Effective communication between registered nurses and adult oncology patients in inpatient settings.

Effective communication between registered nurses and adult oncology patients in inpatient settings.

 

Recommendations

* There is a need for nurses to improve on their psychological assessment and work more closely with patients admitted with a recurrence of cancer. (Grade B)

* Nurses can use information-sharing as a non-threatening approach to engage with patients and build rapport. Nurses should also encourage patients to ask questions and participate in their care. When rapport is established, patients are more likely to express their concerns openly and seek emotional support from the nurses. (Grade B)

* Nurses should be mindful of patients' psychological readiness to communicate, as well as respect their preference as to whom they wish to share their thoughts/emotions with. Similarly, nurses can involve patients' relatives in the provision of effective social support for the patients. (Grade B)

* Institutions need to design ward structures (ward culture and nurses' workload) that support and/or encourage nurses to be person-oriented and take responsibility for providing holistic care to patients. (Grade B)

* Educational programs should be implemented to: (1) inform nurses about the possible challenges in managing and providing psycho-emotional care for oncology patients and; (2) help nurses develop strategies to overcome communication barriers. (Grade B)

* Training courses may be useful to improve nurses' reception and response to patients' cues, as well as providing skills and strategies for effective communication in the emotion-loaded oncology setting. (Grade B)

* There is a need to fully explore the affective factors to effective communication in each individual ward environment before implementing any strategies to improve nurse-patient communication in the ward. (Grade B)

Information Source

This Best Practice information sheet has been derived from a systematic review published by in 2010 in JBI Library of Systematic Reviews. (2) The full text of the systematic review report is available from the Joanna Briggs Institute

(www.joannabriggs.org).

Background

Nurses interact frequently with patients, wherein each perceives the other in the situation and, through communication, sets goals, and agrees on means to achieve the goals. In the oncology setting, communication is further complicated by the patient's life-threatening illness. Being diagnosed with cancer will inevitably create psychological distress and a substantial need for informational and emotional support. In many instances, emotions hinder effective communication.

Effective communication is the cornerstone of nurse-patient relationships. It involves not only sharing of information, but also the provision of emotional care.

Current practice emphasizes quality nursing care, which requires nurses to assess the needs and preferences of the patient through effective communication and provide corresponding care to meet these needs. Effective communication encourages patients to express their anxieties and in return, patients gain emotional relief. Supportive communication enhances patients' psychological adjustment and thus improves patient outcomes. Overall, effective communication plays a crucial role in meeting the cognitive and affective needs of oncology patients and improving the quality of care delivery.

Objectives

The purpose of this Best Practice Information Sheet is to present the best available evidence on the factors affecting effective communication between registered nurses and oncology adult patients in inpatient settings.

Phenomena of interest

This systematic review considered studies that looked into the promoting factors and barriers in effective communication between registered nurses and inpatient oncology adults.

Quality of the research

A total of three studies were included in the quantitative component of the review. One of the quantitative studies was considered to be moderate to low quality, two other quantitative studies were moderate to high quality papers.

Five studies were included in the qualitative component of the review. Three of the qualitative studies were considered moderate quality studies, one high quality and another low quality study.

Results

Quantitative evidence

In a study based in England, the factors influencing nurses' communication with cancer patients were examined.

Specifically, the author investigated the extent of facilitative and blocking behaviors exhibited by nurses when communicating with cancer patients, and the relationship, if any, between nurses' behaviors and their levels of state and trait anxiety, attitudes to death, perceived levels of social support and work environment. Firstly, it was noted that nurses working in wards with role model ward sisters, nurses who experienced stress resulting from giving poor care, and nurses who had completed post-basic education in cancer nursing were better facilitators. In contrast, nurses who received satisfactory support from nurse managers and nurses who would like to talk truthfully and openly with patients but were not sure if they had the skills to do so were poorest facilitators.

In contrast, nurses who were atheists (who believed there were no deities), nurses who used blocking behavior consciously, nurses who were most afraid of dying, nurses who had lower levels of anxiety after completing the most difficult nursing history, nurses who committed a lot of their time to outside interests and nurses who had conflicts with fellow colleagues, exhibited greater blocking behaviors when communicating with patients.

In addition, it was found that nurses also exhibited greater blocking behaviors when taking nursing histories from patients admitted with a recurrence, compared with the new patients and patients for palliative care.

In the second study conducted in a major oncology centre in Texas (USA), self-reported questionnaires were used to better understand the challenges nurses faced in their everyday communication and care of cancer patients and their families. From the responses, a general pattern emerged wherein the Advanced Practice Nurses (APNs), as compared to the other nurses (staff nurses, research nurses and nurse managers), reported lower level of difficulty and felt better skilled in handling some clinical situations.

Regarding the differences in perceived level of difficulty between the APNs and the other nurses, it was found that some situations were significantly easier for the APNs: "handling requests for euthanasia"; "addressing the patient's sexual concerns"; "managing overprotective families"; "intervening with patients who are in denial"; "setting boundaries when families have unrealistic expectations of care"; "discussing Do Not Resuscitate (DNR) issues"; and "intervening with family members who are depressed". Similarly, the APNs perceived they were better skilled in handling some situations: "addressing the patient's sexual concerns"; "handling requests for euthanasia"; "intervening with family members in denial"; "managing clinical situations that pose ethical dilemmas"; "intervening with patients who are in denial"; and "addressing the patient's fears".

In another part of the study, it was discovered that nurses, in general, seemed confident in providing for the physical needs of their patients, but they perceived more difficulty and were less skilled in addressing concerns that were emotionally charged. Specifically, the participants rated "handling requests for euthanasia or assisted suicide" as most challenging. Other areas in which the participants also reported being challenged included: "having several dying patients in your practice at once"; "managing clinical situations that pose ethical dilemmas"; "dealing with families who are in conflict about treatment decisions"; "setting limits with patients who demand too much time"; "managing overprotective families"; "intervening with patient/family members who are angry"; "intervening with patient/family members who are in denial"; "setting boundaries when families have unrealistic expectations of care"; "dealing with the economic impact cancer has on patients and their families".

In the third study conducted in the Netherlands, the relationship between nurses' cue-responding behavior and patient satisfaction were examined. The results showed that patients were implicit in their expression of concerns, and nurses' response to patients' cues was poor. Patients' perceived performance (of nurses) was positively correlated with nurses' cue responding rate and the number of cues used. Patients were more satisfied when nurses responded to their cues, and this likelihood was enhanced when patients used more cues.

Patients who were on palliative treatment were more satisfied with the communication of nurses than curatively treated patients. Older patients were also more satisfied with the communication of nurses than younger patients. Cue responding and palliative treatment independently contributed to perceived performance of the nurse.

Qualitative evidence

25 findings from primary qualitative studies were combined into eight categories and then further grouped into four synthesised findings.

Synthesis One--Promoting Factors in Nurses

The evidence suggests that good communication promoted disclosure. Patients wanted honest and accurate information which needed to be provided by nurses in a sensitive manner. Every individual is unique, so each patient may respond differently to the information delivered. Nurses who were mindful, empathetic and flexible in their approach were better at facilitating patient disclosure. Communication was also enhanced when nurses showed genuine care and concern for patients. This included good eye contact, empathy, engaged dialogue, appropriate tone of voice and touch. In addition, nurses who were knowledgeable and competent increased patients' confidence and trust in them. The findings suggest that nurses need to be equipped with good communication skills/interpersonal skills and embrace a positive attitude to be able to effectively communicate with their patients.

Synthesis Two--Promoting Factors in Patients

The evidence suggests that patients who took an active role in their own care also communicated more with the nurses in terms of information-sharing and collaboration in decision-making. Communication improved when nurses encouraged patients to ask questions and participate in their care. Nurses were considered as an accessible source of professional information. In addition, the information provided by nurses was believed to be more comprehensible than that from doctors.

Synthesis Three--Inhibiting Factors in Nurses

The evidence suggests that communication between nurses and patients centers on collecting information about the patients and giving them information about the disease, treatment options and test results. In addition, nurses tended to give information, often when not requested by patients, to keep the conversation away from what were seen to be 'uncomfortable areas' by the nurses. Nurses who ignored patients cues and concerns also inhibited disclosure from patients. Likewise, nurses who lacked respect, concern and empathy for patients could also prevent open communication. With a focus on performing tasks, it was seen that nurses neglected the human aspects of care. Communication was further impeded as nurses usually used an indifferent and routinised approach when they were focused on getting the job done. As discussed above, it is evident that nurses need to move away from task-orientation to using effective communication and cue-responding behavior in the provision of better psycho-emotional care for the patients.

Synthesis Four--Inhibiting Factors in Patients

The evidence suggests that patients might not wish to talk about their disease. Instead, they preferred to talk about ordinary things and normal lives. This helped them to stay optimistic. In addition, the patient's mood could also influence their desire to communicate with the nurses. It also appeared that patients may prefer to keep their problems to themselves and not burden their listeners. Patients were inhibited in their willingness to talk to health professionals about their disease and need for emotional support. Rather than talk with health professionals, patients turned to their immediate family, friends and colleagues and other patients for emotional support. Considering the evidence, nurses should be mindful of the patient's willingness and readiness to talk. Nurses should also ensure that patients have supportive social network and adequate resources for their emotional needs.

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Acknowledgments

This Best Practice information sheet was developed by The Joanna Briggs Institute.

In addition this Best Practice information sheet has been reviewed by nominees of International Joanna Briggs Collaborating Centers.

Grades of Recommendation

These Grades of Recommendation have been based on the JBI-developed 2006 Grades of Effectiveness (1)

Grade A Strong support that merits application

Grade B Moderate support that warrants consideration of application

Grade C Not supported

Evidence-based Practice evidence, context, client preference judgement

This Best Practice information sheet presents the best available evidence on this topic. Implications for practice are made with an expectation that health professionals will utilise this evidence with consideration of their context, their client's preference and their clinical judgement. (3)

References

(1.) The Joanna Briggs Institute. Levels of evidence and Grades of Recommendations. http://www.joannabriggs.edu.au/About%20Us/JBI%20Approach

(2.) Tay LH, Hegney DG, Ang E. A systematic review on the factors affecting effective communication between registered nurses and oncology adult patients in an inpatient setting. JBI Library of Systematic Reviews 2010; 8(22):869-916.

(3.) Pearson A, Wiechula R, Court A, Lockwood C. The JBI model of evidence-based healthcare. Int J of Evid Based Healthc 2005; 3(8):207-215.