Exploring Nurse's Communicative Role in Nurse-Patient Relations Study

This report summarizes a qualitative study published in the Journal of Caring Sciences, exploring the communicative role of nurses in nurse-patient relations. The study, conducted in Tehran, Iran, involved interviews and observations of nurses, patients, and their families. Through content analysis, the research identified a main category: 'The patient's need-based communication.' This category encompasses identifying patient needs (type of problem, health status inquiries, and monitoring) and communicative behaviors (caring attention, informal education, inducing calmness, and obtaining trust). The findings highlight the importance of understanding and addressing patients' needs to enhance nurse-patient relationships and improve the quality of care. The study emphasizes that nurses' roles are designed according to patient needs; therefore, if these needs are appropriately defined, the relationship will be enhanced and thereby the quality of care will be improved.

Journal of Caring Sciences, 2016, 5(4), 267-276
doi:10.15171/jcs.2016.028
http:// journals.tbzmed.ac.ir/ JCS
*Corresponding Author: Mahvash Salsali (PhD), email: [e-mail]. This study was approved and funded by the deputy
research of Tehran University of Medical Sciences (Project number: 5005).
© 2016 The Author(s). This work is published by Journal of Caring Sciences as an open access article dist
under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc/4.0/). N
uses of the work are permitted, provided the original work is properly cited.
Exploring Nurse’s Communicative Role in Nurse-Patient Relations: A
Qualitative Study
Ali Fakhr-Movahedi1, Zahra Rahnavard2, Mahvash Salsali2*, Reza Negarandeh2
1Department of Nursing, Nursing Care Research Center, Faculty of Nursing and Allied Health Sciences, Semnan University of
Medical Sciences, Semnan, Iran
2Department of Nursing, Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
ARTICLE INFO ABSTRACT
Article Type:
Original Article
Introduction: Recognition the nurses’ communicative roles can influence quality of
patient’s care. Therefore, this study was aimed to explore nurse’s role in nurse-patient
relations.
Methods: This study was a qualitative research in which collected data was analyzed
by content analysis method. The participants were 23 nurses, patients and their families
in medical and surgical wards of a referral hospital in Tehran, Iran. Data were collected
by semi-structured interview and observation.
Results: Data analysis was led to the emergence of a main conceptual category: The
patient's need-based communication. This category was derived from two categories:
1) Identifying the patient’s needs; and 2) Communicative behavior in the face of the
patient’s needs. “Identifying the patient’s needs” was related to “type of the patient’s
problem”, “patients’ inquiring about their health status” and “monitoring the patient’s
health status”. “Communicative behavior in the face of the patient’s needs” was
composed of four subcategories: “caring attention”, “informal education of the
patient”, “inducing calmness to the patient”, and “obtaining the trust of the patient”.
Conclusion: The nurse’s role in relationship with patients is designed according to
patients’ needs. Therefore, if the patients’ needs in clinical settings are defined and
clarified appropriately, the nurse-patient relations will be enhanced and thereby the
quality of care will be improved.
Article History:
Received: 12 Oct. 2015
Accepted: 1 Feb. 2016
ePublished: 1 Dec. 2016
Keywords:
Nurse’s role
Communication
Nurse-patient relations
Qualitative research
Please cite this paper as: Fakhr-Movahedi A, Rahnavard Z, Salsali M, Negarandeh R. Exploring nurse’s communicative role in nurse-patient
relations: a qualitative study. J Caring Sci 2016; 5 (4): 267-276. doi:10.15171/jcs.2016.028.
Introduction
Communication plays a vital role in
professional disciplines such as nursing.
Usually, establishing an effective
communication with patients is an essential
aspect of nursing care.1 Nurses, through
communication skills, can recognize the
patient’s healthcareneeds, as a meaningful
communicationwith patients enable nurses
aspire to enhance a thorough knowledge of
individual patients and their personal
characteristics.2 In fact, positive nurse-patient
relationship includes a wide range of
behaviors in multiple domains of nursing
practice and it is an essential factor in high
quality nursing care.3 Therefore, enhancing the
communication role of nurses leads to their
having a positive opinion of their job and
patients.4
Implementation of research on nurse-patient
communicationis necessaryfor improving
professional nursing knowledge. In this
regards, various studies have been performed
on various aspects of nurse-patient
communication. Bridges et al., concluded that
supportive organizational settings influenced
the emotional engagementof nurses with
patients.2 Kim et al., conducteda study to
explore enabling factors for nurses in
communication effectively with patients. They
concluded that the manager should consider a
set of clinic-based strategies for improving the

Fakhr-Movahedi et al.
268 | Journal of Caring Sciences, December 2016; 5 (4), 267-276
nurse-patient relationship beyond the
conventional communicationskills.5 Moore
believed effective nursing care required a
meaningful communicationwith the patient
and a continued assessment of the patient’s
needs.6 Also, it seems that nurses and patients
are engaged in a reciprocal process that
influences both parties. For this reason,
reflection on nursing skills in this process can
lead to the identification of the difficulties and
the recognition of possible solutions.7 Thus, a
perception to cultural aspects of
communicationcan help nurses in nursing
practice.8
There are few studies about nurse-patient
communication in Iran. In addition, the
majoritiesof these studies havefocused on
communication barriers. Shafipour et al., in a
qualitative study on nurse-patient
communication, found that job dissatisfaction,
routine-centeredcare and lack of trust to
nurses from patients’ views were the major
barriers for achieving effective
communication.9 Also, other factors such as
heavy nursing workload, hard nursing tasks,
nurses’ fatigue, little time to speak with
patients, fast rate of nurses’ speech, a lack of
welfare facilities for nurses and some problems
with the patients such as weak memory and
auditory and visual disorders were considered
as a barrier for communication between nurses
and patients.1,8 Norouzinia et al., concluded
that difference in conversional languages
between patients and nurse, overload of works
and emergency situation of patients were the
most barriers in nurse-patient
communication.10 Also, Azimian et al.,
believed routine-based culture is one of
barriers in establishing nurses’ relationship.11
A review of literature shows that nurse-
patient communication is influenced by
conditions that arise in clinical settings.
However, theimportant point is that few
studies have focused on nurses'
communicative role with patients. Therefore, a
deep understandingof these circumstances
and nurses’ roles in their communication with
patients can help healthcare policymakers to
plan strategiesfor enhancing high quality
nursing care. Therefore, this study aimed to
explore the communicative role of nurses in
their relationship with patients according to
lived experiencesof Iranian nurses and
patients.
Materials and methods
This study was a qualitative research.The
researchers’purpose in this study was to
investigate experiencesthat grounded in
nurses and patient’s relations with the main
researchquestion:“What are the skills and
roles of nurses in relationship with patients?”
Therefore, because of there was no previous
studies dealing with the nurses’ roles during
communicationwith patients, a qualitative
content analysis approach was used.
According to this qualitative approach, the
content of the data was analyzed in order to
categorize the concept.
The study was performed on eleven Iranian
nurses and twelve patients of medical and
surgical wards in a referral university hospital
that it was publicly funded and located in
urban area in Tehran, Iran. The participants
were chosen with a purposeful sampling
method to gather relevant and in-depth data.
All participants were speaking in Persian
language and did not have any illness that
would hinder verbal communication.The
nurses had a bachelor’s degree in nursing.
Professional’swork experiencesof nurses
were between 18 months to 28 years. Two of
the nurses were head nurses and worked on
morning shifts and the other nurses worked on
rotating work shifts. The patients spoke in
Persian language too and aged from 35 to 60.
Also, patients were hospitalizedbecauseof
medical or surgical problems and didn’t have
any mental and cognitive disorders.
Data collection methods were interviews
and observation.First author of the study
conductedthe interviews and observations.
Place of interviewing and observation was in
hospital where the research was taking place.
The interviews were recorded by digital MP3
recorder. After recording, the interviews were
transcribed verbatim. Each interview lasted on

Exploring communication role of nurses
Journal of Caring Sciences, December 2016; 5 (4), 267-276|269
average 30 to 90 minutes. Interviews with
nurses were conducted in nurses’ room in each
unit.
Interviewswith patients were conducted
beside patient's units in hospital. In addition,
to improve the depth of understanding of the
context of communication between nurses and
patients as well as to verify the data gathered
through interviews, 10 unstructured
observationsessions were performed by a
participant observer approach lasting 15 to 180
minutes. Then, each observation session was
transcribed verbatim.
The first two interviews were started with
head nurses as key informants. These
participantshad the most work experience
among all the nurses and worked in different
nursing units. Then, according to data analysis
and constant comparison of the data, the
interviews continued with other nurses and
patients. The primary interview was started
with general questions that had no direct
referenceto the relationshipbetweennurse
and patient such as “Can you explain about
your actions during caring of patients?” that
asked from nurses; or “Can you talk about
nurses’ care in relation to yourself?” that asked
from patients.
However, after transcription and analysis
data, according to emerged data, interviews
were changed and conducted in semi-
structured form. In semi-structured interview,
the questionswere focused on the type of
patients’ needs; concernsof patient during
hospitalization; nurses’ behaviors during
caring of patients; nurses’ actions during
relationshipwith patients and so on. Also,
researcher used probing questions such as aha,
or can you explain more about your idea and
please repeat it again to clarify the
participants’ opinions.
The analysis process was divided into three
phases of preparing, organizing and reporting
the analyzing process and the results.12 In the
preparation phase, researchers read
transcribed interview from beginning to end
several times.
Then, the unit of analysis was selected. In
the organization phase, the primary concepts
(codes) were derived from the data. Then
according to properties, dimensions and
similarities of each concept, they were grouped
into two abstract higher order categories.
Finally, in the reporting phase, the
influencing conditions on nurses’ skills in
communicationwith patientswere explored
and a main conceptual category was derived
from two categoriesthat were formed in
organizing phase.
To enhance the rigor of the study,
researchersused many methods including
rechecking and re-interviewing the
participants about the derived conceptsto
make sense of the data. The researchers also
peer-checkedthe analysis processwith two
other faculty members trained in qualitative
research. In addition, to create maximum
variation, the participants were selected
according to their professionalexperiences,
work shifts, hospitalization time and ages.
This study was part of a PhD dissertation
that approved by the vice chancellor of
research and technology of Tehran University
of Medical Sciences (research contract number:
250/5005). The aim of the study was explained
to the all participants in detail. In addition, the
following points were emphasizedfor the
participants: the voluntary nature of the
participation, the right to privacy, the
anonymity and confidentiality of informants
and the right to withdraw from the study at
any time without any penalty. Also, informed
consent was obtained dynamically and
continuously from participantsbefore each
observation session.
Results
Data analysis was led to emergence of a main
conceptual category: “The patient's need-based
communication”. In fact, patient’s needs
directed the communicativeroles of nurses.
This conceptualcategorywas derived from
two categories,1) Identifying the patient’s
needs and 2) communicative behaviors in the
face of the patient’s needs. The category of
“how to identify the patient’s needs” was
composed of three subcategories: the type of the

Fakhr-Movahedi et al.
270 | Journal of Caring Sciences, December 2016; 5 (4), 267-276
patient’s problem, patients’ inquiring about their
health status, and monitoring the health status of
the patient. The category of“communicative
behavior in the face of the patient’s need” was
also composedof four subcategories:caring
attention,informal educationof the patient,
inducing calmness to the patient and obtaining the
trust of patient. In the following, each category
with its subcategories will be described (Table
1).
Identifying the patient’s needs
Knowing the patient’s needs was the first role
that nurses needed before encountering with
patients. For this reason, this category implied
the “type of patients’ needs”, “patients’
inquiring about their health status”, and
“monitoring the health status of the patient”.
Physical and emotional problems were the
most important needs of the patients.One
nurse expressed“Most patients’problemsare
related to their disease such as nausea and vomitin
or pain” (Participant 9). Regarding the content
of relationship with nurses, one patient said,
“When I had pain, I asked nurses to give me a
analgesic” (Participant 8). The major emotional
problems of the patients were related to their
concerns about the costs of the treatment, time
of discharge from the hospital and
consequences of the disease and their health
status. One nurse in medical unit said, “All
patients are concerned about the costs and the
recovery” (Participant 15).
Another nurse expressed, “Here (in this ward)
the main problem is the cost of the surgery and the
time of discharging from the hospital” (Participant
6). One patient in medical ward said, “I was
expecting to recover and be discharged from th
hospital” (Participant 10).
Table 1. Summary of main conceptual category, categories, sub-categories and open
codes
Main them Categories Subcategories Open codes
The patient's
need-based
communication
Identifying the patient’s
needs
The type of the patient’s
problem
 Acute physical problems
 Patients concerns about treatment
process and related costs
 Emotional concerns
Patients’ inquiring about
their health status
 Asking about diagnostic tests,
procedures, prognosis, medications
and treatment modes
 Asking about discharge time
Monitoring the health
status of the patient
 How to run monitoring
 The content of monitoring
 The run-time of monitoring
Communicative behaviors in
the face of the patient’s
needs
Caring attention  Doing task optimally
 Accessibility of nurse to patients
 Answering to patients’ request
Informal education of the
patient
 Explanation about medication,
medical and nursing interventions
 Patients preparation for diagnostic
procedures
 Discharge preparation
Inducing calmness to the
patient
 Respect to patients
 Nurses’ patience to patients’ requests
 Sympathy with patients
 Listening to patients’ concerns
Obtaining the trust of
patient
 Understanding the patients’ conditions
 Accepting the patients

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Journal of Caring Sciences, December 2016; 5 (4), 267-276|271
Patients’ inquiries about their health status
were another factor that helps nurses to
identify the patients’ needs. The commonest
inquiries were about the diagnosis of
disease,evaluation procedures,treatment
modes and prognosis of disease.One of
surgical ward’s nurse expressed“In our
ward, becausemost patientshavemalignant
illnesses, they tend to have information about
the prognosis,successof treatmentand
metastasis of the disease to their other organs”
(Participant 6). In one of observational
sessions in surgical wards, the researcher
observed the following relationship
between a nurse and a patient:
Patient: Why the result of my biopsy is not
ready?
Nurse: I do not know. Let me asked the lab’s
technician.
Monitoring of the patients’ health status
was another skill used by nurses for
knowing about the patients’ needs.
Monitoring of patients’ needs was
accomplished by following these steps: how
to run monitoring, the content of
monitoring and the run-time of monitoring.
Nurses monitor the patients using their
documents,asking those questions, and
observing their health status. Using
documents related to patients such as
nursing and physicians’ reports were the
commonest method for nurses to get
informed about the patients, as all of nurses
in both medical and surgical wards were
expressed:“Initially, we collectinformation
aboutthe patientsby reviewinghistoryand
reports in their files, and then we practically
help them”. Nurses monitored patients’
status by asking question and observing
them. For examples, one of nurses in
surgical ward was expressed: “I ask patients
about their pain and other problems such as
nausea, dizziness and so on” (Participant 2).
The content of monitoring pertained to
acute and short-term problems of patients.
“Becauseof work overload,we cannot ask
patientsabout long term problems and their
other supportiveresources”(Participant 3).
Alternatively, one patient said, “The nurse
asked me about my current disease”
(Participant 19).
Nurses monitor the patients’ status as
they change shifts. “When I change shifts and
take over the patients from the previous shift, I
get informed about their conditions”
(Participant 5). Another nurse in surgical
ward was expressed, “We do not have enough
time for interviewingall patients.Usually,
during nursing practicesuch as medication
administration, dressing, bed making and so on,
we learn about other demands or problems o
patients” (Participant 21).
Communicative behavior in the face of the
patient’s needs
Communicativebehavior of nurses was
another skill in their encounters with
patients. This category was derived from
four subcategories: “caring attention”,
“informal education of the patient”,
“inducing calmnessto the patient”, and
“obtaining the trust of the patient”. The
nurses’ caring attention was accomplished
by applying maximum efforts to respond
patient’s needs and requests. Most of the
patients believed that nurses performed
their tasks optimally. “Nurses did all tasks
such as giving my medicines, controlling vital
signs, bed making, and injecting intravenous
infusions in a timely manner; In fact, nurses
were doing their tasks to the fullest”
(Participant 7). Another patient in one of
surgical wards was expressed,“All my
requests were done by the nurses as soon a
possible” (Participant 8).
Enhancing the knowledge of patients and
their families about the diseaseand the
treatment process was another
communicative behavior performed by
nurses. Nurses performed patient education
informally during caring procedures.
Patient education focused on giving
explanations in relation to the process of
disease, medication, diagnostic evaluation,
patient preparation for procedures and
others caring recommendations.
One patient expressed “nurses answered all
my questions about the disease and treatmen
(Participant 22). “Most of patients’ questions

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are related to their medication and I explain the
mechanism,side effects and route of
administration”(Participant 8). Discharge
education was performed informally too.
One of nurses in medical ward was
expressed: “I educate the patients when they
are beingdischargedfrom the hospital.Our
education focuses on medication at home, follow-
up care and diet” (Participant 18).
Nurses induced calmness to the patients
by expressing intimacy, showing a
respectful behavior and confronting the
patients’ needs patiently. In this regard, on
of medical ward’s patients was expressed:
“They (nurses) are so kind and listen to my
requests patiently” (Participant 20). Also, a
nurse in surgical ward was expressed:
“Usually beforesurgery,patientsare very
stressful. The night before surgery, I speak with
them and listen to their concerns about surgery
and the operatingroom. I explain about
measurements in the operating room and post-
operation care such as range of mobilization,
attachedtubes and cathetersand so on”
(Participant 6).
Polite and respectful behavior was
another factor that induced calmnessto
patients. Apatient in medical wardwas
expressed: “The nurses’ behavior is very good.
They respectfully interact with me and ask me
about my problems such as headaches and so
on” (Participant 12). Another patient in
surgical ward was expressed: “They (nurses)
performed their tasks and behaved very politely”
(Participant 7). Expressing sympathy with
patients was another method of inducing
calmness. One of nurses in surgical ward
was express: “Some conditionssuch as
amputation and mastectomy is influenced the
patients’ mood. I speak with them about their
conditions and spend more time with them. In
addition, I listen to their concerns and tell them
how to live with their new conditions”
(Participant 21).
Obtaining the trust of patients was
another behavior that performed by nurses.
Trust in patients is created by
understanding the patients’ conditions and
accepting them as individuals with unique
needs. One of head nurses was expressed:
“When you percept the patient’s condition an
accept him or her as someone of your family, the
patient listen to your advice and perform them”
(Participant 5). Trust in patients was
associated with satisfaction from the
nursing personnel, compliance and
following the treatment and caring modes.
Since the most nurses’ endeavors were
directed to patients’ actual needs and they
met these needs on time, the satisfaction of
patientsfrom the nursing care wasvery
high. In addition, when nurses understood
the patients’ conditions, they won the
patients’ trust. A patient in medical ward
was expressed: “Here (in this ward), nurses
are very patient and sensitive to my problem
and requests. They answer my requests fast and
on time” (Participant 20). One of nurses was
expressed: “When I understand the patients,
they follow my recommendations and participate
better in their care” (Participant 23).
Discussion
The aim of this study was to provide insight
into nurses’ roles during communication
with patients. The findings of this study
present new insights into nurse–patient
communication. The findings showed that
communicative roles of nurses were formed
according to patient’sneeds. These roles
were included identifying the patient’s
needs and communicative behavior in the
face of patient’s needs that were applied by
nurses. In other words, after identifying the
patients’ needs, nurses tried to enhance the
quality of care with communicative
behaviors such as caring attention, informal
education of the patient, inducing calmness
to the patient and winning the trust of
patient. Jahromi and Ramezanali concluded
that therapeutic communication with
patients need to achieve care that is
effective and responsive to their needs.1
In Tay et al., study the results shown that
the patients’ demands and needs to
communication could promote the
communication between registered nurses

Exploring communication role of nurses
Journal of Caring Sciences, December 2016; 5 (4), 267-276|273
and patients.13 Also, Granados Gamez
concluded that the nurse-patient
relationship creates the activity of caring.14
So, policy makers must pay additional
attention to eliminate inhibiting factors of
nurse–patient communication process.15
According to findings of this study,
communicative roles of nurses were
categorized according to two concepts:
identifying patients’ needs and nurses’
behavior to patients. Nurses’ attention was
focused more on the acute problems of
patients. Shattell expressed that nurses paid
more attention to patients with more
needs.16 In a study that aimed to
understand nurses' communicationwith
patients, the researchersfound that in
emergency conditions, nurses gave priority
to physical care rather than the patient’s
anxiety.17
In this study nurse were aware of
patients’ needs by self-expression of patient.
In fact, nurses communicated with patients
in informal form and interacted with
patients according to their’ requests about
their problems. Results of Chan et al., study
showed that in informal communication,
communication was initiated by the
patients. Therefore, nurses answered to
them in task-oriented form such as
treatment and procedural techniques.18
Taylor concluded that nurses use different
sources such as nursing notes, patient’s file
and history taking to recognize the patient’s
needs.19 In addition, self-expressionby
patient was another means of making
nursing students aware of the physical
condition of the patient.20
Communicative behavior of nurses was
summarizedin caring attention,informal
education, inducing calmness, and
obtaining the trust of patients. In a study by
Skea et al., interacting warmly with patients
and attending to their care needs were the
properties of valuable and worthy care of
patients.3 Also, nurses are responsible for
providing important information to the
patient.21
Morrow and Conner-Garciabelieve that
helping the patients to understand how to
take their medication and organizing
information for them about medication
information were recommendationsfor
nurse-patient communication about
medication.22 In fact, providing the
biomedical and psychosocial information to
the patient is a positive implication of
nurse-patient communication.23
In this study, nurses enhanced the
patient’s information by informal
education. O'Hagan et al., expressed that
providing and clarifying information for
patient and listening to them are the
characteristicsof effectivecommunication
in nursing care.24 de Leeuw et al., also
concluded that nurses were more attentive
to informational questions of patients than
to address emotional cues.25 Pytel et al.,
found that providing information about
diagnostic tests and modes of treatment
were the most important needs of patients
and families.26
In this study, nurses’ active listening and
respectful and polite behavior were led to
patients’ calmness and trust. Mottram
expressed that some nurses’ behaviors such
as adequate explanation, timely satisfaction
of patient’s requests, intimacy and a
friendly interactionwith the patient are
characteristicsof therapeutic commun-
ication in nursing care.27 In Finch’s study,
patients expected a professional, respectful,
intimate, and professionalbehavior from
nurses.28 Nestel and Kidd believed that
listening actively, speaking clearly and
behaving respectfully were verbal and
nonverbal skills crucial to effective
communication.29 In general, the meaning
of nursing care from the patients’
perspective can be summarized as respect
and safety for the patient.30
Conclusion
The findings of this study were
characterized in multiple roles that nurses
were used in relationship with patients. It

Fakhr-Movahedi et al.
274 | Journal of Caring Sciences, December 2016; 5 (4), 267-276
seems the patient’s needs have an
important role in forming the nurse’s
communicativeroles in clinical settings.
Therefore, if the patients need in clinical
settings are appropriately defined and
clarified, the nurse-patient communication
will be enhanced and thereby the quality of
care will be improved.
The findings of this study can be used as
a guideline forstakeholders and nursing
policy makers to formulate appropriate
strategies to enhance the quality of nursing
care and communication process.
This study was performed with a
qualitative approach and the findings were
limited to the field of study. Therefore,
researcherssuggestmore studies on this
topic in other clinical settings.
Acknowledgments
The authors thank all patients and nurses
who participated in this study
Ethical issues
None to be declared.
Conflict of interest
The authors declare no conflict of interest in
this study.
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