How does communication impact the concept of clinical reasoning in nursing

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.

Method

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.

How does communication impact the concept of clinical reasoning in nursing
Figure 1. Search criteria and results

Results

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).

Discussion

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.

Model case

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.

Conclusion

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.

KEY POINTS

  • 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?