Authors

1. Newell, Stephanie Grad Cert Inn Entrep
2. Jordan, Zoe BA, MA, PhD

Abstract

Review question/objective: The objective of this systematic review is to synthesize the eligible evidence of patients' experience of engaging and interacting with nurses, in the medical-surgical ward setting.

This review will consider the following questions:

* What are the expressed experiences of patients engaging and interacting in patient-centered communication with nurses?

* What are the beliefs, opinions and desires of patients, when engaging and interacting with nursing staff in terms of communicating in ways that meet the patients' needs and wants?

* What factors do patients perceive influence (facilitate or prevent) patient-centered communication and their engagement and interaction with nursing staff?

* What are the experiences of patients of nurses listening to and responding to them within patient-centered communication with respect to their safety and experience of care?

Background: Communication is a way in which humans make sense of the world around them. Communication takes place as an interactive two-way process or interaction, involving two or more people and can occur by nonverbal, verbal, face-to-face or non-face-to-face methods. Effective communication is described to occur when the sender of a message sends their message in a way that conveys the intent of their message and then is understood by the receiver of the message.1 As a result of the communication from both the sender and the receiver of the message a shared meaning is created between both parties.2

Communication can therefore be viewed as a reciprocal process. In the health care literature the terms communication and interaction are used interchangeably.1

Communication failures between clinicians are the most common primary cause of errors and adverse events in health care.3 Communication is a significant factor in patient satisfaction and complaints about care.4 Communication plays an integral role in service quality in all service professions including health care professions.2

Within healthcare, quality care has been defined by the Institute of Medicine as 'care that is safe, effective, timely, efficient, equitable and patient-centred'.5^(p.4) Patient-centered care is defined as 'care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient's values guide all clinical decisions. Patient centered-care encompasses the 'individual experiences of a patient, the clinical service, the organizational and the regulatory levels of health care'.4 At the individual patient level, patient-centered care is care that is 'provided in a respectful manner, assures open and ongoing sharing of useful information in an ongoing manner and supports and encourages the participation of patients and their families'.4^(p.5) Healthcare organizations that are patient-centered engage patients as partners and hold human interactions as a pillar of their service.3

The deepening evidence base for principles and practice of patient-centered care has resulted in increasing recognition of, and greater focus on, the engagement of patients, and the value and benefit of patient engagement. Contemporary healthcare policy across the globe increasingly supports the engagement of patients as partners in all aspects of their own health care and also in systemic quality improvement. In 2005, the World Health Organization's (WHO) World Alliance for Patient Safety established the Patients for Patient Safety program, to improve patient safety globally in collaboration with patient advocates across the world. As a global initiative, Patients for Patient Safety 'believes that safety will be improved if patients are placed at the center of care and included as full partners'.6

In 2011 the United States of America Department of Health and Human Services announced its commitment of one billion US dollars of federal funding7 under The Patient Protection and Affordable Care Act 20108 and launched the Partnership for Patients initiative. The Partnership for Patients public-private consortium, which focuses on patient safety improvements and draws membership from federal government agencies and over 8000 health care providing organizations and individuals, views patients 'as essential partners in improving safety and quality'9 and 'their participation as active members of their own healthcare team is an essential component of making healthcare safer and reducing readmission'.9

In Australia, as part of national health care reforms to improve access to care, the efficiency of care and public transparency of the performance and funding of health services, the Australian Health Ministers endorsed the 10 National Safety and Quality Health Service Standards (NSQHSS) in 2011 and the Australian Safety and Quality Goals for Health Care (The Goals) in 2012. The NSQHSS focus on partnerships with health consumers in their own care and treatment and also in health service planning, the design of care and service monitoring and evaluation.10 Standard 1 - Governance for Safety and Quality, and Standard 2 - Partnering with Consumers, are required to be integrated within all of the other eight Standards.

With patient safety and quality being core to the delivery of care the Safety of Care, Appropriateness of Care and Partnering with Consumers goals have been identified as the three areas that will make up the goals over the next five years until 2017. The Australian Commission on Safety and Quality in Health Care, in providing further justification for the focus on these three areas, states:

They are relevant across all parts of the health care system and aim to focus attention on a small number of key safety and quality challenges which; have a significant impact on the health and wellbeing of individuals, and on the healthcare system as a whole, can be improved through implementation of evidence-based interventions and strategies, are amenable to national action and collaboration.11

The third priority area of The Goals, Partnering with Consumers, reflects patient-centered care practice by ensuring 'that there are effective partnerships between consumers and healthcare providers and organizations at all levels of healthcare provision, planning and evaluation'. Specifically, 'Consumers and healthcare providers understand each other when communicating about care and treatment and health care organizations are health literate organizations''.11

As healthcare focuses on providing services that are patient-centered and methods to ensure this occurs, patients' voice and experience of health care provision is increasingly being sought from an organizational quality improvement perspective. Patients are being surveyed on their healthcare experience across interpersonal areas such as being provided the opportunity by their health professional to ask questions, the level of involvement in their own care4,12 and whether they were shown courtesy, treated with respect and listened to carefully by their health professional.4,13

Surveys of patients' satisfaction with their care are now being superseded by surveys of patient experiences of care. However, current methods used to collect and use information from patients about their care is often retrospective, provides inadequate real time data14 and is not effective in creating action to produce change at the individual patient level.15-17 Methods which focus on including the patient and their information in real-time are considered by many to be crucial to the advancement of improved health outcomes and the reduced costs that are required of health care to be sustainable.14 One such method is patient-centered communication.

The nurse-patient interaction is a core component of nursing science and high quality nursing care.1819 Fleisher et al. contend that 'the main intention of communication and interaction, in the health setting, is to influence the patient's health status or state of well-being'.1 As a profession, nursing predominately requires communicating with, and relating to, patients at the individual level. In the hospital setting nurses undertake many of their patient related duties in a face-to-face manner with the patient at the bedside and these moments can facilitate effective interaction to occur between the nurse and the patient, which is patient-centered. McCabe et al. state that patient-centered communication as "defined by Langewitz et al. as 'communication that invites and encourages the patient to participate and negotiate in decision-making regarding their own care'.''19^{(p,42), 20}

However, qualitative studies by McCabe and Wellard et al, highlighted that nurses interact with patients only when performing administrative or functional activities19 and nursing 'practice was predominately task-orientated'.21^(p.259) The outcome of these studies are supported by Maurer et al. in their report on the tools and strategies available to support patient and family engagement in the hospital setting. Maurer et al. identified that current strategies 'are not attuned to patient and family member experiences of hospitalization'22^(p.5) and that most tools and strategies were 'more reflective of health professional and hospital views and the organization of their work'.22^(p.5) The report identified a gap in the initiation of engagement, which is not driven by the patients and families' needs and preferences as they occur but by the 'opportunities that the hospital makes available'.22^(p.5)

McCabe et al. also argue that nurses' attending behavior, that is their 'accessibility and readiness to listen to patients through the use of non-verbal communication'19^(p.44) requires that they have the underpinning elements of 'genuineness, warmth and empathy'19^(p.44) all of which are components of patient-centered communication. McCabe et al. observed that 'that nurses do not always communicate in a patient-centered way'.19^(p.46)

According to Fleischer et al. 'The listening behavior in the way of listening and asking actually is the beginning of the nurse-patient communication relationship'1^(p.344) McCabe et al. state that the lack of recognition and support by healthcare organizations of the connection and subsequent importance of patient-centered communication in the provision of high quality care has promulgated a culture averse to patient centered communication and is a significant factor in reducing the value that nurses place on providing patient-centered communication to patients.19

It is apparent that tensions exist between service quality and patient-centered care principles and practice. The impact of this tension on care and the patient as an individual is reflected in the literature. McCabe et al. claim that the use of non-patient-centered types of communication can negatively affect a patient's sense of well-being and security.19 Horvey et al. detail patient and family member experiences of not being listened to by their health care providers and describe the resulting consequences to be as severe as the death of the patient during their hospital stay.23

Opportunities for patients to engage and be listened to and be heard by their health care providers at the time they raise and address issues concerning their own care and safety whilst they are in hospital are often overlooked.23 Opportunities for patients to do so may often not be elicited or are missed by clinicians. The information patients can provide about their health status, condition and safety is under-utilised.23

Nursing science considers the participation of patients in their health care as central to the nurse-patient interaction; however audit and research have predominately focused on the evaluation of patient actions and behaviour.18 Therefore, nurse perceptions of patients have been a dominate focus rather than the experience of the patient.18 Tejero points out that nurse-patient interaction measurement instruments have focused on the nurse with 'minimal or no consideration of the contribution of the patient'.24^(p.608)

McCabe et al. conclude that future 'Patient focused studies may identify nursing behaviors that patients value highly in terms of patient-centered communication'.19^(p.48) Given the focus of contemporary health care reforms and policy and the tension between policy and practice in patient-centered care delivery a systematic review on patient-centered communication from the patient's perspective is warranted to investigate and provide the patients perspective and voice to patient-centered health care.

An initial search of the literature has identified a systematic literature review conducted by Fleischer et al. on nurse-patient interaction and communication.1 This 2008 review described the use and definitions of the concepts of nurse-patient interaction and nurse-patient communication from conceptual and theoretical perspectives. However, it did not examine the direct interactions of patients and nurses from the perspective of the patient. An initial search of the Cochrane and the Joanna Briggs Libraries did not identify any systematic reviews on this topic. It is noted that within the Joanna Briggs Library a systematic review by McCloskey et al. on "Patient, family and nurse experiences with patient presence during hand-off reports within hospitals" has been undertaken; however, this review related specifically to patient presence and did not address their experience of that encounter.

The absence of a systematic review on patient experiences of engaging and interacting with nurses at the point of care at the bedside is an identified gap in the literature. The reciprocal nature of communication warrants further understanding of patient communication with their nursing clinicians and the barriers and facilitators to patients' engaging and interacting with nursing clinicians at the bedside in the hospital setting.

The aim of this qualitative systematic review is to synthesize the results of studies exploring patient experiences, beliefs, opinions and desires of engaging, interacting and communicating with nurses at the bedside setting during a hospital stay to allow major themes and concepts regarding the patient experience of patient-centered communication to be identified. A systematic review on the experiences of patients engaging and interacting with nurses will:

(1) further refine what is known about patient centered-communication at the bedside from the patient perspective;

(2) increase the understanding of health service management and nurses on facilitating and supporting patient-centered communication in the provision of quality patient-centered nursing care for patients; and

(3) promote a shift from communication with patients occurring only at times suited to the routine of the clinicians to the integration of proactive patient engagement and interaction throughout the continuum of a patients' hospital stay.