and having their back towards them.

Kinesics are the movements of any part of the body, such as smiling, frowning, leaning forward, and waving hands.

Vocalics are the aspects of the voice used when communicating with older patients. In this study, speaking too loudly, too fast, or even too slow were reported by participants.

Artefacts refer to the use of objects during communication. In this study, some participants reported that they show a bottle or the medication to some older patients who did not understand French to express the time to drink medication. It was followed by a change of position by the older patient, showing that he has understood the message and was ready to swallow his tablets.

Physical appearance refers to how nurses dress when they come to work. As described by one participant in this study, a nurse with a uniform can still look like a drug addict. Another one said that a nurse with a see-through uniform could sexually provoke older male patients.

The Purposes of Effective Nonverbal Communication

The purposes of effective nonverbal communication: the ultimate purpose of nonverbal communication is to help patients with their coping and recovery during hospitalization [ 51 ]. In this study, nurses reported that nonverbal communication assisted them in building relationships with older patients, winning their trust, creating a positive atmosphere, supporting verbal communication, reassuring, and conveying empathy to older patients.

To build relationships : Effective nurse–patient communication has been proven to be fundamental to building a positive relationship between nurses and patients [ 52 ]. Hence, this model advocates for nurses to use one or more channels of nonverbal communication to express their willingness to build relationships with older patients.

To win patients’ trust : Kourkouta and Papathanisou recommend that for nurses to develop relationships with their patients, they must be mindful of their first encounter with those patients because first impressions last forever [ 35 ]. Therefore, we encourage nurses to be aware of their body language on their first encounter with older adults.

To support verbal communication : Communication has two components, namely, verbal and nonverbal. The differences in the native languages of nurses and patients creates communication barriers [ 53 ]. Moreover, verbal communication and nonverbal communication can conflict with each other in one interaction [ 10 ] and patients believe the nonverbal when verbal communication is incongruent with nonverbal communication [ 54 ]. Therefore, this model encourages nurses to ensure the congruency of both verbal and nonverbal communication.

To create a positive atmosphere : The hospital environment is stressful to older patients. The noise of machines, the unfamiliar healthcare workers and environment, the pain, the discomfort, and the uncertainty of death lead to patients’ emotional fluctuations [ 55 ] in an atmosphere of fear and anxiety. Therefore, nurses are encouraged to use nonverbal communication to create a positive atmosphere or to change a negative atmosphere into a positive one.

To convey empathy : Empathy is the ability to understand and share another person’s emotions [ 56 ]. Nurses are encouraged to communicate to older patients that they are compassionate, interested, and concerned about their situations. Knowing the changes that older adults undergo concerning their physical, psychological, social, and environmental health will help nurses better understand older patients [ 57 ].

3.3.2. Context and Environment

Anderson and Risor [ 58 ] have argued about the importance of contextualization and how it relates to the notion of causality for eventual understanding and insight. In this study, the context refers to the types of encounters between nurses and older patients. These range from encounters around health communication, nursing tasks, activities of daily living, and normal social life, as described by Barker et al. [ 59 ]. The context also encompasses the nursing shortages, excessive workload, and poor communication skills that have been identified by Kwame and Petrucka as some barriers to effective communication with patients [ 60 ]. Wards in Cameroon have limited resources and there are out-of-pocket payments for every healthcare service. For example, if patients cannot afford to pay for cotton wool or syringes, they will not receive their prescribed injections. Ward staffing is often limited to one staff member per shift, which limits the interaction of the nurse with the older adult due to lack of time versus accomplishment of the routine.

The environment , within this model, is the ward and the persons involved in the communicative encounter, namely, the nurses, the older patient, and/or the relatives. The ward is mostly a medical ward because there are very few geriatric units in acute settings in Cameroon. Similar to Cameroon, in Ghana [ 57 ], older adults are mostly nursed in general wards together with young and middle-aged adults after diagnosis has been classified as a medical or surgical case. In the wards, at least one relative is requested to stay with the older patient 24/7. During their stay, the relatives participate to care (personal hygiene, medicine intake, temperature checking, etc.) when nursing teams are short-staffed and/or alert the nurses when problems arise, such as in Malawi [ 61 ]. Moreover, the presence of relatives in the ward has been reported as a nuisance to care [ 62 , 63 ]. All employed nurses are certified but not necessarily registered with the Nursing Council, as registration was not compulsory for practice before 2022. Some older adults are often seen as witches by the community and the healthcare population, similar to Ghana [ 57 ] and Uganda [ 64 ]. On the other hand, some are also seen as babies or as intelligent people. All the above-mentioned constitute the context and the environment for effective nonverbal communication between nurses and older patients.

3.3.3. The Action and Interaction Strategies

To achieve effective nonverbal communication with older patients, participants reported on a series of strategies that needed to be put in place, referred to as action and interaction strategies according to the GT language. These were, but are not limited to, being aware of one’s nonverbal communication, being “angels”, putting yourself in the shoes of older patients, and reducing negative attitudes towards older patients. Additionally, creating long-term care facilities, improving acute healthcare structures, enhancing communication skills through education and training, and recruiting more gerontologist nurses were mentioned as strategies for effective nonverbal communication with older adults. However, they will not be discussed in this paper.

Awareness of nonverbal communication : Nonverbal messages are often subconsciously transmitted; thus, nurses tend to be neither aware nor mindful of the value of nonverbal communication when communicating with older patients. In this study, some nurses reported that they had never used nonverbal communication with older patients. This means that they were not aware that they have been using nonverbal communication. Moreover, awareness of one’s nonverbal messages leads to a greater understanding of the messages exchanged [ 65 ]. Nurses should be on constant guard of their NVC to ensure maximum satisfaction of patients [ 66 ], especially their kinesics and proxemics [ 67 ]. After all, awareness of nonverbal communication explains why people respond to us the way they do, and influences how the other person communicates with us [ 41 ]. This means that if older patients respond to nurses in a certain way, it is because of nurses’ nonverbal communication.

Being “angels”: Participants described that to achieve effective nonverbal communication with older patients, nurses should be “angels”. Angels are commonly described as spiritual beings who do good. In this study, being an angel entailed showing concern and interest in older adults, being kind and close to older adults, and conveying empathy. Furthermore, the angelic being of nurses is further evident in their soft voice tones versus commanding tones and positive facial expressions.

Putting yourself in the shoes of older patients : Ageing is an inevitable event, and it will happen to everyone in the absence of premature death. Nurses reported that they do imagine themselves as older adults. Therefore, they attempt to render imaginary care and nonverbal communication that they would want to receive if they themselves were hospitalized. This particular study finding concurs with that of Van Der Cingel, who reported that nurses who cared for older people with a chronic disease put themselves in the patients’ shoes [ 68 ].

Reducing negative attitudes toward older patients : Ageist attitudes, which comprise discrimination, prejudice, and stereotypes toward a person based on their age, have been recognized as a factor influencing older adults [ 69 , 70 ]. Ageist attitudes can lead to age-based disparities in diagnostic procedures, decision-making, and types of treatment offered. As previously indicated, in this current study, some nurses avoided older patients because of alleged witchcraft. Additionally, some nurses shouted at older patients because they saw them as children. Moreover, ageist attitudes are reflected in interpersonal interactions that are patronizing or involve elder speak [ 71 ]. Ageism in healthcare limits older adults’ access to appropriate and respectful care, and results in adverse clinical outcomes [ 72 ]. Ageist attitudes are easy to deal with because although they are social constructs historically and culturally situated, they are individually interpreted [ 73 ]. Therefore, this model advocates for nonverbal communication free of age-related bias, which is essential to high-quality, patient-centered care.

3.3.4. The Pillars to Sustain Effective Nonverbal Communication between Nurses and Older Patients

For this model, pillars refer to factors that influence effective nonverbal communication between nurses and older patients. In this paper, we only list the pillars because they have been extensively discussed in Keutchafo and Kerr [ 35 ] and Keutchafo et al. [ 36 ]. The factors that influence effective nonverbal communication in this model are summarized as nurse-related and older-patient-related factors. The nurse-related factors are awareness of nonverbal communication, personality traits, previous experience with older adults, beliefs system, love for the job and for older patients, and views on older adults. The older-patient-related factors include moods, financial situation, interpretation of nurses’ nonverbal communication, and medical condition.

3.3.5. The Outcomes of the Model

This study evidenced that when nonverbal communication between nurses and older patients is effective, it yields positive outcomes. For this model, the outcomes are categorized as nurse-related, older-patient-related, and operational.

Individual-Related Outcomes

In this paper, we only describe the most cited outcomes by participants. They include better relationships between nurses and older patients, compliance with care and treatment, discovery of the unsaid, and older patient satisfaction.

Communication encompasses the verbal, the nonverbal, and any form of interaction in which messages are created and meanings are derived to influence the nurse–patient relationship [ 60 ]. Likewise, in this model, it emerges that the outcome of effective nonverbal communication is better relationships between nurses and older patients . Although nurses and older patients are strangers at the beginning of the relationship, they are expected to improve their relationship through positive nonverbal communication. Participants in this study reported that they avoided nurses who were always shouting. Consequently, older patients will become closer to nurses who display positive nonverbal communication; this will lead to the betterment of their relationships.

Sumijati et al. have argued that the essence of communication is relationships that can lead to changes in attitudes and behaviors [ 74 ], which in this model is referred to as compliance with care and treatment . One of the outcomes of effective nonverbal communication with older patients is compliance with care and treatment, as described in Figure 2 .

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A model for effective nonverbal communication with older patients.

Nurses in this study reported that older patients did not want to take their medication nor accept certain care. Moreover, studies have shown that effective communication with patients leads to compliance to care and treatment [ 60 ]. As proposed in this model, older patients will be able to accept the care and treatment provided by nurses when nonverbal communication is effective.

The betterment of relationships is expected to lead to the discovery of what older patients do not express or have wrongly expressed. It has been shown that effective communication empowers patients to disclose their concerns and expectations [ 75 ], whereas patients would be less motivated to disclose their needs and feelings to nurses when they have past negative experiences in their interactions with nurses [ 76 ]. Moreover, patients need encouragement to talk about their psychological issues [ 77 ]. However, when communication is effective, older adults feel cared for, respected, and more able to describe their concerns [ 42 ]. This means that when relationships are better because of positive experiences in nonverbal communication with nurses, nurses would discover the unsaid . This is another important outcome in this model.

Older patient satisfaction is one of the outcomes of effective nonverbal communication. Evidence shows that nurse nonverbal positive behaviors lead to higher patient satisfaction [ 78 ]. To improve patient satisfaction, nurses are encouraged to enhance their communication skills [ 63 ]. In this model, and as confirmed by Junaid et al., to ensure maximum satisfaction of patients, nurses should be on constant lookout of their nonverbal communication [ 66 ]. Such a level of awareness will prevent nurses from sending conflicting messages to older adults through their nonverbal communication.

Operational Outcomes

Improved nursing care is one of the hospital-related outcomes. As confirmed by Tran et al., enhancing the effectiveness of verbal and nonverbal communication can improve the quality of care [ 14 ]. Effective nonverbal communication with older patients will make room for nurses to shift from task-oriented care to person-centered care. This will improve the quality of care rendered.

When nursing care is improved, older patients will have shorter lengths of stay in hospital . Participants mentioned the reduction of length of stay in hospital because they viewed older patients as people who not only want to stay at home, but who also want to return home after hospitalization [ 79 ]. Moreover, studies support both a shorter or longer length of stay associated with better quality of care [ 80 ]. As nurses do not decide on the discharge or otherwise of patients, they are encouraged to use effective nonverbal communication with older patients irrespective of the length of stay.

Improved quality of care and shorter stays in hospitals will lead to a positive reputation for these healthcare structures according to this study’s participants. In another study, hospital reputation was one of the factors influencing patients’ choice of hospital in Iran [ 81 ]. In Cameroon, people can often go to a tertiary hospital without previous referral from a secondary or a primary hospital. As healthcare services in public institutions are out-of-pocket payments, these “good” hospitals will see an increase in their financing. Effective nonverbal communication with older patients goes a long way. It not only benefits individuals but hospitals and society in general. Therefore, nurses should strive to sustain effective nonverbal communication with older patients.

3.4. Relationships between Concepts

In this model, all categories and subcategories are directly or indirectly interlinked. The category “ effective nonverbal communication ” is the core category in this model. It comprises the modalities of effective nonverbal communication and its purposes, which are directly linked. For instance, one or more modalities of nonverbal communication can be used to achieve one or more purposes of nonverbal communication in one interaction between a nurse and an older patient; an affective touch coupled with physical proximity can be used to win trust in older patients. The next category is the action and interaction strategies that need to be implemented to achieve effective nonverbal communication between nurses and older adults. This category is directly linked to the core category and intervening conditions. For instance, to support verbal communication, get messages across, and convey empathy or win older adults’ trust, nurses should be aware of their nonverbal behaviors, “being angels”, reduce negative stereotypes about older adults, and put yourself in the shoes of older patients. This shows the links between the purposes of effective nonverbal communication, the actions that should be taken by nurses, and the intervening conditions.

Figure 1 also shows that effective nonverbal communication between nurses and older patients rests on certain pillars that are interlinked and serve together as a solid structure. This means that effective nonverbal communication relies on nurses’ intrinsic factors, positive views of older adults, awareness of nonverbal communication, and nonverbal communication skills. Effective nonverbal communication also relies on older adults’ related factors such as their positive moods, their non-critical medical condition, and their financial situation. The diagram also shows that nurses’ effective nonverbal communication with older patients takes place within a specific context, which is the healthcare encounter. It also depends on the type of interaction between the nurse and the older patient. For instance, if the interaction is more task-related, affective nurses can use touch and sustained eye gaze to convey a positive emotion. The nonverbal communication that happens in a particular healthcare encounter and during a particular type of interaction is expected to yield positive results, such as older patients’ compliance with care and improved nursing care, thus leading to shorter stays in hospitals and the enhanced reputations of these hospitals.

4. Limitations

Although this model of effective nonverbal communication falls under transactional models of communication, it focuses more on the role of nurses; thus, one could argue that this model is linear. Moreover, the model acknowledges that older patients also have a role to play in effective nonverbal communication between them and nurses, but emphasizes nurses as shapers of the communication. A greater number of older patients could have enriched the study findings. However, as confirmed by Hall, Longhurst, and Higginson [ 82 ] and Lam et al. [ 83 ], it was difficult to conduct research with older adults because of the lack of trust in the researcher, lack of interest in the topic, the involvement of family members, and difficulties in obtaining consent. In addition, most of the older adults could speak neither French nor English. This can be seen as a limitation. Another limitation is that the observations were overt; therefore, the proposed model relies only on participants’ reports of what happened as well as interpretations of the observations made. Video recordings of interactions could have captured more details that might not have been captured by the researcher. The last limitation is that views from other healthcare workers, who also communicate nonverbally with older patients in the same settings, could have further strengthened the model.

5. Conclusions

This model adds to the body of knowledge on nonverbal communication between nurses and patients. It also answers the United Nations’ call on more data on older adults from low-and-middle-income countries. This model also provides a tool to help nurses communicate more effectively with older patients who mostly rely on nonverbal communication. The improved communication with older patients is expected to improve the quality of care rendered and the reputation of clinical settings. It is therefore recommended that the model is tested, evaluated, and refined for better outcomes.

Acknowledgments

The authors acknowledge all the participants of this study as well as the College of Health Sciences of the University of KwaZulu-Natal for its support.

Funding Statement

This research received no external funding.

Author Contributions

Conceptualization, E.L.W.K. and J.K.; methodology, E.L.W.K. and J.K.; data analysis, E.L.W.K. and O.B.B.; data collection, E.L.W.K.; writing—original draft preparation, E.L.W.K.; writing—review and editing, O.B.B. and J.K.; supervision, J.K. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and was approved by the Humanities and Social Sciences Research Ethics Committee of the University of KwaZulu-Natal (Number HSS/2008/017D, 23 November 2017).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Communication in Nursing Practice: Gibbs’ Reflective Cycle Essay

Introduction

A Model for Effective Nonverbal Communication between Nurses and Older Patients: A Grounded Theory Inquiry

1. Introduction

2. Materials and Methods

2.2. Study Settings and Context

2.3. Study Participants and Sampling Methods

2.4. Data Collection

2.5. Data Analysis

2.6. Ethical Considerations

3. Results and Discussion

3.1. Purpose of the Model

3.2. Basic Assumptions of the Model

3.3. Concepts and Definitions

3.3.1. Core Concept

The Channels of Effective Nonverbal Communication

The Purposes of Effective Nonverbal Communication