SINGAPORE NATIONAL UNIVERSITY HOSPIATAL (NHU) CENTRE FOR EVIDENCE BASED NURSING
ALICE LEE CENTRE FOR NURSING STUDIES, NATIONAL UNIVERSITY OF SINGAPORE
Tay Li Hui
Honours Student, Alice Lee Centre for Nursing Studies
National University of Singapore (NUS)
Professor Desley Gail Hegney PhD, BA(Hons), DNE, COHN, CNNN, RN, RM
Professor and Director of Research
Alice Lee Centre for Nursing Studies
Yong Loo Lin School of Medicine
National University of Singapore (NUS)
Block E3A, Level 3
7 Engineering Drive 1
Dr. Emily Ang Neo Kim DNurs, MN, BNCert. Edu., ONC, CCNC, RN
Deputy Director (Clinical and Oncology Nursing)
The Cancer Institute
National University Hospital, Singapore
Main Building, Level 2
5 Lower Kent Ridge Road
Institution mainline: 67724819
Communication is the process in which information, meanings and feelings are shared through the exchange of verbal and non-verbal messages.1, 2 Communication among human beings is complex and often is neither linear nor accurate due to varying human responses.3 In order to achieve effective communication, interaction must be bi-directional and mutual understanding has to be achieved. Through effective communication, individuals become aware of and sensitive to one another.4 This enables individuals to develop trust and emotional closeness, which facilitate the development of interpersonal relationships.
In the context of nursing, nurses interact frequently with patients, wherein each perceives the other in the situation and, through communication, sets goals, and agrees on means to achieve the goals.2 It is essential that nurses are equipped with effective communication skills. However, in many instances, emotions can block communication.5 Failure to be empathetic can inhibit interactions.4 Perceived hierarchy of powers and authority has also led to unilateral communication.6
In the oncology setting, communication is further complicated by the patient's life-threatening illness.7 Being diagnosed with cancer will inevitably create psychological distress and a substantial need for informational and emotional support.8 Complex treatment modalities can also induce anxiety in patients.3 Collectively, the emotional load in cancer nursing makes interaction between nurses and patients all the more challenging.
Existing studies have identified internal and external factors influencing nurse-patient communication in an oncology setting.
With regards to internal factors, several studies suggested that nurses' self-awareness, attitudes to death and level of facilitative communication skills can affect effective communication.1, 2, 7, 9 Nurses often fear that patients will unleash strong emotions which they cannot handle, and thus they often stop patients from disclosing their worries by changing the topic or even choosing not to initiate the conversation.10 Nurses also tend to inform patients about treatment and providing practical care rather than to explore their feelings and actively discuss the emotional aspects of the disease.11 Additionally, language barriers could also restrict patients' understanding of nurses' advice, which consequently limited nurses' psychological support for the patients.12
Externally, the environment in which communication takes place has been identified to affect nurse-patient communication.4, 13, 14 Organizational culture may promote or inhibit nurses from working to establish therapeutic relationships with patients.1 Demands of the institutional setting and heavy workload can also limit the time allowed for communication.3
Effective communication is the cornerstone of nurse-patient relationships.3 The significance of effective communication has been emphasized repeatedly in the development of the therapeutic nurse-patient relationship, which in turn will affect patients' perceptions of the quality of the care they receive.1, 2, 15 Quality care means that the nurse does not make assumptions but assesses the needs and preferences of the patient and provides corresponding care to meet these needs.12, 16 Therefore, it is important for nurses to create an environment of trust, in which the patient feels respected, involved and accepted. This will subsequently improve the quality of communication as well as improve patient outcomes.17
Effective communication also encourages patients to express their anxieties, and thus get emotional relief which improves patient outcomes.7 When a patient's own emotional resources are inadequate to cope with the stress they face, psychological distress may result and this will put in additional harm to their physical health.17 Effective communication thereby involves not only sharing information but also providing emotional care, which is also a crucial task in quality nursing.4, 11
In conclusion, the importance of effective communication in an oncology inpatient setting has been described by several studies.3, 8, 9 In particular, cancer diagnoses and complex treatment modalities have been identified to complicate communication.3, 7, 8 The importance of effective communication and its role in decreasing the psychological distress in patients by promoting disclosure have been emphsized.3, 7, 17 Effective communication definitely plays a crucial role in meeting the cognitive and affective needs of oncology patients. Supportive communication can enhance patients' psychological adjustment and thus improve patient outcomes. Overall, it can improve the quality of care delivery.
The objective of this review is to establish the best available evidence regarding strategies to enhance effective communication between registered nurses and oncology adult patients, and the factors affecting such communication in an inpatient setting. Specifically, the review will determine:
1. What are the best strategies to enhance effective communication between registered nurses and inpatient oncology adults?
2. What are the factors enhancing the effective communication between registered nurses and inpatient oncology adults?
3. What are the factors hindering the effective communication between registered nurses and inpatient oncology adults?
Criteria for Considering Studies for this Review
Types of Participants:
This review will consider studies that include oncology nurses and inpatient oncology adults who are more than 21 years of age.
Phenomena of interest:
This review will consider primary studies that examine the strategies to enhance effective communication and factors affecting such communication between nurses and inpatient oncology adults.
This review will consider studies that are carried out in an inpatient setting, regardless of ward specialty, whilst active or palliative cancer treatments are administered.
Types of Studies:
This review will consider evidence from both quantitative and qualitative studies on the strategies and factors affecting effective communication between oncology nurses and oncology adult patients in an inpatient setting.
This review will consider any randomized controlled trials that examine the strategies implemented to improve nurses' communication within adult inpatient oncology settings. In the absence of RCTs other research designs, such as non-randomized controlled trials, before and after studies and cohort observational studies, will be considered for inclusion in a narrative summary.
This review will also consider any interpretive studies that draw on the experiences of the factors that can affect nurses' communication with inpatient oncology adults, including, but not limited to, designs such as phenomenology, grounded theory and ethnography. In the absence of research studies, other text such as opinion papers and reports will be considered.
This review will exclude papers which involve:
- Patients who are less than 21 years of age.
- Patients with intellectual or cognitive disabilities.
- Patients who are not aware of their cancer diagnoses.
- Simulated cancer patients.
- Factors affecting and strategies to ensure effective communication between oncology patients and physicians/therapists/nursing students.
- Factors affecting and strategies to ensure effective communication between oncology nurses and patients' families/relatives.
- Factors affecting and strategies to ensure effective communication during end-of-life care and cancer support group counseling.
- Factors affecting and strategies to ensure effective communication during the disclosure of cancer diagnosis.
- Studies conducted to validate assessment tools for communication.
- Studies conducted to test the effectiveness of communication skills training courses.
- Studies conducted on therapeutic touch.
- Studies not published in English.
Search Strategy for Identification of Studies
Prior to commencing the review, a search of databases (e.g. Cochrane and JBI) revealed no systematic review conducted on the strategies and factors affecting and to enhance effective communication between nurses and oncology patients in the inpatient setting.
The search strategy aims to find published studies and papers. The search will be limited to English language reports. A three-step search strategy will be utilized in each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken. Thirdly, the reference lists of all identified reports and articles will be searched for additional studies.
The grey literature will not be included in this review.
Electronic databases to be searched include:
- Wiley InterScience
The search strategy will be not be limited by year of publication.
Initial keywords to be used for the three review components and their respective combinations used for each search are illustrated in Appendix I.
The titles and abstracts identified from the search will be assessed independently by two reviewers against the inclusion criteria. For all studies that meet the inclusion criteria, full texts of the studies will be retrieved. If the title and abstracts are inconclusive, full texts will be retrieved and thorough evaluation against the inclusion criteria will be undertaken. Once the papers have been retrieved, studies will again be assessed for applicability to the inclusion criteria in order to determine the relevance to the review objectives.
Assessment of Methodological Quality
Qualitative and quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal instruments from the JBI-SUMARI (Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information) (Appendix II). Any disagreements that arise between the reviewers will be resolved through discussion, or with the third reviewer.
Quantitative data will be extracted from papers included in the review using standardized data extraction tools from the JBI-MAStARI (Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument) (Appendix III). Qualitative data will be extracted from papers included in the review using standardized data extraction tools from the JBI-QARI (Joanna Briggs Institute Qualitative Assessment and Review Instrument) (Appendix IV). Any disagreements that arise between the reviewers will be resolved through discussion with the third reviewer.
Where possible, quantitative research study results will be pooled using the JBI-MAStARI. All results will be double entered. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible, the findings will be presented in narrative form. When possible, quantitative results will be combined into a meta-synthesis for evaluation of the overall effects of an intervention.
Where meta-synthesis is possible, qualitative research findings will be pooled using the JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings) rated according to their quality, and categorizing these findings on the basis of similarity in meaning (Level 2 findings). These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings (Level 3 findings) that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form. When significant heterogeneity exists between studies, then data from each study will be presented in a narrative summary.
Conflicts of Interest
There are no conflicts of interest regarding this systematic review.
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Appendix I: Combination of keywords used for search strategy
Appendix II: Critical Appraisal Instruments from the JBI-SUMARI
JBI critical appraisal checklist for randomized and pseudo-randomized studies:
JBI critical appraisal checklist for cohort/case control studies:
JBI critical appraisal checklist for descriptive/case series studies:
JBI critical appraisal checklist for interpretive & critical research:
Appendix III: Data Extraction Tools from the JBI-MAStARI
JBI data extraction form for randomized and pseudo-randomized controlled trials:
JBI data extraction form for comparative cohort/case control studies:
JBI data extraction form for descriptive/case series studies:
Appendix IV: Data Extraction Tools from the JBI-QARI
JBI data extraction form for interpretive & critical research: