Nursing Research in Health Care Communication

Health care communication remains at the core of nursing practice providing the ground work for relationships with patients, family members, and health care colleagues; and the medium for teaching and caring. Verbal communication includes “all behavior conveying messages with language” (Caris Verhallen, Kerkstra, & Bensing, 1997, p.916). Nonverbal communication includes any behavior that imparts information with-out the use of verbal language, including body movement, physical appearance, conversation timing, voice qualities, personal space, and touch (Oliver, S., &Redfern, 1991).
Sustained programs of research in health care communication remain scarce. S. Brown’s(1999) review of the research literature on  patient-centered communication in the Annual Review of Nursing Research contained only 15 nursing journal references out of 69references. The majority of health care communication research has been conducted in psychology and medicine. The following re view highlights contributions that nursing re-search has made to health care communication. The development of expertise in communication has been examined in the clinical set-ting and with educational interventions. 

Health Care Communication

Kotechi (2002) conducted a grounded theory study of baccalaureate nursing student communication and found that the students moved through a four-stage process to develop a “personal communication repertoire”. Stage one, affirming the self, involved self-talk to bolster confidence in communicating with patients and to evaluate their own communication. Stage two, engaging the patient, moved beyond feeling like an intruder to establishing acceptable boundaries, and developing a relationship and rapport with patients. To engage the patient, students used social talk (superficial conversation), professional talk (communication strategies learned in school), and personal talk (communication used on special occasions to share a common experience). 
During stage three, students experienced communication breakdowns when they worked with more challenging patients, but learned to keep going by using additional communication strategies. Students relied heavily on how the staff nurses talked with more challenging patients and incorporated the helpful communication strategies into their repertoire. During stage four, refining the repertoire, stu-dents became more facile in selecting or switching to more effective communication strategies, and did so with greater confidence in order to persevere through more challenging patient-care situations.
The majority of nursing research in healthcare communication has focused on describing how nurses communicate with patients across a variety of clinical contexts. In some studies communication has been conceptualized as either affective (providing social or emotional support) or instrumental (completing a necessary task). Caris-Verhallen and colleagues (1997) examined nurses’ communication with older adults in both the community and extended care setting. Nurses, nursing assistants, and older adults were video-taped and Roter’s Interactional Analysis system was used to score the interactions. A total of 44% to 72% of the communication was socioemotional. Most of the older adults had received care for a year or more, which may have facilitated the increased interpersonal nature of the communication (Caris-Verhallen, Kerkstra, van der Heijden, & Bensing,1998).
A different pattern of verbal communication was found in an experiment in which nurses were videotaped admitting a simulated cancer patient. A total of 62% of the verbal communication was instrumental. Few of the verbalizations encouraged patient input such as asking if patients understood (Kruijver, Kerkstra, Bensing, &van de Weil, 2001). The simulated conditions of the study might have decreased the usual efforts that nurses make to provide emotional support and involve patients during admission interviews. Home care nurses initiated talk about compliance with the medical regimen, an instrumental focus, approximately 60% of the time (Vivian & Wilcox, 2000), suggesting that an instrumental focus might predominate in nursing communication with patients. Studies testing the effects of socioemotional/instrumental communication and patient involvement on patient outcomes might guide the useof more effective communication strategies.
The context for the communication has generally not been directly examined, with the exception of Caris-Verhallen et al. (1998).Studies that have examined nurse and patient communication across different populations and settings provided some insight into the effect of context. For example, while nurses initiated most of the child-health topics with parents during a well-child visit, nurses invited questions from parents in 66% of the visits (Baggens, 2001), a finding contrary to Kruijver and colleagues (2001). It would be helpful to more closely examine the impactof context in future communication studies. Therapeutic use of communication pro-vides a helpful area for nursing research and shifts the focus to the patient and health care provider interaction. Nurses and patients were found to encourage optimism in a constructive, realistic manner during cancer-care communication. Nurses and patients developed positive statements by elaborating on more positive points. Conversations were generally ended on a positive note, often with the patient spontaneously providing the comment (Jarrett & Payne, 2000). Listening in order to understand what has been said is an essential part of therapeutic communication.
Listening involves focusing on the patient, and providing patients the opportunity to talk and find their own interpretation of their experience (Fredriksson, 1999). Research is needed to translate descriptive findings about therapeutic communication into effective interventions. Supporting patients to communicate effectively has reemerged as a nursing research focus, moving beyond testing the effects of communication boards. Augmentative and alternative communication (AAC) devices improve or supplement talking and writing, and include devices such as computer-generated speech. Uncovering the meaning of using AAC devices might encourage nurses to value and support use of such devices. Patients’ experience of using AAC devices to communicate was found to enable humanness. Use of AAC devices helped communicate thoughts but was less effective in communicating emotion (Dickerson, Stone, Panchura, & Usiak, 2002).
A less technical means of supporting patient communication was tested by teaching pain-communication skills via videotape to older adults awaiting surgery. Older adults who were taught the communication skills reported greater pain relief on the 1st day after the operation (McDonald, D., & Molony, in press). The study did not directly measure patient communication and did not clarify which specific communication strategies or combinations were most helpful. Nursing research in health care communication continues to be widely dispersed. Approaches that micro analyze segments of conversation provide some description of the content of the communication, but they do not capture the context, motivations, or consequences. Naturalistic studies (e.g., Jarrett &Payne, 2000; Kotechi, 2002) have provided some helpful insights, suggesting the need to further explore aspects of health care communication from the naturalistic approach, for example, conducting a grounded theory study to identify the basic process by which expert nurses effectively communicate with patients.

The majority of the research has focused on how nurses communicate with patients. Future research must include patient contributions to the communication, testing ways to support patients to effectively communicate with health care providers. Ways of enhancing patient communication must be linked to positive patient outcomes such as increased self-care and decreased pain, and must be obtainable within the constraints of current health care systems.


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