ISSUES IN CLINICAL NURSING

Nursepatient communication: an exploration of patients experiences

Catherine McCabe
MSc, RGN, BNS, RNT

Lecturer in Nursing, Trinity Centre for Health Sciences, St Jamess Hospital, Dublin, Ireland

Submitted for publication: 20 November 2002 Accepted for publication: 13 May 2003

Correspondence: Catherine McCabe Lecturer in Nursing Trinity Centre for Health Sciences St Jamess Hospital Dublin 8 Ireland E-mail: camccabe@tcd.ie

Journal of Clinical Nursing 13, 4149 Nursepatient communication: an exploration of patients experiences Background. Patient-centred communication is a basic component of nursing and facilitates the development of a positive nurse-patient relationship which, along with other organizational factors, results in the delivery of quality nursing care. Nurses are frequently described in the literature as poor communicators, however, very few studies have examined patients experiences of how nurses communicate. Aims and objectives. The aim of the study was to explore and produce statements relating to patients experiences of how nurses communicate. Design. A qualitative perspective using an hermeneutic phenomenological approach was considered to be the most appropriate methodology for this study. Methods. Using purposeful sampling, eight patients in a general teaching hospital in the Republic of Ireland were interviewed. Data were collected using unstructured interviews. Data analysis was a reective process and the ndings were presented through the description and interpretation of themes and sub-themes. Results. Following data analysis four themes emerged. These were, lack of communication, attending, empathy and friendly nurses. Conclusions. The ndings of this study indicate that, in contrast to the literature that suggests that nurses are not good at communicating with patients, nurses can communicate well with patients when they use a patient-centred approach. However, health care organizations do not appear to value or recognize the importance of nurses using a patient-centred approach when communicating with patients to ensure the delivery of quality patient care. Relevance to clinical practice. The implication of these ndings for clinical practice is that the task-centred approach to patient care that is associated with nursing in the past, appears to be alive and well. If health care management want to ensure that patients receive quality nursing care, they will need to consider patient-centred communication to be essential to encourage and support nurses to communicate in this manner.
McCABE C. (2004)

Key words: communication, empathy, nursepatient communication, patient satisfaction, phenomenology, socialization

Introduction
According to Arnold & Boggs (1995) and Balzer-Riley (1996), communication is a reciprocal process of sending and receiving messages using a mixture of verbal and nonverbal communication skills. However, Sheppard (1993) suggests that, in the nursepatient relationship, communi 2004 Blackwell Publishing Ltd

cation involves more than the transmission of information; it also involves transmitting feelings, recognizing these feelings and letting the patient know that their feelings have been recognized. Peplau (1988), Severston (1990), Fosbinder (1994), Wilkinson (1999), Attree (2001) and Thorsteinsson (2002) support this view and indicate that communication is a fundamental part of nursing and that
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the development of a positive nursepatient relationship is essential for the delivery of quality nursing care. However, Crotty (1985), Reid (1985) and Hodges et al. (1986) also highlight that nurses do not communicate well with patients and approach patients only to deal with administrative or functional activities. Morse (1991), Bergen (1992), HaggmanLaitila & Astedt-Kurki (1994), Jarman (1995), Hostutler et al. (1999) and Jarrett & Payne (2000) suggest that this is because nurses are not aware of the meaning and signicance of the nursepatient relationship for patients. This lack of awareness by nurses results in them making assumptions about what nursing care a patient needs or wants because they do not ask patients (Bergen, 1992; Booth et al., 1996). This type of communication is not patient-centered and can adversely affect the development of a positive nursepatient relationship that is essential for the provision of quality patient care. Patient-centred communication is dened by Langewitz et al. (1998, p. 230) as communication that invites and encourages the patient to participate and negotiate in decision-making regarding their own care.

Literature review
In order to investigate trained nurses self-perception of their communication skills, Burnard & Morrison (1988, 1989, 1991) conducted studies using Herons six-category intervention analysis. The ndings of these studies were consistent, in that the participants generally perceived themselves to be more skilful in the authoritative than facilitative categories. The authoritative interventions attempt to direct or control patient behaviour while the facilitative interventions attempt to empower the patient. Burnard & Morrison (1988, 1989, 1991) propose that the ndings of their studies be used as a basis for planning and developing education programmes for training and research into nurses interpersonal communication skills. However, the ndings of these studies are limited by the use of Herons framework because it does not take account of how contextual differences inuence which intervention is used by nurses and it is impossible to know to what degree nurses focused on their intentions or actual behaviour in nursepatient interactions. Therefore, the relevance of the ndings for changing or developing nurses interpersonal communication skills can only be viewed tentatively. Ashmore & Banks (1997) concur with this view and recommend that further exploration of patients perceptions of nurses communication skills be conducted. If, as Briggs (1982), Macleod Clark (1985), Severston (1990), Fosbinder (1994) and Oermann et al. (2000) suggest, good communication is essential for quality nursing care, then it is
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imperative that nursing research elicits patients experiences of nursepatient communication and identies what they value most in their interactions with nurses (HaggmanLaitila & Astedt-Kurki, 1994). Such information can inform nursing theory and education and, therefore, allow nurses to develop patient-centred communication skills that are fundamental to the delivery of quality nursing care. Another view presented by Menzies (1960, 1970), Burton (1985), McMahon (1990), Telford (1992) and Chant et al. (2002) suggests that nurses do not communicate well because of the organizational culture. Traditionally nurses were not encouraged or supported by ward or hospital management to establish therapeutic relationships with patients. According to Menzies (1960, 1970) the reason for this is to protect nurses from difcult emotional situations, thereby preventing stress. Studies by Wilkinson (1991) and McColl et al. (1996) conducted 25 years later concur with this. They found that nurses have the necessary skills to communicate well with patients but choose not to because of the lack of organizational support and encouragement. It appears that, over the last 40 years, this organizational strategy to prevent stress has resulted in a socialization process that has perpetuated the notion in nursing that patient-centred communication should be discouraged and is unsupported by management (Wilkinson, 1991; Graham, 1994; Cody, 1998; Williams, 1998). Bowles et al. (2001) supports this view and adds that criticism of nurses communication may be unrealistic as no benchmark for effective nursepatient communication currently exists. However, in order to establish a benchmark for effective nursepatient communication it is essential to discover patients experiences and views.

Design and method

The purpose of this study was to explore and produce statements relating to patients experiences of how nurses communicate with them. A qualitative perspective using a Heideggarian/Gadamarian hermeneutic phenomenological approach was chosen for this study because it is concerned with reaching a new understanding of the meaning of the phenomenon (nursepatient communication) being studied as experienced by the participants (LoBiondo-Wood & Haber, 1998). The site chosen for this study was a general hospital in the Republic of Ireland and ethical approval was granted by the Hospitals ethics committee.

Sampling
Using purposeful sampling, eight patients agreed to participate in the study. Purposeful sampling is where the

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participants are selected prior to the study on the basis that they have experience of the phenomenon being studied and can articulate this experience (Holloway & Wheeler, 1996; Mays & Pope, 1996). Each participant provided written consent and chose a pseudonym that was the only identication used on any documentation related to the study, thus ensuring their anonymity. The participants included three males and ve females whose ages ranged from the mid-20s to early 70s and who had been inpatients for a minimum of 4 days. This meant that each participant would have communicated regularly with nurses during their stay.

Data collection
Data were collected using unstructured interviews that were tape recorded and lasted 30 minutes on average. Each interview began with me asking the participant to tell me about his/her experiences of how nurses communicated with her/him during their time as an inpatient. The participants were asked to clarify and elaborate on certain issues as this helped the researcher to understand the meaning of the experience of how nurses communicated for individual patients. At some stage during most of the interviews the participants talked about issues unrelated to nursepatient communication. Holloway & Wheeler (1996) refer to this as dross and say that unstructured interviews will always contain a certain amount of irrelevant material. In order to re-focus the participants during interviews I asked the same question If you had to describe the qualities required to be a good communicator, what would you say they were? This was sufcient to re-focus the direction of the interview.

essential for demonstrating trustworthiness. These factors are: credibility, ttingness, auditability and conrmability. The credibility of this study was achieved by including an interview transcript and a thick description of one of the themes in the nal report. As no personal information was recorded during the interviews, all audiotapes used to record the interviews have been retained by the researcher as a record of data authenticity. Fittingness occurs when the ndings of a study t into similar contexts outside the study. The literature used to discuss the ndings demonstrates its ttingness. Auditability of this study was achieved by recording details explaining and justifying any decisions made regarding the study in a reective journal and incorporating this information into the nal report as a decision trail. The conrmability of this study arises from its credibility, ttingness and auditability (Sandelowski, 1986).

Findings
Four main themes relating to aspects of nurses communication emerged from the data analysis.

Theme 1 lack of communication

The participants in this study frequently referred to how nurses did not provide enough information and many commented on how nurses were more concerned with tasks than with talking to them. However, all the participants said that it was not the nurses fault as they were too busy. This theme will be discussed under two sub-themes, patientcentred communication and task-centred communication. Patient-centred communication Patients in this study were reassured when the nurses used a personal approach when communicating with them:
shed say how are you today John?its things like that that help to cheer you up, particularly when youre in hospital. (Mr Clinton)

Data analysis
The aim of data analysis in phenomenological research is to reveal the meaning of the lived experience of the phenomenon being studied for the participants. According to Bergum (1991) and Ray (1994) data analysis in hermeneutic phenomenological research is a reective process. Data analysis in this study was a reective process using the metaphor of the hermeneutic circle to explain the dynamic nature of gaining an understanding of a phenomenon (Annells, 1996) and reference to Gadamers fusion of horizons to explain how the researcher came to a new understanding of the meaning for patients of nursepatient communication. This is presented through the description and interpretation of themes and sub-themes. In order to demonstrate trustworthiness in this study Sandelowskis (1986) framework was used. This framework comprises four factors that are

Some of the participants felt that nurses did not communicate in a patient-centred way because they made assumptions about their concerns and needs. This view is supported by the literature (Bergen, 1992; Booth et al., 1996; Nordgren & Fridlund, 2001):
Yea they (the nurses) were all nice it was just one nurse taking it into her own hand like changing your medicationnot changing it like but giving it when she thought I think she thought she was able to tell me me body . (Jane)

This participant goes on to describe how important it is for nurses to talk to them as individuals:
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C. McCabe Yea, like if shed had have said to me do you feel that you need them now? It doesnt matter how you lookyou could say either yea or no. (Jane)

Theme 2 attending
Attending behaviour is described as the physical demonstration of nurses accessibility and readiness to listen to patients through the use of non-verbal communication (Stein-Parbury, 1993). Attending is a patient-centred process and the basic conditions required on the part of the nurse for attending to occur are genuineness, warmth and empathy (Burnard, 1990; Stein-Parbury, 1993). Although considered an attending behaviour, empathy emerged from this study as a main theme, therefore, is not discussed in relation to attending. Although the participants of this study did not refer directly to the term attending, they described nursing behaviours they valued which are specic to attending. These behaviours will be discussed as the subthemes, giving time and being there, open/honest communication and genuineness. Giving time and being there According to Pontin & Webb (1996) this incorporates giving attention and showing concern for patients:
They (the nurses) always found some time to talk with you and you felt happy when they were gone and theyd come back again, even on their busiest days (Sophie)

Task-centred communication Many of the participants identied how nurses were more concerned with doing their work than communicating with them personally:
especially after nine in the morning and theyre coming around, em, after your breakfast and theyre rushing the beds. You know I heard one woman saying, Oh you might have let me drink me cup of tea. (Mrs Brown)

Patients did not blame nurses for having a task-centred approach. However, this approach resulted in patients feeling that the tasks were more important than they were. Consequently, they did not like to bother the busy nurse:
Every few minutes theyd come in the only time theyd sit down was when they were taking your blood pressuretheyd sit there for a few minutes and then move on to the next patient. (Charlie)

When asked if the nurses spoke to him when they sat down, Charlie said, very little and then added:
I think thats the slackest part but as I said, they cant be sitting down talking with patients Id say theyd be neglecting their own work then (Charlie)

A possible impact of nurses using a task-centred approach when communicating with patients is that patients view nurses as workers not professionals. When asked if he received information about his condition from nurses, Charlie replied:
Oh well theyd never tell you that, I suppose bar you ask them, but Id always wait until the Doctors came around. (Charlie)

This results in patients feeling that nurses are regularly monitoring their physical condition and also their psychological and emotional well being (Pontin & Webb, 1996):
theyd (nurses) call you by your name theyd comment, theyd talk to you even if the ward was busy. (Claire)

Another participant excused nurses lack of communication by implying that it was out of their control:
you cannot expect nurses to hold a conversation with you when they see consultants coming along. (Sophie)

Benner (1984) suggests that expert or senior nurses have the self-esteem and condence to recognize the value of their time and presence for their patients. However, participants in this study suggest that senior nurses did not demonstrate this because although they had the skills, they were too busy:
the more senior nurse would come and shed be good but she had a lot of responsibilityit wouldnt be as easy for her as the others she had the ward round consultants coming and going (Sophie): the students, they were very understanding and you could actually talk to them which was lovely. If there was something worrying you, you could actually say it (Jane)

Nurses were seen by these two participants as a disempowered and subservient group of people who carried out the orders of consultants. Crowe (2000) supports this and suggests that a task-centred approach to care ensures the standardization and predictability of the nurses performance in the nursepatient relationship and is another possible reason why it is supported by organizational management. The result is that the nursepatient relationship is devalued by nurses in favour of a task-centred approach to patient care.
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A possible reason why student nurses give patients more time and allow them to talk to them is that they have not yet been fully socialized into communicating in a task-centred way or because of their lack of expertise there are not as many demands made on their time.

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Nursepatient communication There was one particular girl, she was lovely every morning shed come in and ask how you were or if she was going by shed wave in to you. (Jane)

Open/honest communication According to McCann & Baker (2001), open and honest communication helps patients to deal positively with their illness. The participants of this study valued open/honest communication from nurses and relied on nurses to use language that they could understand:
I think no matter how small or how big a persons diagnosis is, it should be explained from day oneI think from when doctors come around they dont actually convey a lot of information and it is left probably to the nursesId prefer if someone calm said would you like to know? and to be honest and frank (Claire)

Participants were able to differentiate quite precisely what aspect of a nurses non-verbal behaviour was unhelpful:
I wouldnt say it was their body language but their tone was like, em, I like to be the boss the little authority (Jane)

Theme 3 empathy
Although the participants in this study did not refer directly to the term empathy they referred frequently to many of the behaviours that according to Morse et al. (1992) form the basis of empathetic communication. Empathetic communication is described as communication that emphasies the process of emotional engagement of the nurse with the patient (Morse et al., 1992).
I liked them all, but there was one little girl, she was slightly different sympathetic I would say. I think the patient deserves sympathy when they are hospitalised, their complaint may not warrant sympathy but theyre away from their own environment (Sophie)

One participant described the reaction from the nurse when she requested analgesia:
then one of them (staff nurses) would mutter to the other like they cant understand how Im getting two drugs together They actually told me they were too strong. I dont care I said, theyre making my pain go away and they were doing nothing to me like making me dizzy or anything. (Jane)

When asked how she felt when the nurses communicated like this, Jane replied:
I felt I could trust her all rightit was in my interest that she was looking at itbut she had no kind of experience with meI was kinda getting a bit frightened (Jane)

This comment suggests that when nurses use this nonpatient-centred type of communication, it can have a negative effect on a patients sense of well-being and security. Genuineness Egan (1994), p. 55) says that genuineness is beyond professionalism and phoniness. It is an attitude and behaviour that can only be expressed if the nurse is self-aware (Burnard, 1990; Stein-Parbury, 1993). Participants in this study referred to both the nurses verbal and non-verbal communication when identifying genuine behaviours although non-verbal behaviours predominantly inuenced when patients perceived a nurse as genuine or not:
she just had a way about herits hard to put your nger on it but she was jolly and I wont say devil may care but once you were all right, that was everything (Mr Clinton)

According to Morse et al. (1992) sympathy is a rst-level empathetic response and is a verbal and non-verbal expression of the nurses own sorrow or dismay at the patients situation. When nurses were sympathetic, the participants in this study felt that their feelings were justied and made them feel like the nurses understood their situation and cared about them as a person. It seemed important to the participants that nurses communicate their recognition and understanding of the patients situation. They did not expect the nurse to be able to x everything, but it alleviated their anxiety and uncertain feelings when they knew that someone understood how they were feeling:
During the night when I couldnt sleep, one (nurse) came over because she noticed that I was still awake, to see if I was OK that stuck in my mind She knew that I was tired and that I wanted to try and sleep but just couldnt so she came over (Mary Ann)

The participants trusted nurses who empathized with them and were able to identify specic nursing behaviours that demonstrated empathetic communication:
I think the reassurance from the nurse with me at the time of my diagnosis she made me feel at ease straight awayShe just organised everything and was really relaxed and wasnt watching her watch to see was she running late she was just awfully concerned and at the same time, very professional. She added the human touch, like as if she knew what it was like in my shoes (Claire)

The participants valued non-verbal communication as an indicator of genuineness because it demonstrated emotional support, understanding and respect for them as individuals (Bottorff et al., 1995). Many of the participants in this study formed special relationships with the nurses that they perceived to be most genuine:

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Morse et al. (1992) describe this communication as second level empathetic communication response. The nurse has communicated her understanding of Claires predicament and is reassuring Claire by sharing her self. This type of empathy is considered to be patient-focused and results in patients feeling secure and reassured (Morse et al., 1992). This participant also described her experience of nonempathetic communication from nurses which made her feel frustrated and uncared for:
I didnt have a shower for the rst two days at allit just would have taken somebody sensitive enough to understandI mean you can imagine what you feel like when you cant even wash yourself. (Claire)

Theme 4 friendly nurses and humour

All the participants in this study commented on how friendly and happy the nurses were:
I found them absolutely wonderfulthey were good crack and very friendly, made you feel at home (Mrs Brown)

Many of the participants in this study also expressed an appreciation of humour in nursepatient interaction:
when theyre coming around with the medicines, they are laughing and joking with everyone on the wardId have a great joke with them (Mrs Brown)

In this study, humour appeared to improve the participants self-esteem when they could make others laugh and when they could laugh with the nurses. It seemed that the nurses who used humour appeared more approachable to the participants:
Theyd (staff nurses) have a laugh and a joke with youthats what impressed me an awful lot about them. They were very friendly, very nice, you could have a good talk, you could even have a joke on themtheyd know when youd be doing a bit of slagging. (Mr Kelly)

Discussion
Lack of communication was the theme referred to most frequently by the participants in this study. They commented on how nurses were more concerned with completing their tasks than talking to them. Some of the participants were frustrated by this and felt that the nurses did not care about them as individuals. Other participants acknowledged that nurses were more concerned with their work and accepted this as being normal, although they did indicate that they would have liked to be treated as an individual. However, regardless of how the participants felt about how nurses
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communicated, they did not blame them. They all attributed the nurses poor communication skills to them being too busy. Pontin & Webb (1995) and Attree (2001) suggest that patients are reluctant openly to criticize nurses because of a fear of retribution or the passive nature of the patient role or acceptance of the national health care delivery. They propose that instead patients wrap up their criticisms in socially acceptable responses (Pontin & Webb, 1995). This type of communication is particularly evident in the responses from the participants in this study. However, it remains very clear from the participants responses that nurses do not always communicate in a patient-centred way. According to Sines (1995) patients become empowered by a patient-centred approach to communication. It allows them to be a partner in making decisions about their own needs rather than the nurses making assumptions about what their needs are (Sines, 1995). Patient-centred communication does not take up more of the nurses time or require extra resources (Astedt-Kurki & Haggman-Laitila, 1992; Williams, 1998), it is initiated by nurses in the words and body language that they choose to use when approaching patients. A possible reason why nurses do not always communicate in a patient-centred way is that although they have the necessary communication skills, they choose to use taskcentred communication as a protection mechanism against emotional or advocacy aspects of their work (Sines, 1995; Kruijver et al., 2001). This could be because they feel unsupported or even discouraged from communicating in a patient-centred way by management (McMahon, 1990; Wilkinson, 1991; Telford, 1992). The second theme that emerged from the data was attending. When the participants experienced some or all of these behaviours they felt reassured, safe and cared for as an individual. Attending behaviours as experienced or valued by the participants in this study do not require extra time or resources. Knowing that they can trust the nurses to be open/ honest, understanding and be available if they needed them was the level of commitment required by the participants. However, the effective use of attending behaviours by nurses requires that they value patient-centred communication (Arnold & Boggs, 1995) and have a strong sense of selfawareness (Burnard, 1990). The third theme that emerged from the data is empathy. Empathy is dened by Reynolds & Scott (2000), p. 226) as:
the ability to perceive and reason as well as the ability to communicate understanding of the other persons feelings and their attached meanings

Reynolds & Scott (2000) describe empathy as an essential prerequisite for good nursing practice. If nurses fail to

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empathize with their patients, then they cannot help them to understand or cope effectively as individuals with their illness (Morse et al., 1992; Peplau, 1997; Reynolds & Scott, 2000). Most of the participants had positive experiences of empathetic communication by nurses. However, one participant also experienced non-empathetic communication. This made her feel unhappy, uncomfortable and uncared for. Although the issues that she refers to are physical needs, it is important to note that, by not meeting the participants physical needs, the nurses were failing to communicate to her that they understood her predicament or needs. This supports the view that empathetic communication is an essential prerequisite for the delivery of quality nursing care. Because of the positive inuence that empathetic communication and the negative inuence non-empathetic communication has on patients, it is essential that nurses are aware of the impact of the way they choose to communicate has on their patients. The implications are that nurses who chose to use nonempathetic communication favour task-centred rather than patient-centred communication. According to Gould (1990) the professional socialization of nurses encourages them to lose their individuality and lose the natural ability to empathize. This concurs with the literature (Menzies, 1960, 1970; Burton, 1985; McMahon, 1990; Telford, 1992; Graham, 1994; McColl et al., 1996) which suggests that the professional socialization of nurses results in task-centred communication rather than patient-centred communication. The fourth theme that emerged from the data referred to friendly nurses. All of the participants in the study praised the nurses for being friendly, chatty and humorous. This fullled an important social function by relaxing the participants, passing the time and helping them to forget their troubles. A possible reason why all the nurses used humour and were friendly and chatty was that they perceived it as a supercial level of communication that creates an atmosphere that although relaxed and sociable, is unsuitable for dealing with emotional or difcult issues. The nurses, therefore, felt relatively safe communicating this way with all the participants. In contrast, although they can be supercial, social interactions give patients the opportunity to step out of their sick role and according to Sumners (1990) and Astedt-Kurki (2001) humour in the nursepatient relationship helps to establish rapport and trust, relieves anxiety and tension and conveys unspoken emotional messages. This is evident from the ndings of this study. The participants appeared to value highly the informal humorous exchanges with the nurses. This type of communication can help to pass the time and deect from mundane, routine hospital life and patients are frequently instrumental in creating such interactions (Holloway et al., 1998; Jarrett & Payne, 2000).

Implications
The participants in this study indicate that nurses do not always communicate in a patient-centred way even when they have the ability to do so and that nursepatient interaction is heavily inuenced by the work and culture of the organization (Jarrett & Payne, 2000). However, the literature (Peplau, 1988; Severston, 1990; Fosbinder, 1994; Redfern & Norman, 1999; Thorsteinsson, 2002) suggests that a positive nurse patient relationship is essential for quality nursing care and that this can only be achieved through patient-centred communication. The implications of this are that, if health care management want to ensure that patients receive quality nursing care, they will need to consider positive nursepatient communication as essential and not an optional extra (Attree, 2001; Chant et al., 2002). Spending long periods of time with patients does not always result in a positive nursepatient relationship. Astedt-Kurki & Haggman-Laitila (1992) suggest that patient-centred communication does not require additional resources. This implies that staff shortages or being too busy cannot be used as an excuse for poor nurse patient communication. It is the quality of the interaction that determines whether the relationship is a positive one or not and it is the nurse who has the greatest inuence on whether this happens (Milne & McWilliam, 1996). Commitment to providing patient-centred care and a change in individual, professional and organizational values is sufcient (Attree, 2001) in order to result in the delivery of high quality nursing care. At an undergraduate and postgraduate level, education relating to patient-centred communication should focus on illustrating that this type of communication does not require a great deal of time. Role-play and the use of critical incidences is an ideal way of helping students and staff nurses to critically reect on how they communicate with patients (Quinn, 1995). This would also help to develop their sense of self-awareness and subsequently increase their ability to communicate using attending and empathetic communication behaviours. The consequence of this in conjunction with other organizational factors is the delivery of high quality nursing care. This type of teaching strategy would require small group teaching and this has implications for how large undergraduate groups of students are organized for the effective use of such strategies. The ndings of this study and similar patient-focused studies could, however, be used to inform even large groups of nursing students about what patients value about nursepatient communication. There is a need to conduct further research that explores patients experiences of how nurses communicate rather than conducting studies that examine nurses views of what they
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perceive good nursepatient communication to be. Patient focused studies may identify specic nursing behaviours that patients value highly in terms of patient-centred communication. This kind of information would allow nurses to demonstrate and develop specic interpersonal skills that are patient-centred. A possible limitation to this study is that the small number of participants means that the ndings cannot be generalized to a wider context or population, however, the ndings are useful in that they can be used to inform undergraduate and postgraduate nursing students about the possible impact of their communication behaviour on the delivery of quality nursing care.

Conclusion
The ndings of this study indicate that in contrast to the literature that suggests that nurses are not good at communicating with patients, nurses can communicate well with patients when they use a patient-centred approach. However, health care organizations do not appear to value or recognize the importance of nurses using a patient-centred approach when communicating with patients to ensure the delivery of quality patient care. Another reason why nurses may not communicate in a patient-centred way is that they do not know what patients value about nursepatient interactions. This lack of evidence also limits the way in which nurses are educated in relation to how to communicate in a patientcentred way. Unless health care organizations and nurses recognize the importance of communicating in a patientcentred way in order to deliver good quality care, the taskcentred approach to patient care as experienced by the participants in this study will continue.

Contributions
Study design: CM; data analysis: CM; manuscript preparation: CM.

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