Task Focused and Patient Centered Communication Behaviors


Nurses are entrenched in a complex system of clinical relationships some of which include nurse-nurse, nurse-patient and nurse-physician. Communication forms the basis for these relationships and it depends on the nurse’s ability in listening, assimilating, interpreting, discriminating, gathering and sharing of information within dynamic systems comprising of various disciplines and hierarchies (Anderson & Mangino, 2006). Communication is complex, encompassing skill, emotion, cognition and value. Formulation and implementation of daily care plans is among the most vital patient related communications. These activities call for shared responsibility in order to enhance clear, concise, relevant and timely exchange of patient information across disciplines usually in chaotic environments. Lack of effective communication between patients, families and the healthcare team is one of the leading causes of medical errors. It also accounts for over 60% of sentinel event causes reported to The Joint Commission on accreditation of healthcare organizations since 1995 (Manning, 2006).

Relationships provide a foundation for building communication. Relationships change over time and vary between and among nurses as well as other members of the healthcare team. It is quite difficult to develop and nurture clinical relationships in dynamic healthcare environments because there is less opportunity. For instance, an initial encounter with a nurse may occur when there is a need to contact an unfamiliar physician to offer assistance in an emerging critical event. It is not easy to trust unknown colleagues on judgment, decision-making and clinical knowledge (Walrath et al., 2006). The patterns of communication are highly variable. The factors that influence these communication factors consist of individual style differences, education, gender, previous experiences, perspectives, culture, fatigue, stress, social structures and established hierarchies. Environments for clinical care are often noisy, hectic and full of interruptions especially in common places (Miller, 2006). Conversation avoidance devices like personal digital assistants, audiotape players, text pagers and cell phones interfere with the ability of nurses to listen to other people. It is, therefore, worth noting that the complexity of clinical communication increases the chances of communication failure and hence results into inadvertent patient harm (Corless et al., 2009). However, adoption of certain standardized approaches and tools can provide solutions to the improvement of clinical communication, which in turn prevents medical errors (Manning, 2006). This paper will focus on what other people have written regarding the task focused and patient centered communication behaviors in the nursing field, particularly within the context of the United States.

Quality and Safety in Nursing Education (QSEN)

The issues of safety and quality identified in the healthcare system of the United States have led to a call to modify healthcare education, to prepare graduates to work in teams and within healthcare systems that encourage patient safety. The funding by the Robert Wood Johnson Foundation enabled the American Association of Colleges of Nurses and a National Nursing Advisory Board to create six nursing competencies for Quality and Safety Education for Nurses (QSEN). This include patient-centered care, evidence based practice, teamwork and collaboration, quality improvement, safety, and informatics. The competences presented a systematic pedagogical structure for redesigning of course content in order to prepare nursing students to uphold safety and quality while caring for patients. The course redesigning integrated various active learning modalities including simulation, which is ideal for implementing QSEN due to its multiple levels of skills, knowledge and attitudes that are possible to practice and evaluate in each competency (Brady, 2011).

The National Organization of Nurse Practitioner Faculties (NONPF) issues documents that outline the anticipated competencies for nurse practitioner practice to make sure that every nurse practitioner is ready for delivery of safe and high quality healthcare. There are frequent assumptions that quality and safety, in resemblance to patient-centered healthcare, are central to nursing teaching and practice. Conversely, new insights on safety and quality of patients are now on the forefront via the national commission secretaries highlighting the magnitude of this problem in the present healthcare system (Walsh, Jairath, Paterson, & Grandjea, 2010). The Institute of Medicine challenged nursing and medicine faculties to embark on upon educational experiences to ensure adequate preparation of all graduates at all levels for the delivery of patient-centered care with a greater emphasis on evidence-based practice, informatics and quality improvement (Pohl et al., 2009).

Many national commissions have documented substantial problems associated with quality and safety in the healthcare system of the United States. The conclusion from reports of multiple national committees is that providers ought to possess a set of competencies that are different from those developed in the existing educational programs (Day & Smith, 2007). Health professionals that use scientific evidence have to describe the constituents of good care, identify and if possible, close loopholes in good care, and be acquainted with the activities they can initiate. Ideas, execution and will are necessary to incorporate the mentioned competencies in nursing education. Nursing has no agreed competencies that apply to all nurses. On the contrary, medicine has IOM competencies in place (Cronenwett et al., 2007) comprising of patient-centered care, teamwork, evidence based practice and collaboration, quality improvement and informatics (National League for Nursing, 2008). Nevertheless, an incredible historical will to guarantee safety and quality for patients lies at the centre of nursing. This is evident in nursing publications, accreditation guidelines and standards of practice. The American Association of Colleges of Nursing Task Force on the Essential Patient Safety Competencies for Professional Nursing Care, lately completed an improvement to the Essentials of Baccalaureate education for Professional Nursing Practice to incorporate exemplars of safety and quality competencies. The only challenge to this initiative is the lack of teaching materials, teaching strategies as well as the learning assessment techniques with the exception of schools claiming to execute comprehensive safety and quality curriculum (Cronenwett et al., 2007).

The settings of healthcare delivery are redesigning in response to staggering reports regarding to severe safety and quality issues. Emerging perceptions of safety and quality and other related competencies for practice necessitates redesigning of nursing education programs (Day & Smith, 2007). Nurses are the key players in transforming quality and safety in healthcare. New expectations and roles for nurses call for urgent transformation of the nursing curricula and fresh competencies for graduates in order to match patient care needs and practice setting. Nurse educators and nurse executives are required to address the need to develop faculties via strategic partnerships. In order to achieve this vision, practice settings are preparing personnel through investments in education in the effort to attain a new safety and quality culture (Smith, Cronenwett, & Sherwood, 2007). The major target of health professions education should be development of knowledge, skills and attitudes (KSAs) suitable to safety and quality competencies (Sherwood & Drenkard, 2007). Communication behaviors play a primary role in the implementation of the six QSEN competencies for nursing. The following sections discuss the six QSEN competencies for nursing consisting of: patient-centered care, safety, quality improvement, teamwork and collaboration, evidence based practice and informatics.

Patient-centered care promotes active involvement of patients in their own care, thus improving quality and safety by incorporating the patient and family as vigilant partners. Many delivery settings practice patient-centered care by having visiting hours and information transparency to ensure patient and family needs are considered. Faculty and students get exposure to variations in the way clinicians establish partnerships with patients and families. Model units can also help students to develop and apply their skills in clinical environments. Clinicians should design patient education that correspond to cultural health beliefs, deliver care to different families and integrate patient preferences in care plans (Sherwood & Drenkard, 2007).

Teamwork and collaboration skills are necessary for the delivery of healthcare that is coordinated across interdisciplinary settings, teams and timeframes. Education on communication focuses on the development of empathy and the ability to educate and assess patients and families. Communication competencies ought to emphasize on skills in conflict resolution as well as the ability to conduct critical conversations across care teams, including effective use of management strategies in partnership with nursing and inter-professional colleagues. Effective communication within teams is a fundamental aspect of a positive nursing working environment. The protected learning environment for student nurses may limit the opportunity of practicing teamwork skills in the educational experiences. Poor working relations and inadequate communication are often the root causes of safety and near miss events. Nurses need to graduate with skills in team communication to assist in environments where errors occur (Sherwood & Drenkard, 2007).

The third QSEN competency for nursing is the evidence-based practice. Safe and high quality healthcare call for knowledgeable workers practicing from a scientific evidence framework. Nurses encounter fast expanding evidence in all nursing areas including decision-making. Care protocols and standards should originate from scientific evidence (Sherwood & Drenkard, 2007). Furthermore, learning experiences need to motivate students to work from an inquiry spirit where there is constant examination of actions in view of new evidence. Staff can train students on when it is appropriate to deviate from evidence in order to honor the patient’s references (Day & Smith, 2007).

Quality improvement is another important competency in QSEN. The extent to which healthcare services increase the possibility of accomplishing desired health outcomes consistent with the current knowledge determines the quality of care. The permeation of quality initiatives in healthcare has demanded a lot of time from chief nurse executives. Nonetheless, continuous improvement of quality in hospitals attributes to recognition of nursing excellence. The methods and outcomes of quality improvement in student and faculty experiences may be limited to assessment and compliance to care guidelines in particular settings. Innovative practice-academic partnerships can help improve competencies for outcome and quality improvement. Faculty can improve the quality by dealing with practice problems in their specialties and using the experience to establish case studies for students. In addition, faculty can encourage question formation and literature searches to help students gain knowledge of terminology in quality improvement (Sherwood & Drenkard, 2007).

Regarding safety, building a safer healthcare system is designing care processes that prevent or minimize harm. It is the right of patients to be assured of reliable and safe treatment plan implementation to accomplish optimal outcomes. Safety science deals with knowledge of teamwork, quality measurement, use of information and information technology and communications of errors with patients. Poor working relations and communication failures are the primary causes of untoward events in healthcare. Students can practice team communication, function in interdisciplinary teams and learn safety terminology like “do not use”. Clinicians can assist students in safety data collection, analysis and benchmarking against national standards. Both faculty and clinicians can develop problem-based learning tools and case studies associated with safety competencies for staff and across all health professions students (Sherwood & Drenkard, 2007).

Competency informatics enables nurses to seek and assess information source, use electronic systems and provides skills for navigating computer systems to support decisions and flag errors. There is an increase in the use of electronic information by patients and this necessitates nurses to have knowledge concerning their evaluation and application. Faculty should work with partners to help students learn about navigation of electronic health record and evaluation of technology potentiality to cause or mitigate error (Sherwood & Drenkard, 2007). New learning approaches that rely greatly on simulation laboratories is helpful in developing informatics competence among students (Day & Smith, 2007). Some schools and practice partners are working with vendors who supply a variety of electronic systems or manikins to help students develop informatics as well as other QSEN competencies (Sherwood & Drenkard, 2007).

Patient Centered Communication Behaviors

     Patient-centered communication (PCC) refers to a group of communication behaviors and strategies, which enhance mutuality, shared understandings and consequently shared decision making in day-to-day encounters of healthcare (Brown, 1999). It enables the patients to influence and participate in their healthcare. PCC is the root of patient-centered healthcare (Stein-Parbury, 2009). Patient-centered healthcare involves the provision of care that respects and responses to patient’s needs, preferences, and values while ensuring the guidance of patient values in all clinical decisions (Brown, 1999). A patient-centered approach to healthcare shifts the focus of nurses from a task orientation to patient-centeredness where the values and needs of patients are considered. Patient-centered care makes communication and relationship with patients the basis for nursing practice (McCarthy, O’donovan, & Twomey, 2008). A recent research study into experiences of patients with nurses’ communication indicates that nurses focus more on task, as opposed to communicating with patients. This shows that not much has changed towards embracing the patient-centered approach and perhaps most healthcare institutions still lack practices and systems that present the core values of patient-centered care (Stein-Parbury, 2009).

     The Institute of Medicine identified patient-centeredness as one of the key aims in the carrying out the project of restructuring the American healthcare (Institute of Medicine, 2001). There is evidence indicating the use of certain patient-centered strategies by advanced nurses and patients in clinical practice to co-produce clinical discourse that are highly individualized (Brown, 1999). A study was conducted at a big children’s hospital in order to determine the extent to which PCC affects satisfaction with both communication and care. The study required parents of child patients to report on the communication practices of nurses, physicians and other hospital team members during their latest stay in the hospital. The results of the study linked the use of PCC behaviors, particularly immediacy and perceived listening to the satisfaction with communication and care. Additionally, the study indicated a frequent use of PCC behaviors with children in better health than those on poorer health status. Generally, a few people enjoy receiving healthcare because they often get distressed whenever they visit physicians. Patient anxiety may result from lack of supportive and patient-oriented communication behaviors among the healthcare providers (Wanzer, Booth-Butterfield, & Gruber, 2004).

     Many government policies and initiatives have promoted service-user involvement and patient-centered communication as basic concepts in the delivery of high-quality healthcare. The World Health Organization (WHO) also encourages these initiatives by incorporating indicators of health services responsiveness, which is a combination of health system effectiveness and patient satisfaction, in its World Health Reports (Jones, 2007). For instance, some major policy programs have recently resolved to focus on patient-centered communication importance between patients and health professionals in delivering initiatives like shared decision-making (Institute of Medicine, 2001). In addition, various nursing literature have reflected and supported these initiatives. The assimilation of these concepts in both literature and health policy to enhance nursing practices raises questions as to what constitutes suitable and effective clinical communication. This scenario calls for more research concerning nurse communication practices as they transpire in clinical practice (Jones, 2007).

     Among the limitations of research on nurse-patient interaction, is the lack of work that sufficiently explores communication styles in natural clinically based conversations between patients and nurses rather than collecting research data from focus group discussion and staged interviews with nurses or interactions between nurses and the patients’ family members. Aled Jones from School of Health Science, Swansea University, United Kingdom, collected and analyzed research data from student-patient interactions in order to gain some insights into the present interaction practices between student nurses and patients. At the end of the study, he concluded that students experience difficulty in applying the principles of effective communication learnt from the classroom into their individual interactions with patients (Jones, 2007).

     According to Amy Wilson-Stronks, the health disparities project director-Division of Quality Measurement and Research, New York, the patient centered communication standards produced by The Joint Commission (TJC) will go a long way in supporting the work being undertaken by Patient Education Managers (PEMs). PEMs have been advocating for writing of patient materials using clear language and communication techniques that enable patients to understand their respective medical conditions, treatment options and how they would comply with a treatment plan. Dialogue between the healthcare provider and the patient is a prerequisite for positive health outcomes (Wilson-Stronks, 2010). One of the new standards established by TJC, the United States organization that certifies healthcare organizations (Krautscheid, 2008), describes dialogue as a two-way conversation where the healthcare providers gives patients information in an understandable manner while allowing them to provide their own information, as well. Effective communication in healthcare requires providers to learn appropriate education techniques like avoiding medical jargons and using plain language. It is also necessary to use examples in communicating including the use of diagrams, models and pictures to demonstrate procedures and conditions (Wilson-Stronks, 2010).

Task-Focused and Socio-Emotional Communication Behaviors

     Task-focused communication refers to behaviors that are necessary for assessment and problem solving. It involves conversations between patients and healthcare providers whose primary interest is to gather information to help in providing care for the patient. Task-focused communication may involve giving information, asking information and use of skills like clarifying answers from others and asking questions (Pearcey, 2007). Task-focused communications can be being either formal or informal. Formal conversations encompass admission interviews, discussions of advance directives, health assessments or patient-family education. In this kind of conversation, the healthcare provider initiates the interaction with a specific intention of gathering information that will help in diagnosing or treating the patient’s problems. On the other hand, informal conversations can involve asking of simple questions by the nurse such as, “What do we offer you for your meal today?” Like in formal conversations, the focus of informal conversations is to obtain information needed for caring for the patient. In both cases, the healthcare provider initiates the conversation in order to know how best they care for the patient (Mauk, 2010).

     Task-focused communication behaviors of care providers reflect problem-solving skills involving expertise in consultation. Patients also have a role in problem solving. Task-related patient behaviors include an accurate and full reporting of the present and previous symptoms and relevant medical behaviors, comprehension, attentiveness and recall as well as active participation in the patient care process. Additionally, behaviors like compliance and utilization of healthcare may be part of the task functions of patients although not directly expressed within the medical encounter. Socio-emotional communication behaviors are hard to operationalize than the task-focused behaviors. Their aim is to build relationships. Socio-emotional communication focuses on issues with great emotional significance and this call for advanced listening skills. In this type of communication, issues of self-esteem, empathy and trust are fundamental. A health care provider can sometimes initiate a task-focused conversation that can result in great emotional implications (Sanghavi, 2006).

     An investigation was carried out in order to determine associations among task-focused and socio-emotional behaviors of physicians during a medical encounter. The study used audiotapes and transcripts of two standardized cases of patients presented to 43 primary care practitioners by trained, patient simulators. Transcripts were scored for proficiency of the physician and the content analyzed to evaluate the communication process and information content. There was classification of physician communications as either socio-emotional or task-focused. The findings of the study indicated that the physicians used a physician-oriented or a patient-oriented approach; there was no relationship between verbal and nonverbal socio-emotional measures; the physicians adopted either both proficiency and information-giving style or social orientation with patients and finally, the medically informative physicians demonstrated more anxious and interested voices, as opposed to the less informative physicians. The conclusion of the study is that the more medically informative physicians had voice quality despite the less time spent in socio-emotional utterances.

Use of Simulations in Nursing Education

     Improvements in healthcare require integration of academia and practice to bridge nursing education gaps and help in the accomplishment of quality outcomes. Technological explosion has brought about tremendous changes in various sectors of life including nursing (Connor, Honey, Diener, Veltman, & Bodily, 2009). Human patient simulation is a technology that allows nurses and other healthcare team members to refine and apply their skills in real clinical situations and take part in their learning experiences as a way of meeting their educational needs. Simulated clinical situations similar to actual clinical environments help clinicians to gain experiences, learn skills and develop competencies in a planned and prescribed manner (Kobokovich & Beyea, 2004).

     A human patient simulator is a very sophisticated and technologically advanced mannequin in infant, child or adult size. They completely integrate with computer software that enhances the development of pre-planned situations resembling a wide range of clinical situations. Majority of human patient simulators possess anatomically correct pulses; produce heart, lung and bowel sounds; and respond to pharmacological and medical interventions with anticipated physiological responses. It is possible to program these simulators to speak, hence enabling interactions with clinicians, as is the case with actual patients. Human patient simulators are equipped with different features that support various learning experiences. For instance, some simulators allow for the application of wound or trauma care kit or insertion of a chest tube. Such features support the ability of educators to develop learning scenarios that address different clinical needs or problems (Kobokovich & Beyea, 2004).

     Simulation proves to be a suitable strategy for teaching safe clinical practices in nursing education. However, there are barriers to the strategy such as space, cost and faculty resources. Computer-based social simulations demands less resource and are effective in development of skills in critical thinking (Sleeper & Thompson, 2008). A pilot study was carried out to compare resource demand and learning outcomes of students for computer-based versus traditional simulations. The results of the study suggested that the computer-based simulations are an efficient and effective learning strategy for developing patient-centered care competencies (McKeon et al., 2009). Hence, simulation is the mainstay for clinical learning in nursing education, particularly in areas regarding to safety, team building, problem solving and communication (Tanner, 2006).

     Social simulation is a computer-based simulation that interacts with characters, images or documents to make decisions, which determine the sequence of events for students (NexLearn, 2007). Social simulation enhances knowledge retention and skills in critical thinking (Decker, Sportsman, Puetz, & Billings, 2008). The current software enables faculty to establish customized simulation even without the expertise of a graphic artist, designer and sophisticated programmer. A recent study compared the effectiveness and efficiency of traditional manikin-based versus computer-based simulation in order to facilitate education of students on patient-centered care. The study intended to explore the opportunity for enhancing the achievement of student competencies and for reducing financial and workload resource related to simulation education. The findings of the study suggested that both simulations have similar impacts in imparting the patient care competencies in students (McKeon, Norris, Cardell, & Britt, 2009). This supports the assertion that irrespective of the simulation method employed the success of any simulation is dependent on the faculty’s ability to design scenarios that are appropriate to the learning outcomes and realistic with several learning points (Kyrkjebo, Brattebo, & Smith-Strom, 2006).

     Another study was conducted to assess the usefulness of clinical simulations in improving self-efficacy of nursing students in clinical skills as a preparation for real clinical experiences. The analysis of the study data suggested that experiences with clinical simulations could be effective in boosting the self-efficacy of students in patient care. The study also supports the use of clinical simulations in preparing students for real clinical experiences. Due to the current limited availability of clinical placements for undergraduate students in nursing, the clinical simulations offer a suitable option for equipping students with practical skills within a safe environment, without harm to living patients (Bambini, Washburn, & Perkins, 2009). A certain study sought to explore the effects of high-fidelity simulations on the development of clinical judgments in students. The study’s conclusion was that high-fidelity simulation presents students with a forum for advancing their skills in clinical judgment although further research on the same is necessary (Lasater, 2007). It is noteworthy, therefore, that simulations play an important role in equipping and assessment of nursing students for necessary skills and experiences and thereby promoting patient-centered care.

     Nursing programs need to graduate nurses who are ready for practice and who show quality and safety in patient care as well as interdisciplinary communication. A faculty used structured clinical assessment simulations to conduct a quality improvement project in the attempt to evaluate the ability of every nursing student to perform in various aspects of patient care, including effective communication with physicians through telephone in emergent situations. The project involved results reporting of a three-year evaluation of student nurse performance. Alterations in teaching-learning strategies, which comprised of integration of a standardized communication tool, resulted in improvement of student competency. Communication is essential in providing quality and safe healthcare and this emphasizes the need to ensure preparation and assessment of communication competency for all nursing students before exiting their study programs (Krautscheid, 2008).

     In conclusion, reinventing safety and quality education in nursing demands the creation of learning systems and conditions that resemble the clinical microsystem where students learn and discover, test new ideas and attempt to innovate (McKeon et al., 2009). In order to transform care, safety and quality, education ought to be the basis of every clinical course and create opportunities for examining and improving real-life practice problems to prepare nurses for practice (Batalden & Davidoff, 2007). Furthermore, nurse educators need to collaborate with clinical leaders to utilize simulation in creating reliable virtual clinical microsystems where students learn important safety and quality competencies (McGill, & Hobbs, 2008). Computer-based simulation proves to be an effective and efficient technique for nurses to establish and preserve safety and quality competency for better patient outcomes (McKeon et al., 2009).

Roter Interaction Analysis System (RIAS)

     The Roter Interaction Analysis System (RIAS) is a method of analyzing processes applied to taped medical encounters approved by national and international researchers in over 200 communication studies. The RIAS coding framework captures the key patient-centeredness markers and shows the basic functions of medical visits such as data gathering, patient counseling and education, emotion response, and activation and partnership. The communication analysis unit is a complete thought made by the patient or the provider. There is statements allocation to one of 40 categories that are both mutually exclusive and exhaustive. These codes comprise of content, process and affective categories, for patient and providers (Gorawara-Bhat & Cook, 2011). RIAS codes can be used when combined into summary composites or individually to characterize medical dialogue in various ways including the total amount of talk in the visit, patient-centeredness index and the ratio of the provider to patient talk, which indicates verbal dominance. Additionally, coders rate the visit’s effective tone in relation to negative and positive emotion on a 6-Linker scale (Roter & Larson, 2002).

     The RIAS has demonstrated significant reliability and predictive validity to different patient outcomes. The reliability of RIAS across categories ranges from .7 to .9 based on Pearson correlation coefficients. Many researchers have continuously reported similar reliabilities. The coding system has proved to be superior to others regarding its predictive validity to patient effects like compliance, comprehension and satisfaction. The RIAS system is useful in studies that relate communication to physician satisfaction, physicians’ malpractice experience and patient satisfaction. It also helps in evaluation of different types of communication training programs together with residency training and medical education (Gorawara-Bhat & Cook, 2011).

     RIAS, a method of coding medical dialogue, has been used extensively in the United States and Europe and has been utilized in medical exchanges, in Africa, Asia and Latin America. The ability of the system to provide reasonable sensitivity, depth and breadth while preserving practicality, reliability, flexibility, functional specificity and predictive validity to various patient outcomes has contributed to its rapid adoption and dissemination (Haig, Sutton, & Whittington, 2006). A recent study sought to measure the RIAS reliability and to know the volume of technology-related utterances in launched telemedicine clinics and the practicability of using RIAS within the setting. The study’s results showed that traditional RIAS categories associated with task-focused and socio-emotional clusters had fair to excellent reliability levels in the telemedicine setting. The summary technology-related category exhibited reliability for providers, patients and presenters. The study conclusion acknowledged RIAS reliability when applied across several participants within telemedicine setting. The combined technology-related cluster is reliable especially in understanding the patterns of communication with patients who are new to the telemedicine setting. Therefore, the use of RIAS is useful in facilitating comparisons between telemedicine, traditional and face-to-face clinics (Nelson, Miller, & Larson, 2010).

     The RIAS evaluates cure-oriented (instrumental or task related) and care-oriented (affective or socio-emotional) behaviors by coding statements made in provider-patient visits into categories (Roter, 2011). Concisely, RIAS is famous for its use in the assessment of provider-patient communication in conventional face-to-face consultations, particularly in telemedicine. There have been concerns that suggest that interaction analysis researchers ought to consider using the RIAS when studying communication between provider and patient in telemedicine. These include multiple participants, missing information, nonverbal behavior, and reliability and validity. Besides comparison of telemedicine to face-to-face consultations, a modified RIAS can be used in comparison of televideo consultations to each other, across diverse specialties and technical specifications (Roter, Larson, Beach, & Cooper, 2008). An altered RIAS can accommodate differences in the present technology environment, as well as constant changes in provider-patient communication. An increase the knowledge of interaction patterns that lead to better outcomes causes increased emphasis on development of training programs and other interventions to improve provider-patient interactions in telemedicine (Nelson et al., 2010).

     Netherlands Institute of Primary Health Care used RIAS to observe video recordings, in order to explore communication patterns between nurses and elderly patients in two diverse settings. The study consisted of nurse-patient communication in a sample of 181-videotaped interactions, involving 109 patients and 47 nurses. The observation of the video recordings using RIAS yielded 23 types of verbal behaviors. Further analysis produced two socio-emotional categories and three task-related communication categories. The study data analysis by use of RIAS showed that there was a higher amount of socio-emotional interaction within both settings than what the previous studies reported on nurse-patient interaction. The study further indicated that communication in elderly home care was more task-related as compared to communication in elderly homes (Caris-Verhallen, Kerkstra, Van Der Heijden, & Bensing, 2006). The results of this study, therefore, show the reliability of the RIAS in exploring provider-patient communication patterns.


     Human communication is a complex process involving the exchange of ideas, feelings and thoughts, and people communicating constantly via verbal and nonverbal means. Therefore, it is vital for nurses to realize the importance of effective communication in their practice, especially in regards to its purpose and role in their interactions with patients (Dellasega, Milone-Nuzzo, Curci, Ballard, & Kirch, 2007). In nursing practice, effective communication entails the ability to comprehend patients’ idiosyncratic experiences of illness and health, to convey meaningful information that enhances their wellbeing, and to create an opportunity for patients to participate in their care to their desired extents. Communication in nursing practice plays a major role in building useful relationships with patients. Communication competence is a continuous reflection and deepening self-awareness process. Competent communicators may make errors, but they recognize them and contemplate on the ways of addressing similar situations in the future. This is essential in development of communication skills, which is a continuous learning process throughout the nursing career (Stein-Parbury, 2009).

     The Joint Commission identified communication errors as the primary cause of sentinel events in healthcare systems. One of The Joint Commission’s National Patient Safety Goals is to enhance the effectiveness of communication within healthcare providers (Krautscheid, 2008). Previous documentations show the key role of effective communication in healthcare practice and the necessity of communications skills education (Brown, Crawford, & Carter, 2006; Sheldon, Barrett, & Ellington, 2006). This emphasizes the need for nursing programs to graduate nurses who demonstrate safety and quality in patient care including interdisciplinary communication. Faculty can use clinical assessment simulations to evaluate the ability of every nursing student to perform various aspects of care with the inclusion of effective communication with physicians through phone during emergencies (Krautscheid, 2008). However, there are multiple and variable dilemmas concerning approaches to education of communication skills in undergraduate nursing curricula. The dilemmas range from difficulty in demonstration of effectiveness of skills training, use of counseling models and encounter of social barriers to the use of communication skills (Parry & Brown, 2009; Üstün, 2006).

     The amount of clinical skills training at the undergraduate level is increasing dramatically in order to produce nurses who are ready for practice. The number of students entering training is also on the increase and more are now competing for clinical placements. It is, therefore, necessary for students to have basic, practical and interpersonal skills before entering the clinical environment to enable them to explore further learning opportunities once they join the setting. Working pattern changes and the safety culture within healthcare have lead to clinical training review, which has increased demand for trainings that are non-patient based (Maran & Glavin, 2003). Clinical simulations provide numerous learning opportunities for reinforcing students’ understanding of difficult concepts in practice of skills and techniques associated with communication, delegation and teamwork (Howard, 2009). Integration of simulation with clinical practice will, therefore, go a long way in improving clinical experience and consequently improve patient care (Maran & Glavin, 2003).

     The RIAS system is useful in studies that relate communication to physician satisfaction, physicians’ malpractice experience and patient satisfaction. It also helps in evaluation of different types of communication training programs together with residency training and medical education (Gorawara-Bhat & Cook, 2011). An altered RIAS has the ability to accommodate differences in the present technology environment, as well as constant changes in provider-patient communication. An increase in the knowledge of interaction patterns that lead to better outcomes, causes increased emphasis on development of training programs and other interventions to improve provider-patient interactions in healthcare (Nelson, Miller, & Larson, 2010.


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Evidence Based Practice and Applied Nursing Research


Evidence based practice is a nursing and clinical process that involves identifying actual medical problems and using resultant nursing findings in constructive nursing practices (Keele, 2010). The purpose of carrying out evidence based and applied nursing research is to ensure quality and cost effective medical and nursing care to patients and other individuals who may seek treatment and preventive services. The evidence based practice research involves collection, analyzing, interpretation actual research findings to important applicable research in medical and clinical processes.

There are many preoperative clinical procedures that occur at treatment sites both before and after surgical operations.  Melnyk and Overholt (2010) note that all the procedures are crucial in improving the conduct of surgical processes as well as creating appropriate environment for the healing of patients. Preoperative hair removal is one of such nursing procedures and practices which is designed to reduce the Surgical Site infections (SSIs) and other related healthcare infections among hospitalized patients, surgical staff and other surrounding living things. This procedure is considered in this review because of its potentiality in eliminating surgical infections and its flexibility to accommodate new features to suit the current surgical practices.

Pravikoff, Tanner and Pierce (2005) point out that preoperative surgical hair removal has shifted from its previous version as a treatment measure to the now most practiced preventive measure of SSIs. This has been brought about by the consideration of costs that accompany surgical infections such as the resources that patients use in treating these infections, the suffering they undergo in addition to the increased speed of the spread of bacteria that causes these infections. Preoperative hair removal process is conducted by a preoperative team whose goal is usually to prevent any chances of development of surgical infections to patient before, during and after treatment. This procedure involves removing hair from patients body parts scheduled to undergo treatment that is likely to interfere with treatment or surgical operation. This process is however done as per the consent and interest of the patient and is conducted the day of treatment outside but close to the treatment premise (Burns and Grove, 2003). 

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 Surgical hair removal practice has received much attention in the nursing world because of its ability to reduce patient mortality and morbidity, reduce the ever increasing time that patients stay in hospital and increased hospital bills (Hamlin et al, 2008). Though this procedure has successfully aided in addressing all the problems affecting patients and surgical staff, the level of growth and spread of surgical site infections has called for the re-evaluation of the procedure to provide a more appropriate practice that will be able to contain these surgical infections. This will only be possible through implementation of appropriate and accepted research findings that are geared towards improving the functionality of surgical hair removal procedures.

The choice of this procedure has been triggered by its capability to facilitate successful surgical operations and the long time results of saving resources on the sides of the patients and nursing centers. Additionally, the procedure provides adequate scientific evidence in nursing and medical problem solving and decision making. This procedure, like many other nursing procedures can be used to make decisions about the clinical care of both individual and group type of patients. Exceptionally, the surgical hair removal procedure has a positive projected future performance once necessary scientific and applied changes have been effected. On the other hand, the practical process of surgical hair removal procedure has evolved to adopt new and modern surgical technologies to improve its quality and performance. The hair removal procedure has for along time used safety razors as major surgical instruments. However, with time these razors have been replaced with less-risk electric clippers which have been tested to cause minimal harm to human skin. Shaving antibiotics have also recommended improving on the quality of preoperative hair removal.

However, the clinical implications of surgical hair removal are extensive especially to the surgical staff. Since nursing and surgical staff are critical in providing any nursing practice and ensuring the success of nursing procedures, they are most likely to carry out this procedure according to set clinical standards and thus medical ethics can’t be compromised practices (Keele, 2010).  The clinical implication of this procedure is that nursing and medical practices need constant reevaluation to ensure that clinical goals which are patient satisfaction and quality health care provision are achieved. This practice shall improve patient outcomes, confidence in clinical decision making as well as keeping the practice up to date and relevant.

Proposing changes to the surgical hair removal procedure and consequent follow up of the implementation process is the most challenging part in evidence based and applied nursing research process. There are many obstacles to suggesting and implementing changes to preoperative surgical procedures which range from research process barriers, administrative complexities, financial constraints as well as social cultural factors. A more common barrier in implementing change in this procedure is the low value that the nursing and surgical community attaches to research findings. Though the findings on improving the conduct of this practice may seem to alleviate this practice to a more promising level when put into action, incorporating such findings to a running procedure is a difficult task because many medical and nursing staff won’t like to own and facilitate the changes. Additionally, nursing and surgical field is a hectic and busy health care sector thus getting enough time to create awareness to all the parties involved in this procedure may take a long time to implement. Administrative barriers which include seeking support of the relevant authorities and provision of required resources may delay or shadow the implementation of these changes.

Research utilization is a key solution to some of these barriers because it involves the critical analysis, interpretation and utilization of available research findings concerning this procedure to improve the nursing procedure. Incorporating appropriate clinical research findings and evaluating their performance is crucial to overcoming barriers involved in conducting this procedure. However, this strategy will only be successful in a situation where all the parties involved in transition process accept the value research in improving surgical and nursing procedures. Performance improvement is another strategy that focuses on improving the systems, resources and processes to ensure patient satisfaction using the reasonable costs. Performance improvement is intended to address the nursing problems, examine the clinical performance as well as determine indicators that help the improvement of nursing procedures.

Though conducting evidence based research and implementing the findings takes a lot of resources in terms of time and funds the results of implemented findings are far much worthwhile (Hamlin et al, 2008). Engaging organizational efforts and resources in the implementation process of the findings is important to ensure that there is intended change to the practice. Organizing nursing clubs and providing research articles stipulating the proposed changes to the clinical practice are some of the important strategies that can guide in the implementation process. Seeking the support of the related authorities and convincing them of the importance of the intended change can also add value to the implementation process. The support of the patients is also very valuable because their satisfaction is the objective of any nursing procedure and findings that will incorporate important scientific knowledge, improve quality of nursing service as well as ensure cost effective care will earn a majority support of the patients.

All patients expect their treatment to be smooth and less of unpleasant events. However, the presence of surgical site infections is a potential risk to complicating the treatment of patients. Such infections are causes of extended days of patients in healthcares, increased hospitals charges and unnecessary patient discomfort. The members of any surgical team therefore play crucial role in minimizing the possibilities of surgical infections to patients. While these teams understand the risks of preoperative hair removal as well as the implications for the need to prevent surgical infections, then such a team can design and implement the best surgical hair removal processes and procedures.


Burns, N and Grove, S. (2003). Understanding Nursing Research .Philadelphia: Elsevier Health Sciences.

Hamlin, L. et al. (2008). Preoperative Nursing: An Introductory Text. Chatswood: Elsevier Australia.

Keele, R. (2010). Nursing Research and Evidence-Based Practice. Sudbury: Jones & Bartlett Learning

Melnyk, B. and Overholt E. (2010).Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice. New York: Lippincott Williams & Wilkins.

Pravikoff, S, Tanner, B. and Pierce, T. (2005). Readiness of U. S. Nurses for Evidence-Based Practice. American Journal of Nursing, 105 (9), 40–51.