E V I D E N C E S Y N T H E S I S

Factors affecting effective communication betweenregistered nurses and adult cancer patients in an inpatientsetting: a systematic reviewjbr_212 151..164

Li Hui Tay BSc(Nursing)(Hons) RN,1,2,4

Desley Hegney BA(Hons) PhD RN RM DNE COHN CNNN2,3,4 andEmily Ang DNurs MN BNCert.Edu. RN ONC CCNC1,2,4

1National University Hospital, 2The National University of Singapore, Singapore, 3The University of Queensland, St Lucia, Queensland,Australia, and 4The Singapore National University Hospital (NUH) Centre for Evidence-Based Nursing: A Collaborating Centre of theJoanna Briggs Institute

AbstractAim To establish the best available evidence regarding the factors affecting effective communication betweenregistered nurses and inpatient cancer adults.

Method Electronic databases (CINAHL, Ovid, PubMed, ScienceDirect, Scopus and Wiley InterScience) weresearched using a three-step search strategy to identify the relevant quantitative and qualitative studies published inEnglish. The grey literature was not included in the review. The identified studies were evaluated using the guidelinesfrom the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information. A totalof three studies were included in the quantitative component of the review, and the data were presented in anarrative summary. Five studies were included in the qualitative component of the review, and the findings werecategorised in a meta-synthesis which generated four synthesised findings.

Results The factors that were found to influence effective communication were identified in the characteristics ofnurses, patients and the environment. The promoting factors in nurses included genuineness, competency andeffective communication skills. The role of post-basic training in improving nurse–patient communication remainedinconclusive. Conversely, nurses who were task-orientated, who feared death and who had low self-awareness oftheir own verbal behaviours inhibited communication. Nurses were also observed to communicate less effectivelywhen delivering psychosocial aspects of care and in emotionally charged situations. On the other hand, patients whoparticipated actively in their own care and exhibited information-seeking behaviour promoted communication withthe nurses. However, patients’ unwillingness to discuss their disease/feelings, their preference to seek emotionalsupport from their family/friends and their use of implicit cues were some of the factors that were found to inhibitcommunication. A supportive ward environment increased facilitative behaviour in nurses, whereas conflict amongthe staff led to increased use of blocking behaviours. Cultural norms within the Chinese society were also found toinhibit nurse–patient communication.

Conclusion Within the constraints of the study and the few quality papers available, it appeared that personalcharacteristics of patients and nurses are the key factors that influence effective nurse–patient communication withinthe oncology setting. Very little evidence exists to explain the role of environment in effective nurse–patientcommunication, particularly within an Asian setting.

Implications for practice Training can be implemented to inform nurses about the communication chal-lenges, to equip them with effective communication skills and improve their receptivity to patient cues. Information-sharing can be used as a non-threatening approach to initiate rapport-building and open communication. Nursesshould consider patients’ psychological readiness to communicate and respect their preference as to whom theywish to share their thoughts/emotions with. Hospitals/institutions also need to ensure a supportive ward culture andappropriate workload that will enable nurses to provide holistic care to patients.

Correspondence: Miss Li Hui Tay, National University Hospital,Singapore Main Building, Level 5, Ward 58, 5 Lower Kent RidgeRoad, Singapore 119074. Email: taylihui@gmail.com

doi:10.1111/j.1744-1609.2011.00212.x Int J Evid Based Healthc 2011; 9: 151–164

© 2011 The AuthorsInternational Journal of Evidence-Based Healthcare © 2011 The Joanna Briggs Institute

Implications for research Further research on the effect of the Asian culture on effective communicationwithin the oncology setting is required to expand the knowledge in this area. Studies to ascertain the effect of thepatient’s age and place within the oncology treatment cycle are also warranted. The lack of evidence on theeffectiveness of post-basic communication education also requires further investigation.

Key words: communication, haematology, nursing, oncology, systematic review.

Background

Effective communication is defined as ‘a two-way process –sending the right message that is also being correctlyreceived and understood by the other person’.1

Communication enables sharing of information, meaningsand feelings through verbal and non-verbal messages.2,3 Inthe context of nurse–patient interaction, each perceives theother in the situation and, through communication, setsgoals, and agrees on means to achieve these goals.3

However, communication is complex and is often neitherlinear nor accurate due to varying human responses.4

In the oncology setting, communication is further compli-cated by the patient’s life-threatening illness.5 A person diag-nosed with cancer will inevitably suffer with psychologicaldistress and feel a substantial need for informational andemotional support.6 In addition, the complex treatmentmodalities can also induce anxiety in cancer patients.4 Col-lectively, the emotional load involved in cancer care canmake nurse–patient interaction all the more challenging.

According to the data from existing studies, internal andexternal factors influence nurse–patient communication in anoncology setting. With regard to the characteristics of nurses,several studies have suggested that nurses’ self-awareness,their attitudes to death and the level of facilitative communi-cation skills can affect effective communication.2,3,5,7 Nursesoften fear that patients will unleash strong emotions that theywould not be able to handle, and thus they stop patients fromdisclosing their worries by changing the topic or even choos-ing not to initiate the conversation.8 Nurses also tend to useinformation-giving and practical care to avoid active discus-sion of the patients’ emotions.9 Language barriers, especially,could restrict patients’ understanding of the nurses’ advice,which can consequently limit nurses’ psychological supportfor the patients.10

Externally, the environment in which communicationtakes place has been identified as a factor.11–13 Organisationalculture may promote or inhibit nurses from working toestablish therapeutic relationships with patients.2 Institu-tional demands and heavy workload can also limit the timeallowed for communication.4

Effective communication is the cornerstone of therapeuticnurse–patient relationships.2–4,14 For instance, it creates anenvironment of trust in which the patient feels respected andinvolved.15 Effective communication also promotes disclosureof feelings by the patients, from which patients gain emo-tional relief.5 These factors subsequently improve the qualityof nurse–patient communication as well as patient outcomes.

In conclusion, effective communication is especiallyimportant in the oncology inpatient setting.4,6,7 Cancerdiagnoses and complex treatment modalities have beenidentified to complicate communication.4–6 Effective com-munication plays a significant role in decreasing patients’psychological distress by promoting disclosure,4,5,15 as wellas in meeting their cognitive and affective requirements.9,11

Overall, effective communication improves the quality ofcare delivery.

Aim

The aim of this review was to establish the best availableevidence regarding the factors that promoted and/or inhib-ited effective communication between registered nurses andadult oncology patients in an inpatient setting.

Search strategy

After an initial search of databases (e.g. Cochrane and JBI),which revealed that no systematic review had been con-ducted on the factors affecting effective communicationbetween registered nurses and oncology patients in theinpatient setting, a comprehensive literature search in therelevant field was conducted. Electronic databases such asCINAHL, Ovid Full Text, PubMed, ScienceDirect, Scopusand Wiley InterScience were searched using the followingkey words: ‘communication’; ‘nonverbal communication’;‘patient’; ‘inpatient’; ‘nurse’; ‘nurse–patient relations’;‘nurse–patient communication’; ‘nurse–patient interaction’;‘interpersonal relations’; ‘oncology’; ‘cancer’; and ‘onco-logic nursing’. The search was not limited by the year ofpublication. Due to the limited time frame, grey literaturewas not included in this review.

A three-step search strategy was utilised in this review:(i) an initial limited search of MEDLINE and CINAHL wasconducted, followed by an analysis of the text words con-tained in the title, abstract and index terms used todescribe the article; (ii) a search using all identified keywords and index terms was conducted; and (iii) the refer-ence lists of all identified reports and articles were searchedfor additional studies. The titles and abstracts identifiedfrom the search were assessed independently by tworeviewers against the inclusion criteria. For all studies thatmet the inclusion criteria, or in cases where the title andabstract were inconclusive, full texts were retrieved andassessed for applicability to the review objectives.

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Inclusion criteriaThis review considered both quantitative and qualitativestudies that: (i) examined the factors affecting effective com-munication between oncology nurses and adult oncologyinpatients who were �21 years of age (the legal age ofconsent under Singapore Law); (ii) were carried out in aninpatient setting, regardless of ward specialty, whilst activeor palliative cancer treatments were administered; and(iii) were published in English.

Exclusion criteriaThis review excluded studies that involved: (i) patients withintellectual or cognitive disabilities; (ii) patients who wereunaware of their cancer diagnoses; and (iii) simulatedcancer patients. This review also excluded papers examin-ing factors that affect effective communication thatoccurred: (i) during end-of-life care and cancer supportgroup counselling; and (ii) during the disclosure of cancerdiagnosis to the patients. Additionally, studies conductedto validate assessment tools for communication and to testthe effectiveness of communication skills training courseswere also excluded from the review.

Review method

This systematic review was undertaken from November2009 to April 2010 using the guidelines provided by theJoanna Briggs Institute System for the Unified Management,Assessment and Review of Information (JBI-SUMARI).16

For the quantitative component of the review, any ran-domised and non-randomised controlled trials, ‘before andafter’ studies and cohort observational studies were consid-ered. Descriptive survey and mixed-method studies were alsoconsidered for inclusion. Data were extracted using standar-dised data extraction tools adapted from the Joanna BriggsInstitute Meta Analysis of Statistics Assessment and ReviewInstrument (JBI-MAStARI). As the included studies utilised

different outcome measures and/or interventions, statisticalpooling of the data (i.e. meta-analysis) was not possible andthe findings were thus presented in a narrative form.

For the qualitative component of the review, any interpre-tive studies including, but not limited to, designs such asphenomenology, grounded theory and ethnography wereconsidered. Data were extracted using standardised dataextraction tools from the Joanna Briggs Institute QualitativeAssessment and Review Instrument (JBI-QARI) and puttogether in a meta-synthesis. This involved the synthesis offindings using three steps: (i) assembling the findingsaccording to their quality; (ii) categorising these findings onthe basis of similarity in meaning; and (iii) subjecting thesecategories in a meta-synthesis to produce a single compre-hensive set of synthesised findings that was used as a basisfor evidence-based practice.

Study characteristics

An initial search of the literature generated 65 potentialpapers with titles and abstracts (if available) that met thecriteria. However, 22 of these were found to be reviews oropinion pieces and were thus excluded. The remaining 43papers were assessed and divided into quantitative andqualitative components of the review.

Quantitative component of the reviewThree studies were included in this section. Figure 1 providesa description of the retrieval and selection of quantitativestudies during the review process. Table 1 provides a briefdescription of the quantitative studies included in thisreview.

Methodological qualityUsing self-reported questionnaires, Sivesind et al.17 investi-gated the clinical situations in which nurses felt challenged.This is a moderately low-quality study. The inclusion criteria

Figure 1 Flowchart for the retrieval and selection of quantitative studies.

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for participants were clear, and the confounding factorswere dealt with. A focus group was used for content valida-tion of the questionnaire. Statistical analysis of the datawas sound. However, many areas remained unclear. Theseincluded the ways in which participants were sampled andthe outcomes were measured. Comparisons were made, butthere were insufficient descriptions of each group. Addition-ally, although the outcomes of participants who withdrewfrom the study were described, it was unclear whether theywere included in the analysis.

Using videotaped nurse–patient conversations and ques-tionnaires, Uitterhoeve et al.18 had conducted a mixed-method study to investigate the relationship betweennurses’ cue-responding behaviour and patient satisfaction.This was a moderately high-quality study. The inclusion cri-teria for participants were clear, and the confounding factorswere dealt with. Validated questionnaires (Hospital Anxietyand Depression Scale and Heaven & Maguire’s ConcernsChecklist) were administered by the same researcher. Thevideotaped conversations were decoded by trained person-nel using the Medical Interview Aural Rating Scale. Statisticalanalysis of the results was sound. However, the samplingmethod and whether the outcomes of participants whowithdrew from the study were included in the analysisremained unclear.

In England, Wilkinson7 conducted a mixed-method study(using an analytical relational survey) in order to examinethe extent to which the nurses exhibited facilitating andblocking behaviours when communicating with cancerpatients, and whether these behaviours were correlated withthe nurses’ anxiety, their attitudes to death, social supportand work environment. This is a moderately high-qualitystudy. The participants were sampled randomly and theinclusion criteria were distinct. The outcomes were assessedusing validated instruments (Fear of Death Scale, NorbeckSocial Support Questionnaire, and State-Trait Anxiety Inven-tory) and analysed using appropriate statistical tests.However, confounding factors were not dealt with, and theoutcomes of participants who withdrew from the study weredescribed but not included in the analysis. Additionally,descriptions of the comparison groups were insufficient.

Qualitative component of the reviewFive studies were included in the qualitative component ofthis review. Figure 2 provides a description of the retrievaland selection of qualitative studies during the reviewprocess. Table 2 provides a description of the qualitativestudies included in this review.

Methodological qualityBerterö et al.19 investigated the congruity between the caresupplied by nurses and the care demanded by haematologyinpatients. This is a moderate-quality study. The study wasbased on Grounded Theory but was not situated within anyphilosophical perspective. Ethical approval was obtainedfrom the Committee on Research Ethics, Faculty Health Sci-ences, Linköping, Sweden. Data collection methods werecongruent with Grounded Theory. The participants’ voiceswere adequately represented, and the conclusions drawnwere supported by the data. However, themes (instead oftheory) were generated. There was no statement locatingthe researchers culturally or theoretically, and the influenceof the researchers on the study was not addressed.

Bottorff and Morse20 examined the types of nurse–patient interactions in an active treatment oncology ward.This is a moderate-quality ethological study that was notsituated within any philosophical perspective and theresearch aim was not clearly stated. There was congruitybetween the research methodology and the collection/analysis/interpretation of data. The participants’ voiceswere represented and the conclusions drawn flowed fromthe data. However, there was no statement locating theresearchers culturally or theoretically, and the influence ofthe researchers on the study was not addressed. Althoughinformed consent was obtained, it was unclear if ethicalapproval was obtained from an institutional review board.

Kvåle21 had conducted a study to ascertain whethercancer patients in an oncology ward wished to talk abouttheir feelings and difficult emotions while they were hospi-talised. This is a high-quality study that was situated withinHusserl’s phenomenology. In this study, there was congru-ency between the research methodology and the collection/analysis/interpretation of data. The participants’ voices were

Table 1 Description of the quantitative studies included in this review

Citation Geographicalsetting

Design Method

Sivesind et al.(2003)17

Texas Descriptivesurvey

Self-reported questionnaires

Uitterhoeve et al.(2009)18

Netherlands Mixedmethod

Nurse–patient conversations were videotaped and analysed, and thepatients’ cues and nurses’ cue responses coded using the MedicalInterview Aural Rating Scale.Questionnaires were used to assess patients’ level of anxiety anddepression and their satisfaction with the communication.

Wilkinson(1991)7

England Mixedmethod

Self-reported questionnaires.Nursing histories were tape-recorded, transcribed and assessed by anindependent psychologist using a devised coding system for classificationinto facilitative or blocking behaviour, and also its extent of coverage.

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represented, and the conclusions drawn flowed from theinterpretation of the results. Ethical approval was obtainedfrom the Western Norway Regional Committee for MedicalResearch Ethics, and the influence of the researcher on thestudy was addressed.

Liu et al.6 explored the perceptions and expectations ofsupportive communication in hospitalised Chinese cancerpatients. This is a moderate-quality study. The study was notsituated within any specific philosophical perspective, butadopted a qualitative approach to data collection and analy-sis. Results and conclusions appeared to flow from the dataas supported by the participants’ voices. Ethical clearancewas obtained from the university’s and hospital’s ethics com-mittees. However, there was no statement locating theresearchers culturally or theoretically, and the influence ofthe researchers on the study was not addressed.

In the qualitative component of the mixed-method studythat was conducted by Wilkinson,7 nurses’ awareness of theirblocking and facilitating verbal behaviours, as well as theirviews and feelings about communicating with cancer

patients, was explored. This is a low-quality study, which isnot situated within any philosophical perspective. Researchobjectives and method of data analysis were not statedclearly in this study. The study results did not support thegeneral aim of the study. The researcher was not locatedculturally or theoretically, and her influence on the study wasnot addressed. It was unclear whether ethical clearance hadbeen obtained from an appropriate body, but the study wasethical according to the current criteria and was thereforeincluded. The conclusion drawn appeared to be supportedby the interpretation of the data and the participants’ voiceswere adequately represented.

Results

Quantitative component of the reviewFactors promoting effective communication betweenregistered nurses and oncology adult inpatientsIn a major oncology centre in Texas, Sivesind et al.17 usedself-reported questionnaires to better understand the chal-

Figure 2 Flowchart for the retrieval and selection of qualitative studies.

Table 2 Description of the qualitative studies included in this review

Citation Geographicalsetting

Design Method Analysis

Berterö et al.(1996)19

Sweden Grounded theory Participant to passive observations;tape-recorded reflectiveconversations; and field-notes

Constant comparativetechnique of Hutchinson’sthree-level coding

Bottorff & Morse(1994)20

Unclear Unclear Videotaped observations andunstructured interviews

Thematic analysis

Kvåle (2007)21 Norway Phenomenology – Giorgi Unstructured interviews Giorgi’s approach to thematicanalysis

Liu et al.(2005)6

Beijing,China

No specific theoretical framework/philosophical perspective

Semi-structured interview Content analysis

Wilkinson(1991)7

England Mixed method (analyticalrelational survey)

Tape-recorded nursing histories;semi-structured interviews; andfield notes

Thematic analysis

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lenges that nurses faced in their everyday communicationwith cancer patients and their families. Based on theresponses of the 350 nurses who participated, a generalpattern emerged wherein the Advanced Practice Nurses(APNs), as compared to the other nurses (staff nurses,research nurses and nurse managers), reported less difficultyand better skilled in handling certain clinical situations.

When t-tests were used to test for significance of differ-ences in the perceived level of difficulty handling cancerpatients between the APNs and the other nurses, it wasfound that some situations were significantly easier for theAPNs. Some examples are as follows: ‘handling requestsfor euthanasia’ (P < 0.0001); ‘addressing the patients’sexual concerns’ (P < 0.0001); ‘managing overprotectivefamilies’ (P < 0.01); ‘intervening with patients who are indenial’ (P < 0.01); ‘discussing Do Not Resuscitate (DNR)issues’ (P < 0.01); and ‘intervening with family memberswho are depressed’ (P < 0.01).

Similarly, when t-tests were used to test for significance indifferences in the perceived skill levels with regard to patienthandling, it was observed that APNs rated being betterskilled at handling the following situations: ‘addressingpatients’ sexual concerns’ (P < 0.0001); ‘handling requestsfor euthanasia’ (P < 0.01); ‘intervening with family memberswho are in denial’ (P < 0.01); ‘managing clinical situationsthat pose ethical dilemmas’ (P < 0.01); ‘intervening withpatients who are in denial’ (P < 0.01); and ‘addressingpatients’ fears’ (P < 0.01).

In England, Wilkinson7 conducted a mixed-method studyto investigate the extent of facilitative and blocking behav-iours that are exhibited by nurses when communicating withcancer patients, and the relationship, if any, between nurses’behaviours and their levels of state and trait anxiety, theirattitudes to death, their perceived levels of social supportand work environment. A total of 56 nurses from a specialistcancer hospital and a district general hospital participated inthe study.

When stepwise-multiple regression was used at 0.05 levelof significance to test the contribution of predictor variableson facilitative behaviours, it was found that the ward inwhich the nurses worked (P = 0.001), the stress resultingfrom giving poor care (P = 0.012) and having attended anoncology course (P = 0.025) were significant predictors forfacilitative behaviour. That is, nurses working in wards thathad exemplary ward sisters, nurses who experienced stressresulting from giving poor care and nurses who had com-pleted post-basic education in cancer nursing were betterfacilitators. In contrast, satisfactory nurse managementsupport (P = 0.026) and nurses who wished to talk openlywith patients (P = 0.013) were significant predictors for poorfacilitative behaviour. In other words, nurses who receivedsatisfactory support from nurse managers and those whosaid that they would like to talk truthfully and openly withpatients but were not sure if they had the skills to do so, werethe poorest facilitators.

Considering that most nurses at the specialist hospi-tals had completed post-basic training in communicationskills and thus were assumed to provide better patient

communication/care, the Mann–Whitney U-test was used tocompare the blocking and facilitative scores between thespecialist hospital nurses and general hospital nurses. Nosignificant differences were found in the verbal behaviours orcoverage scores of the nurses for recently admitted patients.However, with regard to the more difficult areas of cancerrecurrence and palliative care, nurses at the general hospi-tal demonstrated a significantly higher facilitative score(P = 0.02) and a lower blocking score (P = 0.05) comparedwith specialist hospital nurses. This finding therefore ques-tioned the effectiveness of post-basic training in improvingcommunication between nurses and oncology patients.

Factors inhibiting effective communication between registerednurses and oncology adult inpatientsIn the study by Sivesind et al.,17 it was discovered that nursesseemed confident in providing for the physical needs of theirpatients, but perceived more difficulty and less skilled inaddressing concerns that were emotionally charged. Specifi-cally, they rated ‘handling requests for euthanasia or assistedsuicide’ as the most challenging. Other areas that were alsoregarded as challenging included: ‘dealing with patients’families who are in conflict about treatment decisions’;‘setting limits with patients who demand too much time’;‘managing overprotective families’; ‘intervening withpatients/family members who are angry’; and ‘interveningwith patients/family members who are in denial’.

In the Netherlands, Uitterhoeve et al.18 conducted amixed-method study in order to investigate the relationshipbetween nurses’ cue-responding behaviour and patient sat-isfaction. A total of 34 nurses and 100 patients participatedin the study. Using descriptive statistics, the study showedthat the patients were implicit in their expression of con-cerns. The mean number of cues per conversation was 14.2(95% CI: 12.7–15.7), and 25% of the patients’ discoursecontained cues, only 6% of which contained explicitunpleasant emotion (mean = 0.8, 95% CI: 0.31–1.29). Onthe other end, the nurses responded poorly to patients’ cues,with only 21% of the cues explored (mean = 3.0, 95% CI:2.4–3.6), 24% acknowledged (mean = 3.4, 95% CI: 2.8–4.0) and a majority 55% responded to with distancingbehaviours (mean = 7.9, 95% CI: 7.1–8.8). Moreover, themean perceived performance of a nurse per conversationwas 0.50 (SD = 0.16, range 0.05–0.79 and 95% CI: 0.46–0.53) on a Likert-type scale from 0 to 1.

Using Pearson and Spearman correlations, it was discov-ered that the patients’ perceived performance (of nurses)was positively correlated with the nurses’ responses topatient cues (P = 0.007) and the number of cues used(P = 0.021). Patients were more satisfied when nursesresponded to their cues, and this likelihood was enhancedwhen patients used more cues. It was also found thatpatients on palliative treatment were more satisfied with thecommunication of nurses than curatively treated patients(P = 0.001). Older patients were also found to be moresatisfied with the communication of nurses than youngerpatients (P = 0.025).

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In Wilkinson’s study,7 it was discovered that using descrip-tive statistics, the coverage scores of the nursing historieswere particularly low in psychological assessment as com-pared to physical assessment. Using non-parametric tests(not specified), it was found that nursing histories taken fromcancer patients admitted with a recurrence of their diseasewere significantly less comprehensive than those taken withthe new patients (P = 0.0004) and patients admitted forpalliative care (P = 0.005). Nurses also exhibited significantlygreater blocking verbal behaviours when taking nursing his-tories from patients who were admitted with a cancer recur-rence, as compared with new patients (P = 0.03) and thoseadmitted for palliative care (P = 0.09). These meant thatnurses were significantly less thorough in their nursingassessment toward patients admitted with relapsed cancer.Using Kendall’s Tau correlation (at 1% level of significance)to determine whether verbal behaviours used affected thecoverage of nursing histories, it was found that nurses whohad higher blocking scores consequently had lower cover-age scores for each interview. This confirmed that nurseswho used more blocking behaviours covered less during theinterviews.

When stepwise-multiple regression at 0.05 level of signifi-cance was used to test the contribution of predictor variableson the nurses’ blocking behaviours, it was found that nurses’religion (P = 0.03), self-awareness (P = 0.04) and their fear ofdying (P = 0.023) were significant predictors for their block-ing behaviour. Specifically, nurses who were atheists, thosewho consciously used blocking behaviour and those whowere most afraid of dying blocked patients more frequently.

Qualitative component of the reviewA total of 26 qualitative findings were extracted, and eachfinding was assigned one of the following levels of credibilityaccording to the JBI criteria: Unequivocal [E]; Credible [C]; orUnsupported (see Appendix I). As one of the findings was

not supported by an illustration, it was excluded from thestudy. The remaining 25 findings were then clustered intoeight categories and further grouped into four synthesisedfindings.

Factors promoting effective communication betweenregistered nurses and adult oncology inpatientsPromoting factors that affecting communication can comefrom within the individual, in this case, the nurses (Table 3).

Evidence suggests that good communication promotesdisclosure of feelings from patients. Patients were noted torespond well to honest and accurate information that isprovided by nurses in a sensitive manner. Nurses who aremindful, empathetic and flexible in their approach towardpatients are better at facilitating disclosure of feelings fromthe patients. The evidence has also shown that communica-tion is enhanced when nurses showed genuine care andconcern for patients. This includes good eye contact,empathy, engaging dialogue, appropriate tone and touch.In addition, nurses who are knowledgeable and competentincrease patients’ confidence and trust in them.

From the evidence presented, it is apparent that nursesneed to be equipped with good communication/inter-personal skills and embrace a positive attitude in communi-cating with patients.

Likewise, there are also factors within the patients that canpromote nurse–patient communication (Table 4).

Evidence suggests that patients demanded conversationsin situations where the nurses are attentive and listen to theirthoughts and questions. Patients who were actively involvedin their own care also communicated more with the nursesin terms of information-sharing and collaboration indecision-making. Nurses were also considered as an acces-sible source of professional information. In addition, thepatients believed that the information provided by nurseswas more comprehensible than that from doctors.

Table 3 Factors in nurses that promote nurse–patient communication

Synthesised finding Category Findings

1. Promoting factors in nursesEvidence suggests that nurses who provide

accurate and supportive communication andwho know how to facilitate patient disclosurecan promote communication. In addition,patients trust competent nurses better andshare more feelings with nurses who treat themwith genuine care and concern.

Goodcommunication

Characteristics of supportive communication6 [E] (Finding 19)Facilitators7 [E] (Finding 23)Honest and correct information19 [E] (Finding 6)

Positive attributesin nurses

Doing for20 [E] (Finding 11)Doing more20 [E] (Finding 10)Doing with20 [E] (Finding 12)Patients feel safe in the care of competent staff19 [C] (Finding 7)

Table 4 Factors in patients that promote nurse–patient communication

Synthesised finding Category Findings

2. Promoting factors in patientsEvidence suggests that patients who initiate

conversation in order to collect healthinformation or to take part in their own carecan promote nurse–patient communication.

Patients want or needto communicate

Patients demanded conversation19[E] (Finding 5)Patients wanted to participate in their own care19 [E] (Finding 9)Sources of informational support6 [E] (Finding 18)Urgent information needs and active information seeking6 [E]

(Finding 17)

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As presented in the evidence, nurses can encouragepatients to ask questions and participate in their care inorder to promote communication. Nurses are considered acredible and accessible source of information for thepatients.

Factors inhibiting effective communication between registerednurses and adult oncology inpatientsSimilar to promoting factors, inhibiting factors affectingcommunication can also come from within the individual, inthis case, the nurses (Table 5).

Evidence suggests that nurse–patient communication iscentred on collecting information from the patients andproviding them with information about the disease, treat-ment and test results. Additionally, nurses tend to useinformation-giving to keep the conversation away fromthe supposed ‘uncomfortable areas’. Nurses who ignorepatients’ cues and concerns, as well as those who lackrespect, concern and empathy for patients, prevent opencommunication. With a focus on performing tasks, it isobserved that nurses often neglect the human aspects ofcare. Communication is further impeded as nurses adopt anindifferent and routinised approach when they are focusedon just getting the job done.

As discussed above, it is evident that nurses need to moveaway from task-orientation to using effective communica-tion and cue-responding behaviour to provide betterpsycho-emotional care to patients.

There are also factors within patients that can inhibit com-munication (Table 6).

The evidence suggests that patients might not wish to talkabout their disease. Instead, they preferred to talk aboutordinary things and normal lives to help them stay optimis-

tic. In addition, the patients’ mood could also influence theirdesire to communicate. It also appeared that patients mayprefer to keep their problems to themselves and not burdentheir listeners. Patients were found to be reluctant to talk tohealth professionals about their disease and need for emo-tional support. Instead, they preferred to seek emotionalsupport from their immediate family, friends and otherpatients.

Considering the evidence, nurses should be mindful of thepatients’ willingness and readiness to talk. They should alsoensure that patients have a supportive social network andadequate resources to fulfil their emotional needs.

Discussion

Limited primary studies have been conducted in this area.The extensive literature search did not reveal any ran-domised controlled trials relevant to the research objectivesof this review. Nevertheless, randomised controlled trialswere not expected, as it would be ethically unacceptablenot to provide effective communication to participants in acontrol group. Additionally, more qualitative studies thanquantitative ones were included in this review, as aqualitative approach was more appropriate for the researchobjectives set for this review (i.e. to examine the qualitiesof and the factors influencing effective communication).

Considering cultural/geographical settings, only onepaper6 was based in an Asian country – Beijing. Prominentamong its findings, which differ from those of the studiesbased in the Western cultures, is the role of Chinese culturalnorms in inhibiting effective communication – the percep-tion that psychological needs are to be met by close family

Table 5 Factors in nurses that inhibit nurse–patient communication

Synthesised finding Category Findings

3. Inhibiting factors in nursesEvidence suggests that when nurses focus more

on performing tasks than communication, theirconversations with patients tend to concentratemore on giving and collecting information. Inaddition, nurses who lack respect for and agenuine interest in understanding patients’concerns further inhibit communication.

Interaction isperfunctory

Information-collecting routines19 [E] (Finding 2)Information-giving routines19 [E] (Finding 3)Informers7 [E] (Finding 25)

Negative attitudeof nurses

Ignorers7 [E] (Finding 24)Lack of respect, concern and empathy for patients19 [C] (Finding 8)

Over-focusedon tasks

Doing tasks20 [E] (Finding 13)Medical–technical routines19 [E] (Finding 4)Meeting patients’ basic needs only19 [C] (Finding 1)

Table 6 Factors in patients that inhibit nurse–patient communication

Synthesised finding Category Findings

4. Inhibiting factors in patientsEvidence suggests that patients are

reluctant to discuss their disease anddifficult emotions, but would rathertalk about neutral, everyday events.Additionally, they prefer to speak tofamily members, friends and fellowpatients rather than healthcareprofessionals about their distress.

Patients prefernot to discussdistressing issues

Cognitive avoidance and distancing21 [E] (Finding 14)Normalisation, finding meaning and living in the present21 [E] (Finding 15)Reasons for not seeking emotional support from nurses6 [E] (Finding 22)

Preference toseek emotionalsupport fromfamily, relativesand friends

Informational support and negative effects from fellow patients6 [E](Finding 20)

Sources of emotional support6 [E] (Finding 21)Support from family and friends and others21 [E] (Finding 16)

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members and the social rule to use implicit communicationwith outsiders. The lack of further evidence from Asian coun-tries highlights the importance of further research into theeffect of the Asian culture on effective nurse–patientcommunication.

Overview of resultsIt is evident from this review that factors affecting nurse–patient communication in an oncology setting can originatefrom within the patient, the nurse or the environment. Thisreview has found evidence that while hospitalised, patientsoften seek casual interaction from nurses19 and approachthem for information pertaining to their disease and self-care.6 This information-seeking behaviour, which promotesnurse–patient communication, is especially evident inpatients who are actively involved in their own care.19 Addi-tionally, older patients and patients who are on palliativetreatment have been noted to be more satisfied with thecommunication of nurses than younger patients and cura-tively treated patients.18

In contrast, patients’ unwillingness to discuss their diseaseand feelings inhibits nurse–patient communication.6,21

Patients are observed to prefer seeking emotional supportfrom family members, friends and fellow patients rather thanhealthcare professionals.6,21 Implicit cues, used in bothWestern and Asian cultures to subtly express concerns, arealso considered inhibiting to effective communication.6,18

This is especially so as nurses are observed to respond ratherpoorly to patient cues.

From a nurse perspective, this review has shown thatnurses who are good facilitators of supportive communica-tion promote effective communication.6,7 Positive attributessuch as work competency19 and genuineness20 are alsonoted to promote communication between nurses andpatients. Stress resulting from not providing the standard ofcare that the patient/situation warranted is also associatedwith higher facilitative behaviour in nurses.7

When examining the role of post-basic courses in affectingnurse–patient communication, some inconsistencies havebeen noted. For instance, nurses who have completed anoncology course7 and APNs17 were found to facilitate com-munication better than other nurses. In contrast, the reversehas also been reported. Nurses who have not undertakenpost-basic training in communication skills have also dem-onstrated significantly higher facilitative scores and lowerblocking scores than those who have.7 These conflictingfindings do not provide any definitive information on theusefulness of post-basic education in enhancing effectivecommunication.

With regard to inhibiting factors, it was found whennurses focus more on the task concerned than the person,communication become routinised and tends to lack genu-ineness and concern, therefore inhibiting effective commu-nication.7,19,20 Nurses were noted to perceive greaterdifficulty and to be less skilful in addressing patients’ con-cerns in emotionally charged situations.17 They were lessthorough in conducting psychological assessment, espe-cially for patients admitted with a relapse of their cancer.7

Additionally, it was found that nurses who are atheists andthose who fear death or use blocking behaviours consciouslyare more likely to stop patients from disclosing their con-cerns.7

Finally, this review has also found limited evidence on theeffect of environment on effective communication. As apromoter, a supportive ward environment appears toincrease the use of facilitative behaviour in nurses.7 Theexistence of conflict among staff, however, increases the useof blocking behaviours.7 Ward sisters (nurse managers/clinicians) do, however, play an important role in maintain-ing a cooperative environment and encouraging nurses tocommunicate with their patients.7

Conclusion

Within the constraints of the study and from the few qualitypapers available, it appears that similar to other nursingenvironments, the personal characteristics of patients andnurses are the key influencing factors for effective nurse–patient communication in the oncology setting. Very littleevidence exists on the role of environment in affecting effec-tive nurse–patient communication, particularly within anAsian setting.

Implications for practiceFrom the review, several recommendations for practice haveemerged which would improve nurse–patient communica-tion in the oncology setting. Each of these recommendationsis assigned a level of evidence according to JBI criteria (seeAppendix II).1 Considering the high inhibitive behaviours exhibited by

nurses when discussing emotionally loaded topics andtheir poor response to patient cues, training courses couldbe implemented so as to equip nurses with the necessaryskills for effective communication and improve theirreceptivity to patient cues in the emotionally loadedoncology setting. [Level of evidence 3]

2 Nurses encountered greater difficulty in handling certainclinical scenarios such as dealing with death/dying, andseemed less confident in providing psycho-emotionalcare to oncology patients. Educational programs orsharing sessions can be implemented to inform nursesabout these possible challenges and to develop strategiesto overcome these difficulties. [Level of evidence 3]

3 Nurses are considered a credible and accessible source ofinformation; thus, information-sharing can be used as anon-threatening approach to build rapport with patientsand actively involve them in their own care. Once rapportis established, patients are more likely to express theirconcerns openly and seek emotional support from nurses.[Level of evidence 1]

4 Considering that some patients prefer to share their dif-ficulties with family/friends, nurses should be mindful ofpatients’ psychological readiness to communicate andrespect their preference as to whom they wish to sharetheir thoughts/emotions with. Additionally, nurses can

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involve patients’ relatives/friends in the provision of effec-tive social support for the patients. [Level of evidence 1]

5 The evidence also called for nurses to move away fromtask-orientated care delivery and embrace a positive atti-tude in providing psycho-emotional care to patientsthrough effective communication. Institutions thereforeneed to design ward structures (supportive ward cultureand reduced workload) that will enable nurses to provideholistic care. [Level of evidence 2]

Implications for researchFurther research in certain areas has been identified in orderto better inform nursing practice on effective nurse–patientcommunication in an oncology setting.1 There is a scarcity of evidence on how the environment

affects effective nurse–patient communication, as well asstudies investigating the factors affecting nurse–patientcommunication based in the Asian oncology setting.Further research in these areas is warranted.

2 As the role of the influence of patients’ age and the aim oftreatment on nurse–patient communication in the oncol-ogy setting remains unclear, further research in this area isalso warranted.

3 The inconsistency of the effectiveness of post-basiccourses in improving nurses’ communication also needsto be explored further.

Acknowledgements

This systematic review was conducted under the guidance ofProfessor Desley Hegney (also the secondary reviewer forthis review) as part of the requirements for the degree ofBachelor of Science (Nursing) (Honours) at National Univer-sity of Singapore. I would like to thank Professor DesleyHegney, The National University of Singapore and The Uni-versity of Queensland, for her support and expert adviceduring the process. I would also like to acknowledge andthank Dr Emily Ang, National University Hospital and TheNational University of Singapore, for her advice as thirdreviewer, as well as Dr Rie Konno, The Joanna Briggs Insti-tute, for her support and liaison with JBI.

References1. Effective Communication. Effective-Communication.Net. 2010

Accessed 11 July 2010. Available from: http://www.effective-communication.net/

2. McCabe C. Nurse-patient communication: an exploration ofpatients’ experiences. J Clin Nurs 2004; 13: 41–9.

3. Dunne K. Effective communication in palliative care. Nurs Stand2005; 20: 57–64.

4. Sheldon LK. Communication in oncology care: the effectivenessof skills training workshops for healthcare providers. Clin J OncolNurs 2005; 9: 305–12.

5. Kruijver IPM, Kerkstra A, Bensing JM, van de Wiel HB. Nurse-patient communication in cancer care. a review of the literature.Cancer Nurs 2000; 23: 20–31.

6. Liu JE, Mok E, Wong T. Perceptions of supportive communica-tion in Chinese patients with cancer: experiences and expecta-tions. J Adv Nurs 2005; 52: 262–70.

7. Wilkinson S. Factors which influence how nurses communicatewith cancer patients. J Adv Nurs 1991; 16: 677–88.

8. Razavi D, Delvaux N, Marchal S et al. Does training increase theuse of more emotionally laden words by nurses when talkingwith cancer patients? A randomised study. Br J Cancer 2002; 87:1–7.

9. Kruijver IP, Kerkstra A, Bensing JM, van de Wiel HBM. Commu-nication skills of nurses during interactions with simulatedcancer patients. J Adv Nurs 2001; 34: 772–9.

10. Gerrish K. The nature and effect of communication difficultiesarising from interactions between district nurses and SouthAsian patients and their carers. J Adv Nurs 2001; 33: 566–74.

11. Grover SM. Shaping effective communication skills and thera-peutic relationships at work: the foundation of collaboration.AAOHN J 2005; 53: 177–82.

12. Jarrett NJ, Payne SA. Creating and maintaining ‘optimism’ incancer care communication. Int J Nurs Stud 2000; 37: 81–90.

13. Shattell M. Nurse-patient interaction: a review of the literature.J Clin Nurs 2004; 13: 714–22.

14. Haley JE. Experience shown to affect communication skills ofnurse case managers. Care Manag J 2007; 8: 50–7.

15. Williams AM, Irurita VF. Therapeutic and non-therapeutic inter-personal interactions: the patient’s perspective. J Clin Nurs2004; 13: 806–15.

16. Tay LH, Hegney DG, Ang E. A systematic review on the factorsaffecting effective communication between registered nursesand oncology adult patients in an inpatient setting. JBI Libr SystRev 2010; 8: 913–59.

17. Sivesind D, Parker PA, Cohen L et al. Communicating withpatients in cancer care; what areas do nurses find most chal-lenging? J Cancer Educ 2003; 18: 202–9.

18. Uitterhoeve R, Bensing J, Dilven E, Donders R, deMulder P, vanAchterberg T. Nurse-patient communication in cancer care:does responding to patient’s cues predict patient satisfactionwith communication. Psychooncology 2009; 18: 1060–8.

19. Berterö C, Eriksson BE, Ek AC. Demanding interaction-givenroutines: an observational study on leukaemia patients and theirnursing staff. Intl J Nurs Pract 1996; 2: 201–8.

20. Bottorff JL, Morse JM. Identifying types of attending: patterns ofnurses’ work. Image J Nurs Sch 1994; 26: 53–60.

21. Kvåle K. Do cancer patients always want to talk about difficultemotions? A qualitative study of cancer inpatients communica-tion needs. Eur J Oncol Nurs 2007; 11: 320–7.

Appendix I

Qualitative findingsFinding 1 Meeting basic needs [C]The nurse is talking to the patient, who is asking for someyoghurt with whortleberry. An enrolled nurse comes in witha tray of food, hands it over to the nurse, who puts it on thetable and then discovers that the soup is cold. She says: ‘Youcannot eat cold soup, it will not taste nice, I will take it outand warm it up, so you will get some warm soup.’ [Berterö’96; p. 204]

Finding 2 Information-collecting routines [E]The patient is now indisposed and starts to vomit bile andviscous mucus. The nurse starts to ask such questions to thepatient: ‘How are you doing? Do you feel more nausea now?Have you been vomiting like this before? Are you in morepain now?’ The patient is not able to answer. The patient isbusy vomiting, being nauseated and trying to catch hisbreath. [Berterö ’96; pp. 204–205]

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Finding 3 Information-giving routines [E]Aron is out in the corridor of the ward, talking around withnursing staff and other patients. Jack, the nurse, asks Aron ifhe has got information about brushing teeth and suchthings when the blood tests values are going down. ‘No’,Aron answers and looks puzzled. Well, then I will come andgive you information about that and connect your chemo-therapeutic agents infusion. [Berterö ’96; p. 205]

Finding 4 Medical-technical routines [E]Jack, the nurse went into Ceasar’s room. He is going toconnect some thrombocytes. The patient is sleeping. Thenurse checks the patient’s identity by looking at the patient’sbracelet then connects the infusion while talking a little tothe patient’s wife. She is wondering about Ceasar’s centralvein cannula and when they are going to dress it. The nursepromises to check it up and leaves the room. [Berterö ’96; p.205]

Finding 5 Patients demanded conversation [E]. . . I was wondering, are you very busy tonight? . . . I am sokeen to talking today, so I hope that you can come in herelater on and talk to me, and could you talk about somethingelse rather than the disease. . . [Berterö ’96; p. 206]

Finding 6 Honest & correct information [E]And then I had asked one of the consultants about how bigthis dose [chemotherapeutic agents] was. He said it was notso big, it was fairly weak. And then I meet the next physicianand he tells me that ‘it is quite a lot of chemotherapeuticagents you have got now’. . . ‘What do you mean?’ I asked.‘You have to explain this, you are knowledgeable in thismatter’. One says I am treated with fairly weak doses and theother that I am treated with quite heavy stuff. I cannotaccept that. [Berterö ’96; p. 206]

Finding 7 Patients felt safe in the care of competent staff [C]. . . what do I think? Well, it should be well-prepared, sothere should be no problems then; everything should bethere, they [nursing staff and physicians] should know whatthey are doing and so on, I think . . . [Berterö ’96; p. 206]

Finding 8 Nurses lack respect, concern & empathy forpatients [C]. . . they do not have to ask how I want things . . . it iscareless, I think it is careless . . . you feel totally run over . . . Imean, they do not understand what it is like to be a patient,when they do things like this. [Berterö ‘96; p. 206]. . . They are so careless, coming here just doing their job.That is it, they think we are machines, not human beingsthey are working with . . . [Berterö ’96; p. 207]

Finding 9 Patients wanted to participate in their own care [E][I] want to have my central vein cannula dressed, since thetape has been torn and it is letting in water . . . there is a riskof getting infections, which I do not want . . . [Berterö ’96;p. 207]

Finding 10 Doing more [E][The nurse begins to rub powder on radiation area onpatient’s neck.]

Nurse: It’s sore? Is it sore now?Patient: No. It just kind of burns.Nurse: Yeah.Patient: Burns, burns and itchy. [Pause] Oh well. Just twoshots to go.Nurse: Mm hmm. How many, how long has this been?Patient: Thirty-four shots.Nurse: You’ve sure done well.Patient: Yeah. Considering.Nurse: Mm hmm. [She continues to rub powder on patient’sneck and lower face.]Patient: I didn’t think it would be this is bad. I guess maybea lotta people are maybe worse off than I am when it comesto that.Nurse: That’s right. There are. There’s always something,isn’t it? There’s always someone worse off than yourself.Patient: Yeah. Yeah. I’m not gonna complain. I’ve nevercomplained since the day . . .Nurse: I bet you haven’t.Patient: No. [pause] What for?Nurse: Ah, well sometimes it makes you feel good. It makesme feel good sometimes.Patient: Yeah. Well thank you for the opportunity. Thatsounds strange but, that’s OK. [Bottorff ’94; p. 56]

Finding 11 Doing for [E]She [the nurse] talked to you, and she did things foryou . . . not because it was her duty, but because sheenjoyed doing it for you. And it made you feel you’re notimposing on her, you’re not an imposition, and you didn’tmind asking her to do things for you. That’s very important.Because you don’t want to feel like you’re a burden. You feelbad enough being in the hospital without being made tofeel that you are a burden. I know I do because I’ve alwaysbeen able to do things for myself, and it’s pretty hard for meto accept the fact that I had to let go and let people dothings for me. [Bottorff ’94; p. 57]

Finding 12 Doing with [E]They tell you exactly what they’re going to do and whythey’re going to do it . . . It makes you feel so much morecomfortable and confident, that you know everything’sgoing to be all right . . . [If they do not tell you] it makes younervous because . . . you sort of tense up and wonder howmuch it is going to hurt. [Bottorff ’94; p. 58]

Finding 13 Doing tasks [E][The patient is in the hallway on the mobilizer. The nursecomes into room to make sure there is a clear pathway to thebed.]Patient: I hope my lunch won’t be cold.Nurse: We have a microwave.Patient: I’ve been through this quite a few times. Either mybreakfast or my lunch ends up [cold].Nurse: That seems to happen.Patient: Oh yeah.Nurse: Unfortunately . . .Patient: No problem.

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Patient: No problem.[Silence as the nurse slowly moved patient into the roomand then put down the side rails.]Nurse: Now does this foam and everything go . . .Patient: They’re all attached. Yes. Everything goes with me.Quite a bundle.Nurse: Yeah.[Silence as nurse got everything ready for the transfer backto the bed.]Patient: I’m probably due for a breakthrough soon. It’s thatterrible pain in my leg and shoulders.[Silence as the nurse continued to prepare to transfer thepatient. She checked over the controls and then gave thema try. Nothing worked.]Nurse: What am I doing wrong?[Nurse checked over mobiliser, put side rail up and exitedthe room.] [Bottorff ’94; p. 58]

Finding 14 Cognitive avoidance & distancing [E]No, I don’t want to talk about it. I have not even talked tomy daughters. I try to avoid thinking of it. Yes, I do. I don’tknow why . . . I hope everything will turn out well. I try to bestrong; I want to get back to my life – back to my home. Itis not very much the nurses can do, and I don’t want to talkabout it. [Kvåle ’07; p. 323]

Finding 15 Normalization, finding meaning & living in thepresent [E]One of the nurses is making a national costume for herdaughter. She brought the embroidery and showed it to me.We discussed how to do it. That was fun, and later I broughtmy national costume to the ward, and also pictures. Weshared a common interest that had nothing to do with thestupid disease. It was something more in life . . . It is goodwhen the nurses also discuss various interests with thepatients, not only the patients among themselves. It is goodwhen the nurses are together with us. [Kvåle ’07; p. 323]

Finding 16 Support from family, friends & others [E]I have a good social network around me: family, friends,colleagues, neighbours and many sisters and brothers. I alsohave children and I have a husband. My husband is mygreatest psychologist. We know each other best. But hemust get help sometimes. [Kvåle ’07; p. 324]

Finding 17 Urgent informational needs & active infoseeking [E]When I was diagnosed with cancer, all my family membersimmediately began to search for information about thisdisease. This process was arduous, time-consuming, and hadlittle effect because there was so much information and I didnot know what was useful for me. I think if health profes-sionals could give us the most pertinent timely informationrelated to the disease, it would be helpful. [Liu et al. ’05; p.265; Case 11]

Finding 18 Sources of informational support [E]For knowledge regarding the disease, I mainly asked doctorsand read some books. For nursing information, I askednurses when they provided routine care. [Liu et al. ’05; p.265; Case 4]

Finding 19 Characteristics of supportive communication [E]In truth telling, nurses should take into account patients’conditions and respect their relatives’ opinions, then get toknow what they can say and not say. Each patient should bedealt with individually. [Liu et al. ’05; p. 266; Case 15]

Finding 20 Informational support and negative effects fromfellow patients [E]I preferred to talk about my disease with fellow patients whohave suffered from the same disease, because they havegood practical and experiential knowledge. ’Liu et al. ’05; p.266; Case 13]I would not like to communicate with fellow patients withpessimistic thinking, such as those who have no hope andwho suffer from pain and discomfort. [Liu et al. ’05; p. 266;Case 4]

Finding 21 Sources of emotional support [E]When I was diagnosed with cancer, I immediately went tosee my brother rather than my mother (she is older) orfriends, because my brother was the most suitable person tohelp me. For emotional support, I only talk to my wife.Relatives and friends came to see me and brought me somenutritious food. I have good support from them. [Liu et al.’05; p. 266; Case 2]

Finding 22 Reasons for not seeking emotional support fromnurses [E]When I was in a low mood, I thought talking to others wasof no use. I could not find an appropriate person to talkto. As a man, I think I should be self-reliant. [Liu et al. ’05;p. 267; Case 4]

Finding 23 Facilitators [E]Nurse: Mrs D, could you just start by telling me what hasbrought you into hospital today?Patient: Yes, I had to have my breast off about 3 years ago.Nurse: Did you? Could you tell me why you had to have yourbreast off?Patient: Oh, it was cancer.Nurse: You were told it was cancer at the time, were you?Patient: Yes, Mr W told me.Nurse: How did you feel when he told you that?Patient: Honest to God! Smacked, totally smacked.Nurse: How do you mean, smacked? I’m not sure what youmean.Patient: Shocked, but I’ve coped with it OK until this hap-pened.Nurse: And what’s this?Patient: Terrible pain m my back.Nurse: Is that what’s brought you in here today?

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Patient: Yes, I can hardly walk now its got so bad I can’t sleepfor the pain either.Nurse: Oh dear, you have been having a rough time, Mrs D.Can you tell me what you think is causing the pain?Patient: The cancer. It’s come back in my bones and that’swhy he wants to do some X-ray treatment to relieve thepain.Nurse: Mr W has told you it’s in your bones, has he?Patient: Yes, love.Nurse: What do you think about that?Patient: Well, I’m not pleased. I was very upset what he toldme as I realize that I may not get better. But if he can get ridof this pain I shall be so thankful as my grandchildren arecoming from Canada for a holiday and 1 just want to be ableto enjoy their visit and be able to go out for days with them.[Wilkinson ’91; pp. 681–682]

Finding 24 Ignorers [E]Nurse: Right then, I only want to ask you a few questions. Noproblems since we last saw you 3 months ago?Patient: A bit tired.Nurse: A bit tired. No diarrhea or anything, no sickness?Patient: No.Nurse: Have any of your home circumstances changed? Doyou still live at B?Patient: That’s right.Nurse: And your next of kin is still your wife?Patient: Yes.Nurse: Do you know what you have come in for this time?Has it been fully explained?Patient: Yes, things aren’t right so I’m having some chemo-therapy and a blood transfusion.Nurse: Right, OK. Have they told you how long you will bein for?Patient: Until Monday.Nurse: You’re having the treatment at night, are you? Areyou on any tablets?Patient: Yes.Nurse: Have you brought them in with you?Patient: Yes.Nurse: Can I look at them so I can write them down on theform?Patient: Zantac and Prednisolone.Nurse: I’ll take them off you as we normally take in patients’tablets when they come in and we will give them to youfrom our trolley.Patient: Oh, I see.

Nurse: You’ve got your own transport to get home onMonday, I presume?Patient: Yes.Nurse: Right, that’s it then. Apart from feeling tired, you’vebeen feeling alright?Patient: Well, I’ve got tingling sensations in my toes andfinger ends.Nurse: Are you sleeping alright?Patient: I never do.Nurse: Appetite, is that OK?Patient: No, not really. I don’t feel like food.Nurse: Good. Right then, you know what’s going on, don’tyou? Can I put your wrist label on?Patient: I don’t know which wrist you want.Nurse: I’ll have it on this one then? Right, that’s all I need toknow. Thanks.[Wilkinson ’91; pp. 682–683]

Finding 25 Informers [E]Nurse: Has the doctor told you all about the operation?Patient: Yes, he has, love. I’ve got cancer in the lung that he’sgoing to try and get it out if he can but he’s not sure aboutit.Nurse: Well tomorrow morning, before you go to theatre,we will give you an injection to make you nice and relaxedready for going up.Patient: Mmmm.Nurse: You will be m theatre for a couple of hours andprobably an hour in recovery until you are round from theanaesthetic, when we bring you back to the ward.Patient: Mmmm.Nurse: I’m sorry, but it’s best if you know what is going tohappen, the things to expect. Because they go through yourchest, you have a couple of drains in and that’s to take awayany air and blood that collects in your chest. They will stay infor 2 days and you’ll be connected to two glass bottles, likeI say. You’ll have a drip up as well -Patient: Don’t tell me any more, love. You’re making me feelsick. [Wilkinson ’91; p. 683]

Finding 26 Mixers [Not supported]No ‘voice’. (No specific strategy for blocking. Used a mixtureof facilitative and blocking verbal behaviours and appearedto be genuinely trying to assess the patient’s problems andwere usually more aware of the blocking verbal behavioursthey were using than the informers and ignorers were.)[Wilkinson ’91; p. 683]

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Appendix II

JBI Levels of Evidence on recommendations for practice

Level ofEvidence

FeasibilityF (1–4)

AppropriatenessA (1–4)

MeaningfulnessM (1–4)

EffectivenessE (1–4)

1. Meta-synthesis of researchwith unequivocalsynthesised findings

Meta-synthesis of researchwith unequivocalsynthesised findings

Meta-synthesis of researchwith unequivocalsynthesised findings

Meta-analysis (with homogeneity) ofexperimental studies (e.g. RCT withconcealed randomisation) OROne or more large experimentalstudies with narrow confidenceintervals

2. Meta-synthesis of researchwith crediblesynthesised findings

Meta-synthesis of researchwith crediblesynthesised findings

Meta-synthesis of researchwith crediblesynthesised findings

One or more similar RCTs with widerconfidence intervals ORQuasi-experimental studies (withoutrandomisation)

3. a. Meta-synthesis of text/opinion with crediblesynthesised findings

b. One or more singleresearch studies of highquality

a. Meta-synthesis of text/opinion with crediblesynthesised findings

b. One or more singleresearch studies of highquality

a. Meta-synthesis of text/opinion with crediblesynthesised findings

b. One or more singleresearch studies of highquality

a. Cohort studies (with control group)b. Case-controlledc. Observational studies (without

control group)

4. Expert opinion Expert opinion Expert opinion Expert opinion, or physiology benchresearch, or consensus

Taken from the Joanna Briggs Institute – Comprehensive Systematic Review Training Program Manual: Module 4 Systematic review of evidence generated byqualitative research, narrative and text (p. 84). RCT, randomised controlled trial.

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