Patients' perceptions of their experiences with nurse-patient communication in oncology settings: A focused ethnographic study
Patients' perceptions of their experiences with nurse-patient communication in oncology settings: A focused ethnographic study
Engle Angela Chan 0 1
Fiona Wong 0
Man Yin Cheung 0 1
Winsome Lam 0 1
0 Editor: Carma Bylund, Hamad Medical Corporation , UNITED STATES
1 School of Nursing, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hong Kong, 2 School of Optometry, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University , Hong Kong
Data Availability Statement: All relevant data are
within the paper.
Funding: This work was supported by Research
Grant Council, Poly U 156003/15H to EAC. The
funder had no role in study design, data collection
and analysis, decision to publish, or preparation of
Competing interests: The authors have declared
that no competing interests exist.
A focused ethnographic study was undertaken in two oncology wards of a hospital in Hong
Kong. Data were collected through observations of the ward environment, the activities and
instances of nurse-patient communication, semi-structured interviews with patients, and a
review of nursing documents.
Two main themes were identified: 1. Nurses' workload and the environment and 2.
Nursepatient partnership and role expectations. Within these two themes were related subthemes
on: Sympathy for the busy nurses; Prioritizing calls to the nurses; Partnership through
relationship; Nurses' role in psychosocial care; and Reduction of psychosocial concerns through
Many cancer patients do not expect to receive psychosocial care in the form of emotional
talks or counseling from busy nurses, but appreciate the attention paid by nurses to their
physiological and physical needs. Nurse-patient partnerships in cancer care may reduce the
potential workload of nurses. The psychosocial needs of cancer patients could be optimized
by providing good physical care through effective communication within a time-constrained
Nurses' communication with cancer patients is a recognized challenge and an ongoing issue,
where the focus has been on the holding of difficult conversations [
]. Given the frequent
contact that nurses have with patients, nurses are expected to assume this important role. The
substantial need that cancer patients have for information and emotional support through
effective communication is well documented [
]. While numerous studies on nurse-patient
communication, primarily of a quantitative design, have focused on its effectiveness in relation
to psychosocial care, a recent study [
] found that oncology inpatients gave not only doctors
but also nurses a lower rating on their provision of information than on their technical and
interpersonal skills. There is also a limited amount of evidence on the effect on patients of an
environment characterized by a lack of time. Chan et al.'s work [
] uncovered nurses' use of
routines to talk to patients given the time constraints, and Thorne et al.'s [
] findings noted
the untoward effects of time pressures on patients' perceptions of time mismanagement and
on effective communication. The findings from conventional studies have been applied to
communication training at the basic and continuing professional development levels, but
improvements have been incremental at best [
]. This is largely because of an exclusive
emphasis on the perspective of the healthcare provider rather than on that of patients [
]. Given the
mutual nature of communication, studies are needed that focus more than on the patients'
share of the conversation than has hitherto been the case [
]. Thorne's [
] findings on patients'
perceptions of patterns of poor communication with healthcare providers indicated that
variations remain across contexts, cultures, and conditions. Ultimately, the paradigm shift towards
patient-centeredness places demands on us to understand the experiential reality of the
communication of patients with nurses that is essential to providing holistic cancer care,
particularly in an Asian setting [
Given early detection and advances in medical treatment, many cancer patients have been
living with their disease for many years, receiving long-term curative or palliative cancer care
]. Across their cancer trajectory, they commonly experience both physical symptoms and
distress resulting from the cancer itself or from the anti-cancer treatment [
]. However, the
findings reveal that nearly 50% of newly diagnosed cancer patients and those with recurrent
cancer do not receive adequate psychosocial support, and show a significant level of distress
]. There are also an estimated 26 million of new cancer cases per year worldwide, which
calls for psychosocial care and support to be the sixth vital sign in the standard routine of
cancer nursing care [
]. Despite much evidence from around the world of the need to improve
psychosocial care for cancer patients, gaps and barriers to its delivery still exist [
2 / 17
barriers include the unwillingness of patients to share their concerns, the inability of nurses to
pick up cues from patients or handle patients' emotions, and a focus on the part of nurses on
completing tasks [
], with time constraints being an important external factor. Busy nurses
who do not have much time for patients apart from carrying out their routines are a global and
well-documented phenomenon [
]. Time pressures, which are closely tied to heavy
workloads and understaffing, would hinder patients from disclosing their concerns and expressing
negative emotions to healthcare professionals [
]. Time pressures also restrain nurses from
supporting patients emotionally through effective communication [
]. It may not be possible
to create more time within the growing complexity of a very busy cancer care environment
]. A lack of discussion and effective communication between nurses and patients on
psychosocial issues is another predominant cause of inadequate psychosocial care [20±21].
Factors influencing effective communication. Andersen and Risør [
] have argued for
the importance of contextualization and how it relates to the notion of causality for eventual
clinical usefulness. A study on patients with malignant lymphoma identified the domains of
patients' attributes, healthcare professionals' attributes, and external factors as barriers to
effective communication [
]. Another study identified characteristics of patients, nurses, and the
environment as general influences on communication [
]. Patient attributes, including
negative emotions, a lack of specific knowledge about their disease, and inadequate communication
skills could undermine the confidence of patients in communicating with healthcare
]. Some patients found it challenging to know and remember what to ask. Jotting
down their questions on a piece of paper became their means of communication. When
patients regarded their physician as a higher authority who played an important role in their
cure, they were more inclined to follow instructions without asking questions. Patients' past
negative experiences, such as the feeling of not having been cared for, could also hinder their
subsequent communication with healthcare professionals [
]. It would be easier for patients
to raise questions or concerns if they were familiar with their healthcare providers and had
developed rapport with them [26±27]. Moreover, their perceptions of the emotions or
manners of the nurses could influence the building of rapport, which in turn could affect their
readiness to express their feelings and needs [27±28]. Hence, while reviews have been
conducted of studies on the factors that influence communication with cancer patients, there
appear to have been no studies on the delivery of psychosocial care in routine nursing practice
involving the collecting of qualitative data from patients [
]. Arthur Kleinman's [
explanatory model provides us with insights on what is most important to patients, and presents the
notions of illness, culture, care, and the healthcare system as concepts, rather than entities.
Notwithstanding the biopsychosocial emphasis in our healthcare system, the human
experience of illness is often disregarded. A patient's explanatory model and views of clinical reality
can be quite different from the professional medical model. By freeing ourselves from
ethnocentric and medicocentric views, healthcare providers may become more aware of important
issues that have been systematically ignored in the clinical reality. In addition, it is not known
whether the factors influencing communication that have been identified in studies conducted
in the West can be applied to the situation in Hong Kong, or how Hong Kong patients'
perceptions of communication are influenced by the Chinese culture.
The number of new cancer cases and cancer deaths has been increasing in recent years [
and is predicted to continue to rise as the population ages [
], yet cancer services are barely
sufficient to deal with the current cancer burden. As cancer treatment is costly, 90% of cancer
patients are treated in public hospitals [
]. However, only 6 out of the 42 public hospitals in
Hong Kong provide clinical oncology services. The nurse-patient ratio in a ward is around
1:11 in Hong Kong, whereas the international standard is 1:4±6 [
]. Nursing shortages as well
3 / 17
as the overwhelming responsibilities shouldered by nurses are the challenges that need to be
addressed to improve the quality of the care offered in Hong Kong oncology settings [
The aim of this study was to explore patients' perceptions of their experiences with
nursepatient communication and the psychosocial care delivered within a time-constrained
oncological clinical environment. The findings may reduce the gap between the rhetoric on the
provision of psychosocial care for oncology patients and the meaning of such care to the patients.
Materials and methods
A focused ethnographic approach was adopted since such an approach is suitable for
investigating specific beliefs and practices of particular healthcare processes as held by patients and
] and for focusing on cultures and subcultures framed within a particular
]. In this study, we explore patients' perspectives of their nurse-patient communication,
as a continuous problem, identified in a distinct subculture of cancer nursing care within a
busy biomedical context [
]. Data collection and analysis were performed based on the
principles of the ethnographic approach, which highlights the need to pay close attention to a
distinct issue in cultures or subcultures in a specific setting, and to observe, describe, and
understand how people's behavior is influenced by the culture in which they live. This is done
by immersing researchers in the culture, and by endeavoring to ensure that they enter the
study without preconceptions [
]. Research commenced after ethical approval was obtained
from the Kowloon West Cluster Research Ethics Committees of the hospital and the
Departmental Research Committee of Hong Kong Polytechnic University.
The study site was an oncology unit comprised of two 32±36 bed oncology wards in a hospital.
Participant recruitment was completed through convenient, purposive sampling and a
snowballing technique. Upon recruitment, information sheets were handed out with a verbal
explanation of the study. During patient recruitment, two nurse research assistants worked with the
attending nurses, who helped to identify potential patient participants. Once the patients were
identified, the nurse research assistants approached them directly, explained the study, and
asked them if they were willing to participate. The patient participants were all local people.
The criteria for the inclusion of patients in the study were as follows: patients who were at least
18 years of age, able to communicate in Cantonese, cognitively functioning, and in reasonable
enough health to be interviewed during their hospitalization. Patients with tracheotomy or
who were receiving palliative or hospice care were excluded. Initially, 102 patients were
recruited, but nine of them withdrew, leaving 93 patients. There were various reasons for the
withdrawal. Six were discharged without having completed any procedure; one person's
condition deteriorated and the patient passed away; another was not fit enough to be interviewed
after participating in a procedure and was also subsequently discharged, and yet another was
later found to be unsuitable for the study. In the end, there were 47 female and 46 male
participants, for a relatively gender-balanced sample.
The criteria for the inclusion of nurses were those with at least one year of nursing
experience and one year in the current work setting. This ensured that they had a working
knowledge of the culture of the unit. The initial total number of nurses recruited was 26. Two nurses
4 / 17
withdrew, with one resigning and the other refusing to continue due to the busyness of the
ward. In the end, 24 nurses were recruited.
All of the participants gave their written informed consent to take part in the study and
provided their demographic data. They were assigned an individual code, which was used
throughout this paper to maintain their anonymity.
Two nurse research assistants assumed the role of observers as participants in the ward
environment. Observations took place over a seven-month period from March to October 2016. They
were part of the research team, who also conducted focused observations of the practices of
nurses, the activities of the general nurses, and instances of nurse-patient communication within
the oncology settings. They both were experienced nurses with degrees, who had previously
worked in cancer wards. One had a master's degree. They discussed their observations to obtain
a more complete and detailed picture of the oncology settings [
]. This overcame the problems
of observer reliability and bias [
]. The participants also became accustomed to the presence of
the researchers, thereby minimizing the Hawthorne effect [
]. Despite their past research
experience, they were guided through their first few field visits with the principal investigator and the
team members, and trained in the process of collecting data. The team started off holding regular
weekly meetings, and then monthly meetings, for the research assistants to report on their data
collection process and observations. The observations, which were initially recorded in a small
booklet as field notes, were reported to the principal investigator and discussed with the
members of the research team to generate a contextualized understanding of the culture in the ward.
An expanded account of the observations was written on the basis of these notes.
Before and after each admission, administration of medication (AOM), and wound-dressing
procedure, the patient participants were asked to complete a checklist of any physical and/or
psychosocial concerns they might have [
]. Each participant was given a verbal explanation of
how the study was going to be conducted prior to each procedural observation. Audio-taped
data were collected of the nurse-patient verbal communication that occurred during these
routine procedures. After the care procedure, a semi-structured interview with the patient
participants, which lasted approximately 10±25 minutes, was conducted and audio-recorded. An
interview guide was used (S1 and S2 Files). The interview started with the following
introductory question: Were you able to express your needs in general? Why or why not? Other
openended questions were then used as a guide to elicit the views of the patients, such as on whether
they perceived nurse-patient communication to be important; what perceived facilitators and
barriers affected their communication with nurses, and why. Many patients shared their
thoughts in depth with examples; a few completed the interviews, but their responses were
shorter due to fatigue. The collected data were summarized with the patients to give them a
chance to make further comments or corrections/clarifications on the spot. Data were deemed
to be saturated when the researchers noted redundancy in the data [
]. However, data
continued to be collected from two more patients to ensure that no new themes would arise from the
consecutive interviews. The audio-taped conversations were transcribed verbatim by
experienced student helpers. The student helpers were given a briefing with a template on notation
preferences, in particular, on inaudible sections and conversations with emotional contents.
One of the nurse research assistants also checked the completed transcriptions.
Our analysis was guided by Hammersley and Atkinson's ªgrounded theorizing,º where, while
there is no particular script for analyzing ethnographical data, it is essential that ªdata are
5 / 17
materials to think withº [
] and not only to be managed. The interview transcripts and field
notes were regarded as units of analysis. They were read and compared for contextual
understanding. The research nurse assistant (the second last author) and I (the first author) created
the open coding independently through reading and re-reading the interview transcripts using
key words, phrases, sentences, and paragraphs, reducing the data to codes. Differences in
coding were resolved through discussions. Codes were constantly compared [
] for their
conceptual similarity or related meanings and for their differences by going back to the original text.
They were then grouped into subcategories/subthemes. Revision of codes was an iterative
process, including the backward and forward data assessment and analysis leading to modification
and verification of the categories/themes. This was followed by an axial coding [
] with the
intent to clarify how the emergent subcategories was related to the preliminary categories, and
the relevant codes were further discussed and conceptualized. Regular data sessions [
conducted, in which the other two authors involved with the first and the second last authors
to review the coding, mutually agreed on the codes, and reached a consensus on how to apply
the created codes to the data [
]. This led to broader perspectives and caused us to move
beyond preconceived beliefs and biases in collaborative reflexivity [
]. Notwithstanding the
value of coding for similarities and differences, it was important to immerse ourselves in the
data by repeatedly reading the text until insights were developed [
Agreement on the major themes was reached through extensive iterative discussions
among the authors. Areas of consistency across the subthemes were sought to confirm the
major themes that provided the best description of the culture being studied [
]. There was
also the triangulation of data from field notes written during ethnographic observations,
transcribed interviews of nurse-patient communication during procedural care, interviews with
patient participants, and a document review. These strategies provide a better understanding
of the culture being studied [
] and also serve the purpose of validation. The transcripts that
were made of the nurse-patient interactions and interviews provided a particular view of the
individual in the culture of a very busy oncology unit, validating the meanings and
interpretations of the rich points observed during the fieldwork.
Two main themes were identified: 1. Nurses' workload and the environment and 2.
Nursepatient partnership and role expectations. Illustrative quotes from the interviews and notes
from the field observations are included below. Different patients have been coded using
numbers; PN denotes patients in the North Ward and PS patients in the South Ward.
Nurses' workload and the environment
The heavy workload of the nurses was evident in the shortage of nurses and the time
constraints faced by the nurses, who were engaged in many nursing routines and documentation
procedures. The patients recognized that the nurses were busy, which influenced their views of
the nurses' roles and their interactions with the nurses. The crowded and noisy physical setting
of the wards also did not facilitate nurse-patient communication. This theme consists of two
subthemes: 1. Sympathy for the busy nurses; and 2. Prioritizing calls to the nurses.
Sympathy for the busy nurses. As many cancer patients had been admitted frequently
and had experienced long admission times, they were able to develop a good understanding of
the nurses' work demands, which made them feel sympathetic towards the nurses. The
following quotation from a patient is illustrative.
6 / 17
There is too much paper work, but then you wouldn't have any records if you don't have
the paper work. Nurses are really too busy. Every day, the shift handover is done by a
quarter after three in the afternoon and then non-stop till nine without any supper. I can see
that the nurses in this cancer ward have worked very hard . . . administering medications,
taking temperatures, changing diapers, weighing the patients, doing x-rays. They are simply
so busy that they wouldn't have time to talk to patients.º PN38
The various demands on the nurses were also observed and recorded in the field notes, which
illustrated how the nurses undertook their work in a busy ward, and how their work patterns and
their need to move quickly and multi-task would hinder nurse-patient communication.
The nurses are at their busiest during the doctor’s round on weekdays. . . . They rush in and
out of the cubicles many times. They also run from one patient to another in the ward.
Commonly, they are providing procedural care for one patient while replying loudly to another
neighboring patient in the cubicle. (Field notes)
Apart from the nurses' workload, the physical setting of the ward was found to influence
nurse-patient communication as well. The crowded ward environment, the background
noises, and the distance between the patients' rooms and the nursing station were not
conducive to communication.
One cubicle is crammed with ten or more beds. It is common to see a crowded environment full
of camp beds and stretchers in the corridor. The distance between the patients is so close that
their conversations with nurses are easily overheard by their neighbors. It is likely that the
patients’ privacy is being breached when needs or concerns are disclosed. The patients’ coughs,
cries, and moans, along with the sounds emitted from vital sign monitors, electrocardiogram
(ECG) devices, and intravenous (IV) infusion pumps, make the environment too noisy for
communication. Isolation rooms are less crowded and quieter. However, the location is far away
from the nursing station. The nurses only approach the patients during routine care and when
the patients ask for help. The patients there have even less contact with the nurses. (Field notes)
In essence, the patients understood that the nurses had a heavy workload because they had
observed the nurses' routines, fast movements and engagement in multi-tasking. The crowed
and noisy physical environment provided us with more background for understanding that,
for patients, the act of talking to the nurse was not an easy one, as it would require some
planning on the parts of the patients. The lack of privacy and noise levels in the ward could
discourage patients from engaging in any private conversations with the nurses. This, and the
patients' sympathetic understanding of the nurses' work demands had an impact on the
decisions that the patients made and the priorities that they set in getting help. The patients were
essentially trying to be supportive of the nurses' work patterns in their making of requests and
Prioritizing calls to nurses. The patients understood that the nurses were too busy to
fulfill all of their needs given their busy work within time constraints. Thus, they would only
bring up concerns that they perceived to be urgent±mainly those concerning their
physiological changes and needs.
ªYesterday, when I seemed to have high blood pressure, as it was as high as 190/108 in the
afternoon, I asked the nurse to take it [my blood pressure] again at night-time. I think it is a
serious problem that I need to raise immediately. . ..º PS41
7 / 17
Patients would also look for an opportune time to raise concerns, which were primarily of
non-physical nature, which they perceived to be less urgent. They were considerate of the
nurses in that they tried not to interrupt them.
ªI wonder why I can't do better with the [colostomy] bag, despite practicing everyday. . ..
[I'll] just ask [the nurses] when they are free to come in.º PN25
Patients learnt to make their requests, so as to receive timely responses from busy nurses.
The patients' ªeffectiveº communication with the nurses was also promoted through the
building of relationship. According to Gordon [
], relationships do not exist solely on their own;
rather, they are developed between nurses and patients through constant physical, medical,
and technical encounters, with all three types of encounters being intricately connected. With
the building of a relationship, a partnership could develop between the patients and nurses.
Nurse-patient partnership and role expectations
In any partnership, the people who are involved will assume roles±in this case, the roles of
nurse and patient. They will work towards a common goal. This theme has three subthemes, 1.
Partnership through relationship; 2. Nurses' role in psychosocial care; and 3. Reduction of
psychosocial concerns through physical care.
Partnership through relationship. A sense of partnership was observed to have
developed between the nurses and the patients as they built a relationship. A relationship could be
established through the transfer of information as a goal in an instrumental biomedical
], with the involvement and participation of the cancer patient. Even if such
participation is minimal, it provides a basis for the development of comfort, confidence, and trust.
The following dialogues were extracted from the nurse-patient interactions in an AOM
procedure, they show how the development of a partnership was facilitated between the nurse and
the patient during routine care.
When the nurse was administering chemotherapy, she gave the patient a pertinent
explanation and information, and reminded the patient to report any adverse reactions, saying
“because chemotherapy . . . is a big deal.” The patient replied, ª[I] now know . . . [I] must ring the
bell for you if [I have problems during chemotherapy]. [I] depend entirely on you, not on any of
the others,” expressing the sentiment that he regarded the nurse as the most trustworthy person
to offer him help when he needed it. “Yes, you’re right. [We] also depend on you . . . [we] really
need [your help],” was the nurse's response, which gave the patient the encouragement and
confidence to communicate his needs. Such a conversation reflected their interdependent and
collaborative/supportive relationship, which seemed to show that they could rely on each
other to contribute to the patient's care and health. With the establishment of rapport and the
patient's familiarity with his own condition because of the long duration of his disease and his
frequent admissions to the hospital, the patient could also partner with the nurses and share
some of the responsibility of caring for himself by expressing his needs.
However, relationship building process could be hindered by the patients' negative
experiences arising from misunderstanding. One patient described how a misunderstanding about a
request relating to her diet made her less ready to communicate with nurses when she was in
doubt about the medication administered by the nurse, which then led to further
misunderstandings and a difficult relationship.
ªI don't know when I'll be discharged. If I knew I was going to leave today or tomorrow, I
wouldn't ask [the nurse] to change the meal. Since I thought I wouldn't go home so soon, I
8 / 17
asked the nurse to change the meal for me, but she said `sometimes . . . congee and
sometimes . . . rice, change again and again.' I sensed that I was troublesome to her and she
didn't like me . . . this made me upset. I dare not communicate and talk anymore with her
in the future.º PS27
Patients' negative experience of their interactions with nurses would inevitably shape their
subsequent communication with them. Patients would be less motivated to disclose their
feelings and needs to nurses. Apart from the importance of developing a relationship and
partnership with the nurses, patients' perceptions and expectations of the roles of nurses also
influenced how willing the patients were to express their psychosocial needs.
Nurses' role in psychosocial care. Given the patients' past experiences with the nurses'
emphasis on physical care, the patients' lack of familiarity with the responsibilities of nurses
and their perception of the ability of nurses to provide psychosocial care led the patients to
hold few expectations of nurses in this area.
ª. . . [I] haven't talked about my worries . . . [the nurses] can't solve the problems; actually,
they can't help because they have their own responsibilities. They have already done a lot
for [the patients]. If they were social workers or chaplains, then I would talk [about my
concerns] because they would be specialists in counseling, that is, in helping [patients] gain
Given the high cost of chemotherapy medications, financial issues were often a stressor for
cancer patients. However even if patients experienced financial difficulties, they seemed to
prefer to approach a doctor instead of a nurse, as illustrated below.
ªI haven't mentioned [my financial concerns] to the nurses here. They think I don't need
target therapy at the moment, then [I] don't need to ask anymore. I'll just leave it to the
doctor to talk about [my financial concerns] when I really need [target therapy].º PS34
Patients did not often expect to receive psychosocial care from nurses. Indeed, the physical
aspect of cancer patient's condition is the prime concern of nurses, especially in
Reduction of psychosocial concerns through physical care. Nurses placed a higher
priority on delivering physical care when time was tight and they could not expect to meet the
patients' psychosocial needs. However, the patients expressed much appreciation for the help
that they received from the nurses in fulfilling their physical needs. Despite the lack of focus on
psychosocial care, the patients' psychosocial comfort could also be, and was, enhanced through
the provision of good physical care during procedures.
ªAt least I feel that [nurses] can help me. . .. As nurses have their own professional role, they
are not [there] to take care of our psychological needs. . .. I've already felt `psychologically
better' when they are in their professional role of administering medications. Just like
before, I told the nurse that I had a headache. She asked me `Do you need any analgesics to
relieve the headache?' Actually, this is what she has already done in her profession. She has
given me suggestions on how to solve the problem. At least she can help me relieve my
headache. That's already enough.º PS45
9 / 17
Besides alleviating the physical pain of the patients, which gave the patients psychological
comfort, the nurse would provide the patients with an explanation of their physical condition,
which could also ease the patients' fears.
ªThe nurse explained to me why my legs are weak. . .. [Her] assessment, information, and
reassurance about my physical needs mitigated my worries.º PS27
Repeated hospitalizations gave cancer patients the opportunity to observe the heavy
workloads of the nurses. However, the building of a relationship between the nurses and the
patients meant that the two parties interacted continuously, underscoring the potential for
forming a partnership in care, which not only could help the patients adhere to their care
regime, but also perhaps alleviate some of a nurse's workload. Conversely, patients' negative
experience of their interactions with nurses could cause the patients to lose the motivation to
disclose their emotional concerns to nurses, although, admittedly, many of the patients in this
study were not aware of the role played by nurses in providing psychosocial care. The few that
seemed to recognize that nurses could play this role, perceived that the time constraints on
nurses made it impossible to receive psychosocial attention from them. This suggests that
while the provision of psychosocial care to patients might not be something that is expected or
even possible given the patients' understanding of the role of nurses and the time constraints,
one way of reducing the psychosocial concerns of patients is for both nurses and patients to
focus on the physical needs of patients as the priority.
Communication in the context of time pressures
This study shows that patients often did not explicitly express their needs because of time
pressures, which is an organizational barrier to communication [
]. It is well recognized that
understaffing is the main cause of time pressures [
]. Previous studies have also shown that
the influence of Chinese culture can inhibit patients from disclosing their needs. Patients feel
embarrassed about bothering the nurses, so that they express their physical pain only when it
has become intolerable [
]. In our study, the patients' patterns of communication with the
nurses also seemed to be shaped by their understanding of how busy the nurses were and by
the pattern of the nurses' routines. Whether or not the patients decided to initiate
communication depended on whether they thought that their problem should be promptly solved or
could be further delayed until the nurses came to provide procedural care. If the patients
believed that their problem was life-threatening or intolerable±usually when they experienced
physiological changes or physical pain±they would seek immediate help from the nurses,
regardless of how busy they thought the nurses were. Previous studies have indicated that
patients seldom engage in active discussions with nurses on psychosocial problems such as
those arising out of worries about their finances. Chinese patients are more reserved than
Westerners about openly discussing sensitive topics with healthcare professionals [
are ashamed to receive help from a social worker, and will not talk about their financial
]. In the present study, the patients also rarely brought up the subject of their finances.
However, rather than relating to Chinese cultural influences or to feelings of embarrassment,
the reason that they did not discuss the problem of finances seem to relate more to their
perception that the financing of their treatment was a secondary concern that did not need to be
mentioned or urgently resolved±or which would become urgent only when the need arose.
Coupling the importance of being involved in their own care with an understanding of how
busy nurses are with their work, patients would prioritize their needs and delay reporting
10 / 17
them, or not report needs that they perceived to be less urgent. This, however, could pose
In addition, healthcare professionals can be reluctant to become involved with hospitalized
cancer patients in fear of placing a burden on a vulnerable group [
]. This attitude, and the
adoption by nurses of the role of being the experts, could cause nurses to have doubts about
the ability and motivation of the patients to participate in their care.
Building rapport for partnership and communication
The concept of partnership was central to the patients' self-control and ownership of the
management of their symptoms [
]. The findings [
] revealed that hospitalized patients who were
more actively involved in their own care often initiated conversations and approached nurses
for information pertaining to their illness and self-care. The effective exchange of information
is critical to the ability of clinical nurses to assess and educate cancer patients and their
families, perform symptom management, and coordinate care. This, in turn, promotes
nursepatient communication and facilitates nurse-patient partnerships. As in other studies, this
study found that nurses are skilled at eliciting clinical information to empower patients and at
building therapeutic relationships [
]. Being empowered, patients could become more
proactive at engaging in self-care activities [
]. Similarly, in the current study, some ªexperiencedº
patients were found to be helpful at lightening the workload of the nurses, since they
understood how busy the nurses were and readily shared some self-care responsibilities. Patient
empowerment was found to be a feasible way to promote physical self-care through a
nursepatient partnership in a time-constrained oncology setting.
The Hospital Authority [
] also advocates the forming of nurse-patient partnerships
through effective communication as a key strategic direction in improving the quality of care
in Hong Kong. Empowering patients to care for themselves is considered to be the optimal
approach to managing physical conditions. Currently, this approach is being applied to some
cancer out-patients through the launching of self-management courses [
involvement in physical self-care can also be put into practice within in-patient oncology settings, as
the present study shows that patients could be empowered with the ability to monitor
themselves and report on their own condition during chemotherapy. Since the success of a
partnership requires interpersonal and communication skills from healthcare professionals [
patient's perception of a negative attitude on the part of the nurses can probably be attributed
to inadequate communication skills and a lack of mindfulness on the part of the nurses, who
are used to taking a factual approach when speaking to patients without being aware of the
impact that their words could have on the patients [
]. Baillie [
] acknowledges that personal
reflections on working experiences and feedback from colleagues are of value to the
professional development of nurses.
Awareness of the role of nurses in cancer care
This study found that there was a widespread belief among patients that nurses have a major
role to play in managing symptoms, but little to do with providing psychosocial care. Many
others were unaware of the role played by nurses in psychosocial care and were reluctant to
express their psychosocial concerns [
]. Nurses could play many different roles in
psychosocial care, for instance, by assessing needs, acknowledging distress, managing symptoms of
distress, clarifying treatment options, educating the patient about variations in distress during the
transition period, building trust, clarifying access to resources, and providing assistance with
referrals for emotional needs such as counseling [
]. However, our findings show that many
oncology patients did not regard the provision of psychosocial care, such as acknowledging
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emotional distress and engaging in counseling, as the kinds of roles undertaken by nurses. The
few who did think that nurses could have such roles wondered whether they were close enough
to the nurses to discuss their psychosocial concerns with them. Patients have been observed to
prefer to seek emotional support from family members and friends rather than from
healthcare professionals [
It could also be asked whether all cancer patients require emotional support, since previous
studies have revealed a significant variance in the need for such support depending on the type
of malignancy suffered by the patient. Patients with leukemia and lymphoma were more likely
to report having had discussions about emotional issues (58.1%) than those with thyroid
cancer (17.4%). The age and race of the patient are also factors that influence the need of the
patient to discuss the psychosocial implications of his/her cancer. Further investigation on the
subject is needed to provide insights to guide psychosocial care planning for patients [
Close connection between physical and psychosocial needs
This study may heighten nurses' awareness of the interactions between physical and
psychosocial needs and the related aspects of care for their patients in a time-critical environment. The
interrelationship between physical needs and psychosocial management was demonstrated in
the present study, which showed that the psychological state of the patients changed with the
physical care that they received. The art of managing symptoms has been defined as the skill of
coping with the distress arising from experiencing symptoms [
]. Studies have elaborated on
how profoundly symptom management can affect the psychosocial aspects of a patient's life.
Unrelieved physical symptoms, such as pain, fatigue, sleeplessness, vomiting, and constipation,
are considered risk factors for distress [
]. In this study, good physical management involving
effective nurse-patient communication in procedural care promoted psychosocial comfort in
the patients. In this busy ward, the general focus on cancer care was for nurses to provide
physical care to patients, treating the psychosocial aspect as something separate. Surprisingly, the
patients also accorded a lower priority to their psychosocial needs, and had no expectations
that the nurses would play a psychosocial role. This finding complements, yet differs from,
Dilworth et al.'s finding [
] that the barrier to receiving psychosocial care most frequently
reported by patients (38.77%) is their view that there is ªno need for psychosocial services and
support,º followed by a lack of information and not knowing that the service is available.
Similar to the findings of [
], the present study shows that nurses frequently considered their
core task to be medical management, and that both nurses and patients placed an emphasis on
the physical care provided by the nurses. This suggests that a focus on the physical comfort of
the patients could enhance the patients' psychological well-being. Therefore, nurses could
consider promoting psychosocial comfort in patients by improving the quality of their physical
care through effective communication during nursing procedures and when providing
symptom relief. This is a possible solution to achieving the nursing goal of balanced care within the
Following through with Kleinman's explanatory model for our findings on the concepts of
illness, culture, and care has reminded us that despite the emphasis on the biopsychosocial
model, particularly for cancer care, nurses and patients continue to live in a culture of
biomedical dominance. It is important for nurses and other healthcare providers to take into account
patients' concepts of psychosocial care in working with busy nurses, and their perception of
the importance of nurse-patient communication. The findings provide an alternative view of
patients' appreciation of the importance of the physical care delivered by nurses for their
psychosocial health, so that there is a need to re-examine the dualistic view of mind and body, and
to integrate the findings into practice.
12 / 17
Patients' perceptions of the busyness of the nurses and the clinical environment will alter their
patterns of communication. They appreciate the demands on nurses, but could be persuaded
to communicate more openly if they build a relationship with the nurses. They could be
empowered to partner with the nurses to become involved in their care. However, negative
perceptions or misunderstandings of the attitude of the nurses could affect the patients' desire
to communicate with the nurses and the feasibility of forging a partnership with them.
This study also implies that there is a need to improve the nurse-patient relationship by
encouraging nurses to strengthen the practice of mindfulness and improve their
communication skills. In addition, the patients' limited disclosure of their psychosocial concerns relates
not only to their perception of their relationship with the nurses, but also to their perception of
the roles played by nurses and of the nurses' competence in providing psychosocial care.
Another key finding of this study is the interrelationship between psychosocial care and the
physical needs of patients. While physical and psychosocial care could be considered separate
matters for cancer patients, the provision of good physical care through effective
communication is the key to promoting the psychosocial well-being of patients. This may be the optimal
way to realize the goal of providing holistic care to cancer patients within Hong Kong's
understaffed oncology settings.
Implications for practice
From the findings, the following recommendations for practice can be made, which may
improve nurse-patient communication from the perspective of the patients.
First, given that cancer patients will prioritize their needs before considering whether or
not to ask nurses for help, it is important for nurses to empower those patients, yet work
closely with them, by continuously assessing and monitoring changes in the patients'
condition, only then will patients have the ongoing ability to act as partners with busy nurses in
managing their own care.
Second, considering patients' perceptions of the importance of rapport, it is essential for
nurses to become more aware of their communication skills and personal attitudes. It may be
useful of holding informal and flexible reflective workshops for nurses to learn about
communication through a model of appreciation rather than deficit. The support of hospitals is
paramount for nurses to be able to reconstruct the clinical reality of their communications and
dialogue with peers.
Third, since patients did not consider, or were unaware of the role of nurses in providing
psychosocial care, particularly emotional counseling, it would be helpful for nurses to listen to
and understand the views of patients in order to bridge the gap between the patients'
expectations and the actual role of nurses.
Lastly, the patients' appreciation of the impact of physical care on their psychosocial needs
offers busy cancer nurses, who would only be able to attend to the psychosocial needs of
patients when time permits, an alternative way of attending to such needs.
S1 File. Semi-structure interview guided questions (English).
S2 File. Semi-structure interview guided questions (Chinese).
13 / 17
The research team would like to thank the nurses and the patients for their involvement in this
study, which can contribute to an understanding of nurse-patient communication and of the
kind of psychosocial care that is feasible to provide in busy biomedical cancer wards.
Conceptualization: Engle Angela Chan.
Data curation: Fiona Wong, Man Yin Cheung.
Funding acquisition: Engle Angela Chan.
Investigation: Fiona Wong, Man Yin Cheung.
Methodology: Engle Angela Chan.
Project administration: Man Yin Cheung.
Resources: Engle Angela Chan.
Software: Man Yin Cheung.
Supervision: Engle Angela Chan.
Validation: Engle Angela Chan, Man Yin Cheung.
Visualization: Engle Angela Chan.
Formal analysis: Engle Angela Chan, Fiona Wong, Man Yin Cheung, Winsome Lam.
Writing ± original draft: Engle Angela Chan, Man Yin Cheung.
Writing ± review & editing: Engle Angela Chan, Fiona Wong, Winsome Lam.
14 / 17
15 / 17
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