NURSE EDUCATION TODAY (1985) 5, 130-134 0 Longman Group Ltd 1985

Communication between nurses and their patients

Margaret Crotty

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.

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.

INTRODUCTION

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-

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 nurse’s 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.

fore require the nurse to take communication with patients more seriously.

Main research question

Is there a significant difference in the amount

M Crotty SRN SCM OND DN(Lond) CertEd RNT, Senior of interaction occurring between the sister,

Tutor, Continuing Education, Wolverhampton School of trained staff and learner nurses, and their

Nursing patients?

130

Review of the literature

There is a good deal of evidence to show that

patients view communication as a central issue

in their care. Cartwright (1964) showed that

patients tend to be more critical about poor

communication than about any other aspect of

their hospital experience. Some studies have

concentrated on patients’ reactions to specific

investigations or surgical procedures. It has

heen established that giving adequate informa-

tion and explanation prior to operations or

investigations can result in reduced pain, dis-

comfort, anxiety and stress. This was high-

lighted by Wilson-Barnett (1978) in her study

of patients undergoing barium enema examina-

tion; she demonstrated the benefit to patients

from being given specific information about

the procedure. Two studies undertaken by

Hayward (1975) and Boore (1979) assessed the

efYeccs of giving information to patients, on

their feelings pre-operatively and their pro-

gress post-operatively. Both these studies found

that giving information was beneficial to the

patients.

A study by Rhys-Hearn (1968) of the work

of nurses in general wards demonstrated that it

is basic needs for physical care which deter-

mine how much attention patients receive and

rhat it is the junior nurses who spend most

rime communicating with the patients. Stock-

well t 1972), in ‘The unpopular patient’, noted

that the largest proportion of time spent by

nurses talking to patients - 75 per cent - was

during the giving of physical care.

One researcher, Wells ( 1980), found that

rntirely personal communication between nurses

and patients was infrequent and usually social

in nature. Where two nurses were attending

one patient she found they often conversed

only with each other. The average length of

sustained verbal conversations was found to

be approximately 1 minute 30 seconds. She

caid that the brevity indicated that the nurses

did not give high priority to this aspect of

patient care.

The Royal Commission on the National

Health Service (1979) highlighted the fact that

,qood communication is rarer than some might

think. The survey found that ‘31 per cent of in-

patients considered that they had not been

given sufIicient information about their treat-

ment and care’.

Macleod Clark (1981) audio- and video-taped

talk between nurses and patients. Analysis of

these conversations showed that even in non-

threatening situations nurses spoke to patients

in ways which do not encourage communi-

cation. She suggested that one reason why

nurses fail to attempt to improve nurse--patirnt

communication is that closer c.ommunication

may result in the nurse becoming too invol\,ed

in the inevitable difficulties and sufferings of

her patients. This view supported thr work of

Menzies (1970). who, in her anal?-sis of hos-

pitals as social systems, suggested that hospital

staff avoid communicating with patients in

order to protect themselves from the anxiety

which might result by becoming too involved

with patients.

Conclusions

All the evidence suggests that improved com-

munication at every point on the continuum

results in improvement in patient well-being

and recovery.

Little research has been carried out on the

analysis of interactions between the nurses and

patients in general wards. In view of

Anderson’s (1973) statement that ‘talking to

patients is a fundamental component of the job

role of the nurse’, this lack of research is

surprising.

METHOD

Selection of the ward

One ward was chosen for the study, a female

ward of 24 beds situated in a local general

hospital. The staff consisted of one sister, two

staff nurses, an enrolled nurse and student

nurses in each year of training. This ward was

chosen because it was one of several where the

researcher carried out clinical teaching.

132 NURSE EDUCATION TODAY

Collection of the data

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.

It was decided to identify verbal interaction as the unit of study and to consider:

1. the number of interactions which occurred;

2. the length of each interaction; 3. the activity the nurse was performing

during the interaction; 4. the differences between each grade of the

above factors.

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.

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

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.

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.

The location of the interaction, the reason for the interaction and the person initiating it were recorded.

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-

peared off-hand and abrupt.

DISCUSSION OF THE FINDINGS

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.

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.

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?

Main findings

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.

Number of interactions

Out of a total of 75 interactions for all grades of staff, the learners performed 33, trained staff 24, the sister 18.

This result is similar to that of Rhys-Hearn

( 1968), who found that it was the junior nurses

who spent most time communicating with the

patients.

Length of interactions The mqjority (69 per cent) of the intrractions

for all three grades of staff were under two

minutes in length.

\Vells (198Oj, in her study, found the

average length of interactions to be 1 minute

30 seconds.

Just over half (52 per cent) of the effective

interactions were performed by the learners,

the (rained sta8‘ had 26 per cent and the sister

21 prr cent.

Activities during the interactions

The learners’ activities during the interactions

were mainly functional (90 per cent), the

trained staffs activities were also mainly func-

tional (83 per cent), but the sister’s activities

wer‘r mainly clinical or administrative (72 per

c’cn( i. Slockwell (1972) had similar results from her

study, all interactions were entirely task init-

iated: nurses did not approach patients unless

the!- were going to do someting to them, eg.

give treatment. Some patients had no verbal

contact with nurses or other patients for hours

at a time.

In this study, when the effective interactions

were analysed, it was found that 80 per cent of

the sister’s interactions occurred during clinical

or administrative activities; all activities of

trained staff were functional, domestic or social;

and 92 per cent of the learners’ effective inter-

actions were during functional, domestic or

social activities.

Differences between each grade

All the efFertive interactions of the three grades

of staff were recorded as being positive in

manner. The overall majority of interactions

i 71 per cent) were recorded as positive in

manner. The nurses appeared to have the right

attitude to the patient but wer(’ handicapped

by lack of time. The sister’s one ncgatil~e

response was while she \vas helping ;I vrnr-

puncture technician to take blood: she had

been called away from hrr o\~n M.Ork and

seemed preoccupied. Sistrr‘s nrlltral rcsponscs

were all during clinical acti\.itics which I‘(‘-

quired concentration. I’1 le neulr,tl rtxponsrs of

the trained staK were while they were perfi,rnl-

ing routine activities such ax c-ollcc~tirlg crockery

and making beds - they apprarrd borrd. ‘l’he

learners’ neutral responses occurred lvhen r+

moving bedpans, makin,? hcds :md combing

patients’ hair.

Only 15 of the 75 interactions rrcxxded were

initiated by the patients. Of‘ thcic. six were

addressed to the sister, two to the trained staff

and seven to the learner nurses.

Conclusion

The findings from this study suggrst that vcr-

ha1 interaction by all grades of nursing staff is

not satisfactory in either quantity or quality.

Only 31 per cent of all the interactions wcrr

considered effective. The remainder wcrc undrr

two minutes in length and wc‘r(* noted b!_- thr

observer to be short with often only one or t\vo

words being spoken. If, as suggrstrd at the

outset, communication is so central to nursing

carr, how do these patirnts fare:’

The learner nurses were continuously with

the patients, caring for them. .Vthongh thcsv

had the majority (33) of interactinns recorded,

21 of these wrre ineffrctivr. bclng under two

minutes in duration. ConsidrriIlg the time

spent with the patient and the opportunity to

interact because of thr nature’ of the work

carried out, this is a disappointing result.

The trained staff wrre also with (hr patitbnts

continuously, but they had xl c\‘rn smaltcr

number of intrractions (24 ‘T‘ht$r proportion

of effective intrractions (26 per cmtl, ic. over

two minutes duration, is similar- 10 that of the

sister (21 per crntj. However. thr activities the

sister performed were mainly- c,linical or ad-

ministrative, with little opportunity to intrr-

act with the patient; so this fi,qure is not

134 NURSE EDUCATION TODAY

surprising. It seems that carrying out nursing care for the patient does not ensure that inter-

RECOMMENDATIONS

action takes place. This study suggests that most interaction

between nurse and patient is carried out by learner nurses. These nurses have only received

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

sister. For the nursing process to be effective in

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

individualised nursing care. Have the sisters and trained staff developed

their own interpersonal skills? If they have, why are they not using them? To answer these and other questions, it would be necessary to

carry out a more extensive study to see firstly if these findings are typical of the pattern of

interaction in general.

It is recommended that a more extensive study is carried out on nurse-patient verbal com- munication in other general wards, to deter- mine if the findings from this small study are typical of the pattern of interaction between nurses and their patients.

It is also recommended that the teaching of communication skills should be included in the basic nurse education curriculum. This process should be continued after registration, by the provision of workshops on communication skiIls applicable to the different requirements of each

specialty.

References

Anderson E 1973 The role of the nurse. Rcn, London Boore J 1979 A prescription for recovery. Rcn, London Cartwright A 1964 Human relations and hospital care.

Routledge & Kegan Paul, London Hayward J 1975 Information - a prescription against pain.

Rcn, London Macleod Clark J 1981 Communication in nursing. Nursing

Times 77 (1): 12-18 Menzies I 1970 Social systems as defence against anxiety.

Tavistock, London Royal Commission on the National Health Service 1979

Report, para 10.26. HMSO, London, p 130 Rhys-Hearn C 1968 How many high care patients?

Nursing Times 14: 504-505 Stockwell F 1972 The unpopular patient. Rcn, London Wells T J 1980 Problems in geriatric nursing care.

Churchill Livingstone, Edinburgh Wilson-Barnett J 1978 Patients’ emotional responses to

barium X-rays. Journal of Advanced Nursing 3: 3746