Rebekah Luoma
Public Health Nurses Perceptions: Nurse-Client
interaction
Thesis
Central Osthrobothnia University of Applied Sciences
Degree Program in Public Health Nursing
December 2007
Luoma, Rebekah. Public Health Nurses Perceptions: Nurse-client Interaction.
Kauhava, 2007. Central Ostrobothnia University of Applied Science. Final Thesis.
29 pages + 2 appendices.
Supervisor: Solvin, Raakel, Senior Lecturer MNSc
Contact person working life: Somppi, Marja-Liisa, Head Manager of Health Care
Inspector: Hillman, Marjatta, International coordinator, Senior lecturer, MNSc,
PHN, RN
Keywords: Nurse-client Interaction, Communication Skills, Public Health Nurse,
Patient-centered care.
ABSTRACT
Purpose: This qualitative research is to describe Public Health Nurses
experiences of Nurse-client interaction. The aim is to describe Public Health
Nurses views on Patient-centerdness, interaction, and counseling, and also to find
out how the Public Health Nurses are using verbal and nonverbal communication
skills in their interaction with clients.
Methods: Five Public Health Nurses participated voluntarily in this research. The
data was collected through questionaire format, during a one month time period.
The questionaire consisted of 14 open-ended questions.
A qualitative descriptive phenomological approach was used. The data was
analyzed using Colaizzi’s analysis approach.
Results and Conclusions: The findings included that the Public Health Nurses
value Patient-centered care, interaction, and counseling, but did not describe in
detail about these topics in their working life. Public Health Nurses described
using communication skills such as listening, questioning, and informing in their
work, but little or lacking was touch and empathetic communication skills.
Contents
1. Introduction…………………………………………………………………..1
2. Nursing Theory and Communication.......................................................2
2.1 Professional Communication…………………………………4
2.1.1 Verbal and Nonverbal……………………………………….4
2.1.2 Listening.............................……………………………….. 5
2.1.3 Touch...............……………………………….....................6
2.1.4 Questioning.............………………………………..............6
2.1.5 Informing.............………………………………..................7
2.2 Patient-Centerd Communication.........................................8
2.3 Therapeutic Communication...............................................10
3. Previous Studies......................................................................................12
4. The Puropose of the Research........................……….............................14
5. Methods...................................................................................................15
5.1 Design................................................................................15
5.2 Target Group......................................................................15
5.3 Data Collection...................................................................16
5.4 Measures and Analysis......................................................16
5.5 Reliability, Validity, and Ethics………………………………17
6. Results of Research................................................................................19
6.1 Public Health Nurses understandings of Nurse-client
interaction and patient-centered care.....................................19
6. 2 Communication skills used in client interaction.....……....20
7. Conclusion of Results..............................................................................24
8. Discussion...............................................................................................26
9. Sources...................................................................................................29
1
1. INTRODUCTION
Human beings are essentially social beings and a major part of living involves
communications with other people in one way or another. Communication is a
basic fundamental tool used in nursing care and in nurse-client interaction.
Although over the past years there has been extensive research on the subject of
nurse-client communication, there has been little research done on the selfawareness of nurse’s own communication skills.
The purpose of this research is to find out Public Health Nurse’s awareness of
their interactions with clients and find out their use of therapeutic and patientcentered communication skills. There is a lot of research done on the topic of
nurses communication skills, but this research finds out what nurses opinions of
patient-centered care, interaction, and counseling, and finds out what type of
communication skills they use in order for communication to be therapeutic.
The reason I am interested and decided to do research on this topic is because as
a student I have been in many different practical placements and noticed that
there is a lack of communication between nurses and clients. I have also found it
difficult as a student nurse in some situations to communicate and interact with
clients, so I feel this is an important subject to me and nursing professionals.
Especially because nurse-client interaction is the basis of a nurse-client
relationship.
The results show that not all communications skills used are having therapeutic
effects to the nurse-client interaction. It shows that nurses have a good basic
theory of interaction, and patient-centered care, but it is not exactly shown in the
information how it is put into practice.
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2. NURSING THEORY AND COMMUNICATION
Theories have been developed in nursing to explain phenomena important to
clinical practice. Nurses use theories to guide their practice. In order to
understand nursing communication it is important to examine nursing theories on
the subject.
Communication definitions vary depending on the subject associated with it. Here
are some definitions relating to the nursing science: Communication is a complex
composite of verbal and nonverbal behaviors integrated for the purpose of sharing
information (Crowther, 1991). And another definition from a nursing theorist King
(1981) is “Interpersonal communication between individuals is classified as verbal
and nonverbal.” So we see through these definitions that communication is the
means of transferring information and that it is a fundamental component of a
relationship. And both of these concepts are relevant in the nurse client
relationship.
In Sundeen, Stuart, Rankin, Cohen’s book Nurse Client Interaction the
communication process is made up of five components. First component is the
sender. The sender uses verbal and nonverbal communication to transmit a
message. The second component is the message itself- what is said through
words and nonverbal language. The third component is the receiver. The fourth
component is feedback. And the fifth component is Context- which determines the
meaning of the interaction. The following Figure 1. Communication model, shows
this communication process.
Sender
Receiver
Message
Feedback
Context
Figure 1. Communication model (Sundeen et al. 1997)
In Arnold and Boggs (1999) theory of Interpersonal Relationships, focuses on
factors in communication styles that are the basis for the applying communications
3
skills in the nurse-client relationship. Within the nurse-client relationship, any
exchange of information between the nurse and client carries messages about
how to interpret the communication. Metacommunication is a broad term used to
describe all of the factors that influence how the message is perceived (see fig.2).
Metacommunication
Verbal
Culture
Native Language
Gender
Vocal Pitch
Nonverbal
Body Language
Culture
Gender
Appearance
Figure 2. Metacommunication model (Arnold et al. 1999)
Theory and conceptual models overall contribute to the individualization of nursing
and these are factors that improve nurse-patient therapeutic relationship.
In addition as most nursing theory focuses on communication as a distinct aspect
of the role of the nurse, it is important to explore the potential contribution of
nursing theory and conceptual models of nursing to communication practice
(McCabe & Timmins, 2006).
The Roper-Logan-Tierney Model is a conceptual and theoretical nursing model
that was developed in Edinburgh. It is used intertwined with the nursing process:
assessment, planning, implementation, and evaluation, in order to individualize
nursing care. The Roper et al. model of living is composed of 5 factors including,
Activities of living (AL), Lifespan, Dependency/Independency continuum, Factors
influencing the AL’s, and Individuality in living. Roper et al. also defines twelve
activities of living that are essential in every human’s life. (Holland, K., Jenkins, J.,
Solomon, J., & Whittam, S. 2003)
Roper et al. emphasized the individual nature of this process of nursing and the
necessity for patient participation, all essentials of what we may begin to consider
4
as patient-centered care. Their model also allows for specific assessment of
individual needs and problems in the activity AL of communication as a result may
be said to facilitate patient-centered communication.
In their commentary on communication as an AL, Roper et al. (2003, p.22)
highlighted that this is “a highly individual activity”, but “it is not the individual who
is crucial, but the interpersonal relationship” (McCabe etc. 2006).
2.1 Professional Communication
2.1.1 Verbal and Nonverbal
Verbal communication consists of either words spoken or written (Anderson, Keith,
Novak, & Elliot, 2002). Language provides the symbols used in verbal
communication, and word symbols have a variety of meanings for individuals.
Verbal communication includes spoken and written language that transfers
information from one person to another. Elements that are essential in verbal
communication are a sender, a message, a receiver, feedback, encoder, decoder,
meaning and purpose. (King, 1981)
To enhance the patients feelings of competence, the nurse is required to show
verbal attentiveness such as paraphrasing and encouraging utterances as uhms’s
and ah’s, and helping patients to explore the topic by means of open ended
questions (What have you tried before?). (McCabe etc. 2006)
Non-verbal communication (without words) is conveyed by gesture, expression,
body posture, intonation, and general appearance (Anderson etc. 2002). Nonverbal communication is often referred to as body language. Conveying more of
what a person feels, thinks, and means than what is actually stated in words is
also considered as non-verbal communication.
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The nurse may display nonverbal behaviors, such as, looking at the patient while
listening, positive body language while the client is talking by head nodding and
forward leaning as a sign of attention (Culley etc. 2001). Emphasis is given to
nonverbal communication as a way of gaining information about an individual or
group (King, 1981).
2.1.2 Listening
Listening is defined by Sundeen et al. as an active process of receiving
information and examining one’s reaction to the messages received. The
therapeutic value that listening has is that it nonverbally communicates to the
client the nurse’s interest in the client (Sundeen, 1997).
Active listening is a powerful process in which a nurse hears a client’s message,
decodes its meaning, and provides feedback to the client regarding the nurse’s
understanding of the message. Through active listening it is possible for client’s to
be in a safe environment, and communicate openly and feel like they are being
understood. The nurse needs to concentrate on the client’s verbal and nonverbal
communication, and listen not only for the hard facts but also actively listening for
attached values, attitudes and feelings. (Arnold & Boggs, 1999)
Silence is periods of no verbal communication among participants. The
therapeutic value that silence gives is nonverbally communicating nurse’s
acceptance of the client (Sundeen, 1997). Silence can be a skill if used
appropriately giving the patient time to think and talk, and also for the nurse to
answer in an appropriate and patient-centered way (McCabe etc. 2006).
Feedback and Paraphrasing are two characteristics of active listening.
Paraphrasing is repeating in your own words what someone has just said to you.
This may show the patient that you are really interested in what they are telling
you and it requires you to actively listen.
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Paraphrasing can prevent misunderstanding and misinterpretation of information,
and can encourage communication that is open. (McCabe etc. 2006) Restating
also asks for validation of nurse’s interpretation of the message (Sundeen, 1997).
2.1.3 Touch
Physical touch may be used as a potent communication approach when helping
patients meet their physical needs and actively listening to someone. Touch may
be a crucial communication means when working with babies, children, elderly,
and people who have disabilities such as deafness, or blindness.
Skin is a significant media of communication and is referred to as the mother of
the senses. Skin facilitates a specific kind of nonverbal communication called
touch. Touch, which is the first our senses to develop, represents a person’s first
experience in communication with another human being. (King, 1981)
Touch is usually conveyed as a caring, and validating form of communication,
which it is a vital form of communication throughout the lifespan (Arnold & Boggs
1999). Touch can be empathetic by showing an understanding and support and
can consequently ease patient anxiety and worry (Wondrak, 1998). Touch can
give comfort and security to patients who are troubled and worried about their
future, and it can also add significance or emphasis to the spoken word (McCabe
etc. 2006).
2.1.4 Questioning
Questioning is an important communication skill that we may use to reach our
communication goals. For examples we may use questioning to start a
conversation and keep it going, gain information about others, increase our
knowledge, to encourage participation in groups, determining others level of
knowledge, encouraging other to reflect and evaluate, and also to control
conversations. A nurse can achieve these goals through open and closed
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questions. Open questions give the client an opportunity to give as much or as
little information that they want to give, and it also can make them feel relaxed and
comfortable and allows them to talk freely for longer periods (McCabe etc. 2006).
Open-ended comments are general comments asking the client to determine the
direction the interaction should take. Examples of how open questions may begin
are with how, what, or can you tell me about. (Sundeen, 1997)
Closed questioning only offers limited and specific responses. Closed questions
may be helpful in the first stages of the nurse-patient relationship to get the
conversation started, but if used exclusively, closed questions can limit the
contribution of the patient to the interaction and can result in the nurse controlling
the extent and length of the conversation. However this communication does
happen frequently in nursing because nurses are busy and usually have a limited
amount of time to spend with patients and closed questioning allows nurses to get
specific information quickly. Closed questioning may also lead the patients to
answer what they think the nurse wants to hear, and this is a reason why open
questions are more patient-focused than closed questions (McCabe etc. 2006).
2.1.5 Informing
When clients are given information about their illness, plan of care, length of time
they will be in hospital, and how they can cope at home it reassures them.
Moreover, clients may become stressed and anxious if given too much information
at once. The nurse needs to be able to access the client’s needs depending on
their level of intelligence, education, previous experience, and knowledge of their
illness. (McCabe etc. 2006)
It is not always such an easy task for the nurse to access these needs at first so it
is good if the nurse asks the client to repeat what she has just told him or her.
This should be done in a sensitive way and with telling the reason to the client.
Written information should always be provided when giving verbal information.
8
When giving verbal information the tone, pitch, and speed of voice should be taken
into consideration. These can effect the way the client perceives the message.
When giving information to a client summarizing is an import communication
technique to use. Summarizing is a statement of main areas discussed during
interaction, and it’s therapeutic value is that it helps clients to separate relevant
from irrelevant material; serving as a review and closing for the interaction
(Sundeen, 1997).
2.2 PATIENT-CENTERED COMMUNICATION
Patient-centered communication is defined as communication that invites and
encourages the patient to participate and negotiate in decision making regarding
their own care ( Langwitz et al., 1998, p. 230 ).
Nurses are familiar with the concept of patient centered care because it is often
referred to in nurse education and nursing theory as the context in which nurses
should plan, organize, and provide patient care. Nurses adopt a communication
style that focuses on the completion of tasks relating to patients rather than
communicating with the patient as a person with their own individual needs, and
this is considered not to be patient-centered care. Inviting and encouraging a
patient to participate and negotiate in planning their own care through the context
of warmth, genuineness and empathy will be providing patient-centered care.
(McCabe etc. 2006)
In order for communication to be patient-centered, nurses must have the qualities
of warmth, genuineness, and empathy (Rogers,1961).
Warmth is showing an individual that you respect them and they are special, which
is crucial in the development of a relationship. To do this successfully a person
would need to show constant positive regard toward others in a nonjudgmental
way. Genuineness is a concept that means a person perceives another to
communicate in an open, honest, and sensitive way. This is done through
congruent verbal and non-verbal communication, it means that they match one
9
another and this is important in the therapeutic nurse-client relationship. (McCabe
etc. 2006)
Empathy is the ability to a person to perceive and understand another person’s
emotions accurately, and the ability to put oneself into the client’s position (Arnold,
& Boggs, 1999 pg. 110). Patients value empathetic communication skills such as
understanding and anticipation of their needs (McCabe, 2004).
Empathy is fundamental to all helping relationships and is a must for high quality
nursing care. Nurse’s failure to empathize with their patients results in patients not
understanding or coping with their illness. Empathy is patient centered
communication that develops trust and establishes rapport in the nurse-client
relationship. This can be achieved through communication skills such as active
listening, touch, and questioning in a patient-centered way. (McCabe etc. 2006)
Wiseman (1996) states these basic requirements in order to be empathetic: Ability
to listen, ability to take on another’s term of reference, ability to understand without
judging, and ability to communicate that understanding.
Empathy is a vital part in facilitative communication and it is an ability that you are
able to learn, to appreciate another person's thoughts and feelings from his point
of view without losing your own identity. It is the ability to understand one’s
experiences without actually going through the same experiences in your own life.
It is the ability to feel "with" and "for" the client. It is important, however, to note
that empathy contains no elements of sympathy, agreement or pity (Mikanowicz &
Shank, 2007).
Patient-centered empathetic communication portrays the nurse’s understanding
and recognition of the patient’s situation. Patient-centeredness requires
recognition of the uniqueness of the individual; it requires core communication
skills and an individual patient needs assessment. (McCabe etc, 2006)
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2.3 THERAPEUTIC COMMUNICATION
Arnold and Boggs 1999, define therapeutic communication to be a goal-directed,
focused form of dialogue used as a tool in health care to promote a client’s well
being and positive response to treatment.
Therapeutic communicaiton takes place within intrapersonal, interpersonal, and
physical environments. The intrapersonal environment involves a person’s internal
thought processes, feelings, interpretations of messages, and self-reflection about
the meaning of message to the individual. The interpersonal environment consists
of the nurse and client, the family of the client or involved persons with the client,
and the multidisciplinary health care team They physical environment is where the
therapeutic communication takes place, for example a health care facility. (Arnold
& Boggs 1999)
The goals of nurses’ using therapeutic communication skills is not to treat or cure
a disease or disorder, but to provide a sense of well-being for patients by making
them feel relaxed and secure. Through this therapeutic communication trust and
rapport may evolve between the patient and nurse. Therapeutic communication
also develops a focused and purposeful relationship established by the nurse in
order to assess, plan, implement and evaluate the care of a patient. The main
characteristics of therapeutic nurse-client communication skills are a perception of
caring, openness, warmth, genuineness, empathy and purpose on the part of the
nurse. These characteristics are similar to those qualities of patient-centered
communication. (McCabe etc, 2006)
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Sundeen et al 1997, states the following therapeutic and non-therapeutic
communication techniques as in the TABLE 1. communication techniques below.
TABLE 1. Communication techniques (Sundeen etc, 1997)
Therapeutic Communication
Techniques
Non-therapeutic
Communication Techniques
Listening
Silence
Establishing guidelines
Open-ended questions
Reducing distance
Acknowledgment
Restating
Reflecting
Seeking clarification
Seeking consensual validation
Focusing
Summarizing
Planning
Failure to Listen
Failure to probe
Parroting
Being judgmental
Reassuring
Rejecting
Defending
Giving Advice
Stereotyped responses
Changing topics
Patronizing
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3. PREVIOUS STUDIES
Researchers: M. Wynia and J. Matiasek, August 2006, USA. Research title:
Promising Practices for Patient-Centered Communication with Vulnerable
Populations: Examples from Eight Hospitals in the USA.
The Aim of the research was to determine how hospitals use patient-centered
communication to improve health care in vulnerable populations.
Problems:
1. Organizational factors that led them to develop initiatives to improve
patient-centered communication.
2. What they thought every U.S. hospital or health system should be doing to
improve patient-centered communication.
3. 3. Lessons learned from their efforts.
Results: The researchers and hospitals came up with these Nine Promising
Practices for the development of patient-centered communication which include:
having passionate champions to advocate for communication programs; collecting
information on patient needs; engaging communities; developing a diverse and
skilled workfoce; involving patients; spreading awareness of cultural diversity;
providing effective language assistance services; addressing low health literacy;
and tracking performance over time.
Although this is a large organizational structured research to improve patientcentered communication, this gives me reassurance that there is a need to
improve nurses’ communication skills. It is highly needed that big organizations
like hospitals are seeking ways to improve patient-centered communication skills I
believe it is also highly important for the improvement to start within the individual
health care worker. That is why I think it is important to find out Public Health
Nurses awareness of their patient-centered and therapeutic communication skills.
13
Researchers: Poskiparta Marita, Liimatainen Leena, and Kettunen Tarja. April
1998, Jyväskylä, published 1999. Research title: Nurses’ self-reflection via
videotaping to improve communication skills in health counselling.
Aim of the research: Was to describe nurses’ opinions of their communication
skills in health counselling situations and to analyze the levels of reflectivity.
Problems:
1.Describe nurses’ ability to self-reflect on their verbal and non-verbal
communication skills, and the purpose and intent of communication,
and needs to improve them.
2. How do educational intervention and watching the nurses’s
videotapes of the counselling sessions affect their ability to self-reflect
on their communication skills?
3. Describe the levels of reflectivity in nurses’ verbal and written
evaluations of their communication skills.
Results: Nurses told that they are able to use familiar language, listen and to
encourage patients to express their feelings and ask questions. Nurses did not
give much feedback on their non-verbal communication skills in their reflections.
Nurses desired to develop their listening skills, ability to encourage patients to ask
and express their feelings, and to improve preparations for counselling sessions.
My opinions: this research has supported my idea that nurses’ need to be selfaware of their communication skills. This study also showed that there is still
much improvement needed in nurses overall communication skills, and there
needs to be a solid foundation of this subject area in the nursing schools.
Although nursing education is developing through the years, it is still needed that
the individual nurse values how good a communicator he or she is.
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4. PURPOSE OF THE RESEARCH AND PROBLEMS
Aims of the research: The purpose of this research is to find out Public Health
Nurses awareness of their communication skills, focusing on patient centered and
therapeutic communication. Also to find out the different communication skills
used in their work focusing on listening, questioning, touch, informing, and
empathy.
Problems:
1. How are Public Health Nurse’s viewing Patient-centered Care, Interaction
and counseling?
2. How are Public Health Nurses using communication skills in order for
interaction to be therapeutic and patient-centered.
These research questions will help me find out and support the aims for this
research project. By finding out the Public Health Nurses own opinions and ideas
about Patient-centered care, interaction, and counseling it will help me understand
their awareness of these topics in their work through nurse-client interaction. Also
in discovering the different communication skills the PHN’s use will support if the
interactions are therapeutic and or patient-centered.
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5 METHODS
5.1 Design
The design used in this research is qualitative. The reason for this is because the
researcher wanted to discover deeper and meaningful findings about nurse-client
interaction. And with this approach it helps develop an understanding of human
experiences, which is important for health professionals who focus on caring,
communication, and interaction (Holloway, & Wheeler, 2002; pg. 19).
In each qualitative approach the purpose is to examine meaning, and the unit of
analysis is words and phrases, not numerical values, as in quantitative (Burns, &
Grove, 2007; pg. 63). The approach used was descriptive phenomological,
because this research describes Public Health Nurses’ experiences of interaction
between their clients. A descriptive study is designed to gain more information
about characteristics within a particular field of study, and the purpose is to provide
a picture of a situation as it naturally happens (Burns, etc. 2007; pg. 240).
The
purpose was to seek the Public Health Nurses own interpretations and
perspectives on the topic, and to get a holistic viewpoint from the participants.
5.2 Target Group
Public Health Nurses are the participants chosen for the research. The reason I
have chosen Public Health Nurses for this research is because in their work in
Mother, Child, Elderly, and Family Welfare Clinics they have deep interaction with
clients and need good communication skills. The Public Health Nurses in these
clinics have more interaction and time with clients than compared to nurses on the
wards in hospitals. They were chosen by convenient and purposive sampling. I
have been in a practical placement in Kauhava Neuvola, so I had contacts from
there, and I also live in Kauhava, so it was convenient. And this group of
participants were of purpose, they fit the criteria needed because they were in
16
everyday working situations interacting with clients through communication. They
were all employed by Kauhava Health Center.
All of the PHN’s who took part in the research participated on a voluntary basis,
and all participants remained anonymous. The questionnaire used in the research
was sent to each PHN’s private work email and if they decided to participate in the
research they printed out the questionnaire and filled it out, and then if was mailed
to me through the post. They did not write their names down in the questionnaire
form so I was not able to know each individual participants answers.
5.3 Data Collection
The collection of data was done through questionnaires devised by the researcher.
The questionnaires (see appendix 2) consisted of fourteen open ended questions,
and one question open for comments. The opportunity for bias in a questionnaire
is less than in an interview, but questionnaires have less depth than interviews
(Burns, etc. 2007; pg. 382). The data collection was done through a period of 1
month in August 2007. The participants in the research where received an
attachment through their work email with the questionnaire’s. One out of the five
sent the results through an email attachment and the rest through the post. The
data collected is subjective because it is based on individuals own perceptions in
the environment. The data has been collected in a naturalistic environment
because the PHN was able to decide where to fill out the questionnaire.
5.4 Measures and Analysis
The number of participants in the research is 5. The questionnaires were sent to
10 Public Health Nurses so the response and participant rate was 50%. The
average age is 50.2, the youngest being 27 and the oldest two at 58 years. The
average number of years worked is 18, the shortest number of years worked were
3 and longest 30. All the participants were female.
I used Colaizzi’s (1978) analysis approach steps 1-5 in my data analysis.
(Holloway, & Wheeler, 2002)
17
1. Reading of findings- I read through all of the questionnaires and translated
them all from Finnish to English, also two Finnish speakers translated the
questionnaires to clear the possibility of misunderstanding.
2. Extracting significant statements- I made side notes of the statements that
stuck out to me as unusual or awakening text.
3. Formulate Meanings- I read through all the questionnaires again and made
sure I understood what the participant is saying in their answers, that I was
getting the view from the participant. In this step I tried to make sure I
understand from the participants point of view, and I asked for second
opinion from a Finnish PHN student to confirm my understanding to be
correct.
4. Clustering of themes- In this step I compared all the similar answers to each
of the separate questions together, and then I went through again and all of
the unusual or different answers I left separately. Then I clustered the
questions into different categories, Listening, Touch, Informing, and
Empathy.
5. Exhaustive description of data- I read through the data again and
categorized the results into the two problems. The written descriptions were
translated as literally as possible from the original Finnish transcripts, they
were translated by the researcher, and another Finnish PHN student, and
one other Native Finnish speaker.
5.5 RELIABILITY, VALIDITY, AND ETHICAL ISSUES
Before the questionnaire was distributed to the participants, it was proofread
through and understood by the research instructor, a Finnish PHN student, and a
Finnish occupational therapist. After it was improved by the thesis instructor the
questionnaire was send as an attachment with the research permission and cooperation forms to the Head Manager of Health Care in Kauhava Health Center.
After it was approved by the Manager of Health Care, Marja-Liisa Somppi, it was
then sent to the PHN’s of Kauhava Health Center.
18
Ethical issues have been taken into consideration for this research. The
participants choose voluntarily to participate in the research. Also all of the
information received in the research is kept in confidentiality and the participants
remain anonymous. The research benefits not only the participants as in bringing
about reflection and self-awareness of their working styles, but it also benefits the
clients because the participants may develop and try to better their ways of
interaction with clients.
Reliability is the ability of a research tool to achieve consistent results (Holloway,
etc., 2002; pg. 288).The questionnaire is reliable in the fact that the proofreaders
understood it, although it is impossible to say that the same outcomes will come
every time the questionnaire is used, because each individual is unique, but
similar answers are presumed. Validity in qualitative research is seen as the
extent to which an instrument measures what it is supposed to measure. It is the
extent to which the researcher’s findings are accurate, reflect the purpose of the
study, and represent reality (Holloway, etc., 2002; 288.) The research is valid
because the questionnaires serve the point to support the problems and find out
meanings of the problems and aims of the research. And the questionnaire
served the point to give accurate findings and represented reality. (Holloway, etc.,
2002)
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6 RESULTS OF RESEARCH
6.1 Public Health Nurses understandings of Nurse-client interaction and
patient-centered care.
The most common statement about interaction by the PHN’s was that is happens
between two people, and between the client and health care worker as
communication. The following statements show the varying degrees the PHN’s
defined interaction.
“communication between the client and worker through means of
words, expressions, and gestures”.
“……the whole work”.
These statements differ in depth on the topic of interaction. Both of these
statements are true about interaction but there were no deeper in depth
descriptions or thoughts about interaction or how it is in their daily work.
Patient-centered Care was commonly described as it is based on individualized
client needs. One PHN went further to say that Patient-centeredness
“…..is not a routine pattern of care”.
This was a good addition to the though of individualized care because no matter
how we think or give individualized care we have to remember not to do based on
the routine pattern of care, because then it is actually not individualized. Another
PHN said that
“….it is leaving out all own and other experiences”
.
20
This was another good point made because it is supporting how we can give
individualized care. The depth to the concept that I was looking for was lacking in
the responses on Patient-centered care.
Counseling was viewed by the PHN’s to be based on individualism. One PHN did
not reply. One PHN said that it is
“taking clients own background into consideration”.
PHN’s views of Patient-centered care, Interaction, and counseling is that the
PHN’s failed to give a holistic point of view from each subject. They only shortly
described in a sentance or two of what it concretley means.
6.2 Communication skills used in client interaction
PHN’s described using questioning to find out client’s needs. Only one PHN
mentioned that she uses using open and closed questions to find out patients
needs. Below are two separate statements
“Asking lots of questions.”
“Ask what’s on my mind.”
These statements do not show using questioning as a therapeutic communication
technique.
One PHN used questioning as a therapeutic communication skill as shown in the
following statement
“…..I use concrete questions to find out if I understood what the client
said to me, and to encourage the clients to participate in decision
making about their own care.”
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Only one PHN stated that she uses questioning
“To know that the client has understood the information I have given
them.”
This is also another way to use questioning as a therapeutic communication
technique, and keeping the care patient-centered by treating the client as an
individual.
The common idea about touch as a communication technique was that it is rare,
depends on the client and that you need to read the client. One PHN said
“….nowadays touch is much less used with elderly clients, and most
of them need it.”
Another PHN said
“….it is comforting.”
These two above statements show that touch can be a therapeutic communication
technique and that is is needed more in nurse-client interaction.
One PHN stated
“I only use it during nursing procedures.”
This statement refers to the lack of touch used in nursing communication.
Many of the PHN’s described that they use informing as a communication skill by
considering the clients’ ability to take in the information, their age, and
backgrounds like education. Also one PHN said
“….not to speak only in medical language.”
Another PHN stated that in informing a client
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“ I measure can the client take in new information at that moment.”
These are ways informing is used as a therapeutic communication skill in the
PHN’s work.
PHN’s had associations between listening and nonverbal communication. Giving
the client space and time was another familiarity mentioned. One PHN said
“Don’t be scared of silent moments.”
This is a way to use listening as a therapeutic communication technique because
silence can add importance to the client’s situation and show understanding.’
One PHN said
“My own body language and nonverbal messages support the
understanding of the client”.
This demonstrates a way that active listening can be used to show the client that
you understand them and is interested in what they are saying.
In using empathy as a communication skill one PHN stated
“By thinking, Could I be in the same situation myself, and how would I
want to be treated.”
This is a good example of how a PHN can use empathy in interaction with a client.
One PHN said
“I am not able to put myself in anbody’s situation.”
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Another PHN said
“I often question client’s opinions through words.”
These statements show a lack of empathetic communication skill used in
interaction with clients
PHN’s communication skills portray somewhat patient-centeredness and
therapeutic communication, but there is a lack of well roundedness in
communication skills. There was evidence of basic communication skills, but not
in the sense of their skills to be fully patient-centered or therapeutic, especially
because empathy and touch was missing in a lot of PHN’s descriptions.
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7. CONCLUSION OF RESULTS
PHN’s have basic fundamental communication skills such as listening,
questioning, and informing. They also viewed Patient-centeredness, counseling,
and interaction to be important and valued in their work.
Compared to the theory the PHN’s had the common idea that interaction is
communication between the nurse and client. But they all failed to analyze deeper
what it means in the Healthcare setting. For example, as it is the basis for a client
relationship, and that its purpose is to give information to support health in the
client.
PHN’s got it right on key that Patient-centered care is based on an individualized
needs assessment. But they did not explain further like the meaning of it to be
including the client to participate in decision making about their own care through
empathy, genuineness, and warmness.
Questioning was used as a communication technique in PHN’s work but it was not
clearly described. No PHN’s went deeper as to say that for example we may use
questioning to start a conversation and keep it going, gain information about
others, increase our knowledge, to encourage client participation, to find out the
client’s level of knowledge, encourage clients to reflect and evaluate.
PHN’s use of touch as a communication technique was not very clear. They also
did not go deep into the topic. Many said that it is personal or depend on the
situation. The PHN’s failed to evaluate touch in the way that it brings emphasis to
the spoken words, eases anxiety and worry, or that it is the main means of
communication between the PHN and babies, children or adults with disabilities,
and elderly.
Although PHN’s described good communication skills for listening such as using it
along with silence and nonverbal communication techniques, they failed to
mention about feedback and paraphrasing.
25
Feedback and Paraphrasing give the client reassurance that you have listened
and understood what they were saying to you, alongside with nonverbal hints.
Empathy was a gray area, some PHN’s showed they used empathy in client
interaction and mentioned unempathetic communication skills in client interaction.
PHN’s failed to mention holistic idea of empathy as it is the ability to recognize and
reason, as well as the ability to communicate understanding of the other person’s
feelings and their attached meanings.
The results of the research were aimed to answer the research problems
1. How are Public Health Nurse’s viewing Patient-centered Care, Interaction
and counseling?
2. How are Public Health Nurses using communication skills in order for
interaction to be therapeutic and patient-centered.
The amount of information from the questionnaires was not as much as I
expected. I only got short answers without going deep into the subject. So as a
result of this it was difficult to analyse the results, because I think the results could
have been more thourough and deeper. But maybe because of the problems with
nurses being so busy contributed to this, they did not have much time to fill out the
questionnaire. Or maybe I should have had a longer time period for the
questionnaire to be filled out. In the end I did get enough information to analyze
results and make conclusions for this research.
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8. DISCUSSION
The reason for doing this research on the topic of communication and interaction
was because it is a very interesting area to me in it’s relation to nursing. Also
because I have noticed it is a difficult concept to put into nursing practice, as I
have seen and experienced in my practical placements.
There has also been so many previous researches on the topic of Nurse-Client
interaction, and the topics of needed continuing nursing education in
communication skills (Carrol, et al 1990).
My goal through doing this research was to find out how PHN’s viewed their own
communication skills with their client’s, and what skills they use to in client
interaction. I as a student have been challenged in improving my communication
and interaction skills with clients in practical placements, and have also noticed so
many times nurse’s who have poor communication skills and techniques. In
previous studies nurses have said they need to improve their communication skills
in the areas of listening, interviewing methods, motivation, giving advice and
feedback (Carrol, et al 1990).
The processes in which I used to reach these goals was to develop a
questionnaire of open ended questions on the topics of Patient-centered
communication, therapeutic communication, and communication skills such as
listening, questioning, informing, touch, and empathy. Then I selected the
participants who would best fit this research. I choose to ask PHN’s who work in
the health center of Kauhava to participate on a voluntary basis. The
questionnaires were distributed through the PHNs private work email. This way
was easy and convenient for the researcher. It was also convenient for the
participants because they could look and the questionnaires and fill them out in
their own time. Although this also had a downside, because I did not receive as
many participants as hoped and the information received was not as much as
hoped.
27
But there was enough participants and information to go on with the research.
The results of the study were that PHN’s described using basic communication
skills like listening, questioning, and informing, but were lacking the use of touch
and empathetic communication. Also their views of Patient-centered and
therapeutic communication were on a basic level, because they failed to describe
deeper into the subject areas and imply how they use it in their work.
Some problems may have been in the data collection, I could have made
interviews with the PHN’s alongside with the questionaire’s, or used videotaping in
nurse-client interaction. I would have then recieved more deeper meanings and
associations for the results, and a more thourough research. I also could have
meet the PHN’s individually to distribute the questionaire’s and discuss with them
about participation in the research. Then maybe I would have gotten more
participants for the research. But with the short time and business in my life I
chose the easier way to do it electronically through email.
Also maybe the timing of the research was not the best, because it was in August
during one month. Maybe there were many PHN’s on holidays and the others
were so busy making up for the others work. If I would have made the time period
longer maybe then I would have received more participants.
This research can be used in many ways. PHN’s and other health professionals
may view this work to realize their competencies in their communication skills and
client interaction. Also Health Care Centers may use this work as a way to see in
what areas PHN’s need to develop skills and what types of continuing education
programs could be developed for employees. This research could be developed
further into a larger study as researching all of the health care centers employees
communication skills. Then the health care center could evaluate all of the
workers skills and then update them or give them opportunities to further
education in certain areas. This research could also be continued in a way that
clients of the health center would evaluate the staffs communication skills and their
satisfaction in the care they receive. Then it would bring a more holistic result to
the topic.
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I learned through doing this thesis that their is always room for improvement. In
our own personal lives and professional lives. I have learned a lot about
interpersonal communication through the reading of theory books for this research.
I have also learned how important it is to be aware of how we work and perform
our work, and that there should always be good reasoning to support our ways of
working.
I have also learned through this research the importance of planning and revising.
This is needed as a skill in our everyday lives and professional lives. Also I have
learned how important it is to be able to co-operate with other professionals, and
have good communication skills. Throughout this research it was important for me
to be able to communicate with students, teachers, health care workers, and so
on. I have learned the importance of teamwork and how to act in a
multidisciplinary team, through the co-operation work in the thesis.
This research has shown me weaknesses and strengths I have. I need to become
more organized and follow through plans I make, this is a challenge for me in the
future. Also I have learned that I have willpower to succeed in projects like this
and I am happy I was able to complete this project. This project has helped me
prepare for professional life and given me good insights into research work. My
colleagues, classmates, and teachers have been a great help to me in this project.
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SOURCES
Anderson, D. M., Keith, J., Novak, P. D., & Elliot, M. A., Sixth Edition 2002.
Mosby’s Medical, Nursing, & Allied Health Dictionary.
Arnold, E. and Underman Boggs, K. 1999. Interpersonal Relationships
Professional Communication Skills for Nurses, 3rd edn. London. WB Saunders.
Blackwells Dictionary of Nursing. Oxford. Blackwell Scientific Publication. 1994.
Burns, Nancy, & Grove, Susan. 2007. Understanding Nursing Research.
Saunders. Elsevier Inc.
Carrol, & Rowland-Morin. 1990. Verbal communication skills and patient
satisfaction. Evaluation Health Professional 2. pgs 168-185.
Crowther D. 1991. Metacommunications: A missed opportunity? Journal of
Psychosocial Nursing 29 (4):1316
Culley, L. & Dyson, S. 2001. Ethnicity and Nursing Practice. Basingstoke.
Palgrave
Holland, K., Jenkins, J., Solomon, J., & Whittam, S. 2003. Applying the RoperLogan-Tierney Model in Practice. Churchill Livingstone
Holloway, & Wheeler. 2002. Qualitative Research in Nursing. Second Edition.
Blackwell Science Ltd.
Johnson. J.R. 1994. The communication training needs of registered nurse
Journal of Continuing Education in Nursing. Pgs. 213-218.
King, 1981. A theory for nursing. John Wiley & Sons Inc.
McCabe, C., & Timmins, F. 2006. Communication skills for Nursing Practice. New
York. Palgrave Macmillan
Mikanowicz, C.,& Shank, S. 2007. Communication Strategies. National Center of
Continuing Education, Inc.
Wynia, M. & Matiasek, J. Promising Practices for Patient-Centered
Communication with Vulnerable Populations: Examples from Eight Hospitals, The
Commonwealth Fund, August 2006
Peplau, H.E. 1952. Interpersonal Relations in Nursing. New York. G.P. Putnam
Poskiarta, Liimatainen, & Kettunen. Nurses’ self-reflection via videotaping to
improve communication skills in health counseling. 1998. Patient Education and
Counseling. Volume 36, Issue 1, 1 January 1999, Pgs. 3-11.
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Rogers, C.1961. On becoming a person. Boston: Houghton Mifflin.
Rowe, J. 1999. Self-awareness: Improving nurse-client interactions. Nursing
Standard, 14, 37-41.
Sundeen, S. 1997. Nurse Client Interaction. 6th edition. Mosby-Year Book Inc.
Wondrack, R. 1998. Interpersonal Skills for Nurses and Health Care Professionals.
Oxford. Blackwell Science.
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APPENDIX 2/1
Dear Public Health Nurses,
I am Rebekah Luoma, a Public Health Nurse student at Central
Osthrobothnia University of Applied Sciences in Kokkola. I study in an
international group, and the teaching language is in English. I have
just finished with my 3rd year of nursing studies and now it is time for
my final thesis work. I would really appreciate it if you would take
participation in my research project. My thesis will be in the English
language, but I have translated the questionnaires into Finnish. My title
is Public Health Nurses Perceptions: Nurse-Client Communication.
The questions are open ended, and there are 15 questions.
I believe this research will benefit Public Health Nurses and Clients.
Attached is a questionnaire for you to fill out if you would like to
participate.
Many thanks.
Best Regards,
Rebekah Luoma
Puh. 040-9114110
[email protected]
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APPENDIX 2/2
Age, Ikä:
Number of years worked as a TH:
Olen työskennellyt terveydenhoitajana__________vuotta
1. Please explain what you understand about the following concepts:
Miten ymärrät seuraavat käsitteet:
InteractionVuorovaikutus
Patient-Centered CarePotilaskeskeinen hoitotyö
CounselingNeuvota/Ohjaus
2. What is your opinion about your own communication skills?
Miten arviot omia vuorovaikutustaitojasi?
3. How do you feel about the communication between you and your clients?
Miten arvioisit sinun ja asiakkaittesi välistä vuorovaikutusta?
4. How do you find out your clients needs?
Miten selvität asiakkassi tarpeet?
QuestioningKysymällä
ListeningKuntelemalla
ObservingHavainnoimalla
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APPENDIX 2/3
5. How do you establish trust and rapport from your clients?
Miten saavutat luottamuksellisen suhteen asiakkaaseen?
6. Why is giving time so important to clients?
Miten osoitat asiakkaallesi olevasi huomaavainen?
7. How do you let clients know that you understand what they are saying to you?
Miten ilmaiset asiakkaallesi ymmärtäväsi häntä?
8. What skills do you use to encourage the clients to participate in decision making
regarding their own care?
Millä tavalla motivoit asiakastasi osallistumaan oman hoitonsa suunnitteluun ja
toteutukseen?
9. How do you enable yourself to be in the client’s reality?
Miten asetat itsesi asiakkaan asemaan?
10. If you do not agree with a client’s situation how you enable yourself to understand
them?
Ollessasi eri mieltä asiakkaasi tilanteesta, millaisia keinoja käytät asettuessasi hänen
asemaansa?
11. How do you view touch as a communication technique?
Miten näet fyysisen kosketuksen vuorovaikutuksen välineenä?
12. What is the meaning of open and closed questions?
Mitä tarkoittavat avoin kysymys ja suljettu kysymys?
13. What do you consider when giving information to a client?
Millaisiin asioihin kiinnität huomiota informoidessasi asiakasta?
14.How do you know the client has understood the information you have given them?
Miten tiedät että asiakas on ymmärtänyt antamasi tiedot?
15. Muita kommentteja:
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