Communication between nurses and their patients

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<ul><li><p>NURSE EDUCATION TODAY (1985) 5, 130-134 0 Longman Group Ltd 1985 </p><p>Communication between nurses and their patients </p><p>Margaret Crotty </p><p>This paper outlines a small study carried out to assess the interaction between nurses and patients in a general medical ward. In view of the implementation of the nursing process, which must involve nurses in close communication with the patient, it was decided to measure the actual amount of interaction occurring between the sister, trained staff, learner nurses and their patients. </p><p>The findings suggest that interaction by all grades of staff is not satisfactory in its quantity or quality, and raises the question as to whether nurses have the communication skills that are necessary in order to assess, plan, implement and evaluate the nursing care of a patient. </p><p>INTRODUCTION </p><p>The implementation of the nursing process requires the nurse to establish a close relation- ship with th.e patient. Emphasis is placed on meeting the psychological and emotional needs of the patient as well as their physical needs. The nursing process is a systematic problem- solving approach to nursing care. It sets the patient in the centre of all activities and is a tool which can be used for giving indivi- dualised patient care. There are four stages described in the nursing process: assessment of the patient, the planning of care for the patient, the implementation of care, and the evaluation of the care delivered. All four stages mean close contact with the patient and there- </p><p>In view of the implementation of the nursing process, it was decided to set up a small study of the communication between nurses and their patients. It was felt that as nursing is in- creasingly being seen in terms of fulfilment of patients needs, rather than an accomplishment of a range of routine tasks, the use of the nursing process should facilitate communication with all patients. The nurses commitment to individualised care must inevitably involve meaningful communication with the patient. As communication is so central to care, it was decided to examine what communication ac- tually takes place between the nurse and her patients. </p><p>fore require the nurse to take communication with patients more seriously. </p><p>Main research question </p><p>Is there a significant difference in the amount </p><p>M Crotty SRN SCM OND DN(Lond) CertEd RNT, Senior of interaction occurring between the sister, </p><p>Tutor, Continuing Education, Wolverhampton School of trained staff and learner nurses, and their </p><p>Nursing patients? </p><p>130 </p></li><li><p>Review of the literature </p><p>There is a good deal of evidence to show that </p><p>patients view communication as a central issue </p><p>in their care. Cartwright (1964) showed that </p><p>patients tend to be more critical about poor </p><p>communication than about any other aspect of </p><p>their hospital experience. Some studies have </p><p>concentrated on patients reactions to specific </p><p>investigations or surgical procedures. It has </p><p>heen established that giving adequate informa- </p><p>tion and explanation prior to operations or </p><p>investigations can result in reduced pain, dis- </p><p>comfort, anxiety and stress. This was high- </p><p>lighted by Wilson-Barnett (1978) in her study </p><p>of patients undergoing barium enema examina- </p><p>tion; she demonstrated the benefit to patients </p><p>from being given specific information about </p><p>the procedure. Two studies undertaken by </p><p>Hayward (1975) and Boore (1979) assessed the </p><p>efYeccs of giving information to patients, on </p><p>their feelings pre-operatively and their pro- </p><p>gress post-operatively. Both these studies found </p><p>that giving information was beneficial to the </p><p>patients. </p><p>A study by Rhys-Hearn (1968) of the work </p><p>of nurses in general wards demonstrated that it </p><p>is basic needs for physical care which deter- </p><p>mine how much attention patients receive and </p><p>rhat it is the junior nurses who spend most </p><p>rime communicating with the patients. Stock- </p><p>well t 1972), in The unpopular patient, noted that the largest proportion of time spent by </p><p>nurses talking to patients - 75 per cent - was </p><p>during the giving of physical care. </p><p>One researcher, Wells ( 1980), found that rntirely personal communication between nurses </p><p>and patients was infrequent and usually social </p><p>in nature. Where two nurses were attending </p><p>one patient she found they often conversed </p><p>only with each other. The average length of </p><p>sustained verbal conversations was found to </p><p>be approximately 1 minute 30 seconds. She </p><p>caid that the brevity indicated that the nurses </p><p>did not give high priority to this aspect of </p><p>patient care. </p><p>The Royal Commission on the National </p><p>Health Service (1979) highlighted the fact that ,qood communication is rarer than some might </p><p>think. The survey found that 31 per cent of in- </p><p>patients considered that they had not been </p><p>given sufIicient information about their treat- </p><p>ment and care. </p><p>Macleod Clark (1981) audio- and video-taped </p><p>talk between nurses and patients. Analysis of </p><p>these conversations showed that even in non- </p><p>threatening situations nurses spoke to patients </p><p>in ways which do not encourage communi- </p><p>cation. She suggested that one reason why </p><p>nurses fail to attempt to improve nurse--patirnt </p><p>communication is that closer c.ommunication </p><p>may result in the nurse becoming too invol\,ed </p><p>in the inevitable difficulties and sufferings of </p><p>her patients. This view supported thr work of </p><p>Menzies (1970). who, in her anal?-sis of hos- </p><p>pitals as social systems, suggested that hospital </p><p>staff avoid communicating with patients in </p><p>order to protect themselves from the anxiety </p><p>which might result by becoming too involved </p><p>with patients. </p><p>Conclusions </p><p>All the evidence suggests that improved com- </p><p>munication at every point on the continuum </p><p>results in improvement in patient well-being </p><p>and recovery. </p><p>Little research has been carried out on the </p><p>analysis of interactions between the nurses and </p><p>patients in general wards. In view of </p><p>Andersons (1973) statement that talking to </p><p>patients is a fundamental component of the job </p><p>role of the nurse, this lack of research is </p><p>surprising. </p><p>METHOD </p><p>Selection of the ward </p><p>One ward was chosen for the study, a female </p><p>ward of 24 beds situated in a local general </p><p>hospital. The staff consisted of one sister, two </p><p>staff nurses, an enrolled nurse and student </p><p>nurses in each year of training. This ward was </p><p>chosen because it was one of several where the researcher carried out clinical teaching. </p></li><li><p>132 NURSE EDUCATION TODAY </p><p>Collection of the data </p><p>The study was carried out by the researcher using non-participant observation. The staff of the ward were informed that communications in the ward were being studied, but as the researcher was a frequent visitor to the ward, no problems were encountered. </p><p>It was decided to identify verbal interaction as the unit of study and to consider: </p><p>1. the number of interactions which occurred; </p><p>2. the length of each interaction; 3. the activity the nurse was performing </p><p>during the interaction; 4. the differences between each grade of the </p><p>above factors. </p><p>The three grades of staff - sister, trained nurse and learner nurse - were observed for live minutes each in rotation, for a total time of seven hours. </p><p>An observation sheet was devised and used to record the main activities of the nurse during verbal interaction. These activities were divided into five main descriptive categories: clinical, administrative, functional, domestic and social. Clinical activities included carrying </p><p>out aseptic procedures, administering medi- cines, assisting the doctor. Administrative activ- ities included doctors ward rounds, writing reports, arranging the discharge of patients. Functional activities included the bathing of patients, making beds, giving out drinks. Domestic activities included the tidying of lockers, making tea and running errands. Social activity was defined as talk with patients for no specific purpose. </p><p>The duration of each interaction was re- corded in three categories, as follows: under two minutes in length was considered to be too short to be an effective interaction; two to three minutes was considered a reasonable length of time for an effective interaction to occur; over three minutes was considered suffi- cient time for a good interaction to occur. </p><p>The location of the interaction, the reason for the interaction and the person initiating it were recorded. </p><p>The manner displayed by the nurse was recorded, using the three categories of positive, neutral and negative. Positive was defined as friendly, pleasant and interested; neutral was where the nurse appeared disinterested and uninvolved; and negative where the nurse ap- </p><p>peared off-hand and abrupt. </p><p>DISCUSSION OF THE FINDINGS </p><p>From the outset, the intention of this study was to examine the interaction which takes place between nurses and their patients related to their grade and role. </p><p>The nursing literature highlighted the im- portance of good communication. It was stressed that this was not just a pleasant op- tional extra, but central to the care of the patient. Some of the studies were concerned with stress in patients prior to surgery and investigations, and these found that the giving of information considerably reduced stress in the patient and complications after surgery. There seems little argument among nurses about the value of communication. </p><p>As the nursing process was being imple- mented in the wards of the hospital where this study was carried out, and as communication with the patient is an essential part of this approach to nursing, certain questions had to be asked. What communication does actually take place between the nurse and the patient? Is there any difference in the quantity and quality of interactions of the different grades of staff? During what types of activity does most interaction take place? </p><p>Main findings </p><p>It was found that the learner nurses interacted more with the patients than did the trained staff and the sister in charge of the ward. </p><p>Number of interactions </p><p>Out of a total of 75 interactions for all grades of staff, the learners performed 33, trained staff 24, the sister 18. </p></li><li><p>This result is similar to that of Rhys-Hearn </p><p>( 1968), who found that it was the junior nurses who spent most time communicating with the </p><p>patients. </p><p>Length of interactions The mqjority (69 per cent) of the intrractions </p><p>for all three grades of staff were under two </p><p>minutes in length. </p><p>\Vells (198Oj, in her study, found the </p><p>average length of interactions to be 1 minute </p><p>30 seconds. </p><p>Just over half (52 per cent) of the effective </p><p>interactions were performed by the learners, </p><p>the (rained sta8 had 26 per cent and the sister </p><p>21 prr cent. </p><p>Activities during the interactions </p><p>The learners activities during the interactions </p><p>were mainly functional (90 per cent), the </p><p>trained staffs activities were also mainly func- </p><p>tional (83 per cent), but the sisters activities </p><p>werr mainly clinical or administrative (72 per </p><p>ccn( i. Slockwell (1972) had similar results from her </p><p>study, all interactions were entirely task init- </p><p>iated: nurses did not approach patients unless </p><p>the!- were going to do someting to them, eg. </p><p>give treatment. Some patients had no verbal </p><p>contact with nurses or other patients for hours </p><p>at a time. </p><p>In this study, when the effective interactions </p><p>were analysed, it was found that 80 per cent of </p><p>the sisters interactions occurred during clinical </p><p>or administrative activities; all activities of </p><p>trained staff were functional, domestic or social; </p><p>and 92 per cent of the learners effective inter- </p><p>actions were during functional, domestic or </p><p>social activities. </p><p>Differences between each grade </p><p>All the efFertive interactions of the three grades </p><p>of staff were recorded as being positive in </p><p>manner. The overall majority of interactions </p><p>i 71 per cent) were recorded as positive in manner. The nurses appeared to have the right </p><p>attitude to the patient but wer( handicapped </p><p>by lack of time. The sisters one ncgatil~e </p><p>response was while she \vas helping ;I vrnr- </p><p>puncture technician to take blood: she had </p><p>been called away from hrr o\~n M.Ork and </p><p>seemed preoccupied. Sistrrs nrlltral rcsponscs </p><p>were all during clinical acti\.itics which I(- </p><p>quired concentration. I1 le neulr,tl rtxponsrs of </p><p>the trained staK were while they were perfi,rnl- </p><p>ing routine activities such ax c-ollcc~tirlg crockery </p><p>and making beds - they apprarrd borrd. lhe </p><p>learners neutral responses occurred lvhen r+ </p><p>moving bedpans, makin,? hcds :md combing </p><p>patients hair. </p><p>Only 15 of the 75 interactions rrcxxded were </p><p>initiated by the patients. Of thcic. six were </p><p>addressed to the sister, two to the trained staff </p><p>and seven to the learner nurses. </p><p>Conclusion </p><p>The findings from this study suggrst that vcr- </p><p>ha1 interaction by all grades of nursing staff is </p><p>not satisfactory in either quantity or quality. </p><p>Only 31 per cent of all the interactions wcrr </p><p>considered effective. The remainder wcrc undrr </p><p>two minutes in length and wcr(* noted b!_- thr </p><p>observer to be short with often only one or t\vo </p><p>words being spoken. If, as suggrstrd at the </p><p>outset, communication is so central to nursing </p><p>carr, how do these patirnts fare: </p><p>The learner nurses were continuously with </p><p>the patients, caring for them. .Vthongh thcsv </p><p>had the majority (33) of interactinns recorded, </p><p>21 of these wrre ineffrctivr. bclng under two </p><p>minutes in duration. ConsidrriIlg the time </p><p>spent with the patient and the opportunity to </p><p>interact because of thr nature of the work </p><p>carried out, this is a disappointing result. </p><p>The trained staff wrre also with (hr patitbnts </p><p>continuously, but they had xl c\rn smaltcr </p><p>number of intrractions (24 Tht$r proportion of effective intrractions (26 per cmtl, ic. over two minutes duration, is similar- 10 that of the </p><p>sister (21 per crntj. However. thr activities the </p><p>sister performed were mainly- c,linical or ad- </p><p>ministrative, with little opportunity to intrr- </p><p>act with the patient; so this fi,qure is not </p></li><li><p>134 NURSE EDUCATION TODAY </p><p>surprising. It seems that carrying out nursing care for the patient does not ensure that inter- </p><p>RECOMMENDATIONS </p><p>action takes place. This study suggests that most interaction </p><p>between nurse and patient is carried out by learner nurses. These nurses have only received </p><p>a brief introduction to interpersonal skills dur- ing their study blocks. They need to develop and use those skills under the supervision of trained nursing staff. This did not appear to be happening in this study. The sister, because of the activities she performed, did not interact a great deal with the patient. The trained staff performed the same activities as the learner but interacted in a similar patterns to that of the </p><p>sister. For the nursing process to be effective in </p><p>nursing care, the sister and trained staff must be able to communicate well, otherwise assess- ment, planning, implementation and evalua- tion of care are impossible. The sister and trained staff must provide the role model for the learner nurses, in order that they may develop the interpersonal skills required for </p><p>individualised nursing care. Have...</p></li></ul>

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