nurse practitioners’ communication styles and their impact on patient outcomes: an integrated...
TRANSCRIPT
REVIEW
Nurse practitioners’ communication styles and their impact onpatient outcomes: An integrated literature reviewCody R. Charlton, MS, APRN, FNP-C (Family Nurse Practitioner)1, Karen S. Dearing, PhD, APRN-C (Assistant
Professor)2, Judith A. Berry, DNSc, APRN, FNP-C (Assistant Professor)3, & Mary Jayne Johnson, PhD,
APRN, FNP-C (Assistant Professor)4
1 Department of Corrections, State of Utah, Draper, Utah
2 534 SWKT, College of Nursing, Brigham Young University, Provo, Utah
3 458 SWKT, College of Nursing, Brigham Young University, Provo, Utah
4 Intercollegiate College of Nursing, Washington State University, Spokane, Washington
Keywords
Nurse practitioner; communication; styles;
patient centered; outcomes.
Correspondence
Karen S. Dearing, PhD, APRN-C,
College of Nursing, Brigham Young University,
534 SWKT, Provo, UT 84602.
Tel: 801-422-4963; Fax: 801-422-0536;
E-mail: [email protected]
Received: December 2006;
accepted: September 2007
doi:10.1111/j.1745-7599.2008.00336.x
Abstract
Purpose: The purpose of this review was to examine the published research from
1999 to 2005 describing nurse practitioner (NP)–patient interactions and to
determine the best practice to enhance patient outcomes.
Data sources: Databases searched included Academic Search Elite, Cumula-
tive Index to Nursing and Allied Health Literature (CINAHL), Health Source
Consumer Edition, Health Source Nursing/Academic Edition, Medline, and
PsychInfo.
Conclusions: Two communication styles described in the literature and deter-
mined by authors were (a) biomedical and (b) biopsychosocial. The biopsy-
chosocial style is identified as patient-centered communication. Seven studies
were then analyzed for NPs’ communication styles and the impact that they had
on patient outcomes. The studies analyzed demonstrated that biopsychosocial
(patient-centered) communication style positively influences patient outcomes
as evidenced by (a) improved patient satisfaction, (b) increased adherence to
treatment plans, and (c) improved patient health.
Implications for practice: The results of this review indicate that patient-
centered communication incorporated into the NPs’ practice is associated with
improving patient outcomes such as (a) improved patient satisfaction, (b)
increased adherence to treatment plans, and (c) improved patient health. Future
research needs to be performed in order to fully study the relationship between
NPs using patient-centered communication style and its impact on patient
outcomes. Clinical recommendations are made based on findings of the inte-
grated literature review.
Introduction
Nurse practitioner (NP)–patient communication is essen-
tial to the process of care. Communication between the NP
and the patient assists in targeting patients’ healthcare
needs. However, the type of communication between NP
and patient can influence patient outcomes (Suarez-
Almazor, 2004). Several recent studies evaluating com-
munication between the healthcare provider (HCP) and
the patient linked the increases in patient satisfaction and
adherence to treatment plans, more appropriate medical
decisions, and better health outcomes with the style of
communication exhibited by the HCP (Crawford &
Makoul, 2003). Unfortunately, there have been no studies
382 Journal of the American Academy of Nurse Practitioners 20 (2008) 382–388 ª 2008 The Author(s)Journal compilation ª 2008 American Academy of Nurse Practitioners
that comprehensively examined the relationship of NPs’
style of communication and its impact on patient
outcomes.
Background
Communication is defined as the act of imparting or
transmitting information, both verbally and nonverbally.
HCP–patient communication is the interaction between
the HCP and a patient. This interaction involves an
exchange of words, gestures, feelings, thoughts, and
attitudes. There are two specific styles of communication
that have been used by HCPs: the biomedical and
biopsychosocial.
The biomedical, or traditional, style of communication
takes a patriarchal, authoritative approach that focuses
only on signs and symptoms of patients’ complaints. In this
style, the HCP asks closed-ended direct questions and gives
patients directions to follow with little or no patient input.
(Anderson, 2002) The biopsychosocial style of communi-
cation actively engages the patients in discussion and
decision-making processes regarding their own care and
is also referred to as patient-centered communication. The
biopsychosocial style of communication encourages shar-
ing of patients’ ideas, establishes patients and providers as
partners, takes patients’ emotional and social environ-
ments into account, and requires open-ended questions
and mutual participation (Anderson).
The literature on patient-centered communication is
divided on patient outcomes; however, there is general
agreement that many patients prefer being involved in
deciding on the type of care they will receive. For example,
when provided with patient-centered communication,
patients report higher satisfaction and improved outcomes
without significant increases in time and money for the
provider (Anderson, 2002). Patient-centered communica-
tion skills are associated with improved health outcomes,
improved patient and clinician satisfaction, and less risk of
malpractice suits (Fortin, 2002). Other benefits from
implementing patient-centered communication are (a)
it is simple for the provider to incorporate, (b) it allows
the patient to feel included, and (c) it is inexpensive.
Other studies have shown conflicting results for patient-
centered communication. Michie, Miles, and Weinman
(2003) stated that there is inconsistent evidence that
patient-centered communication is associated with bene-
ficial physical and psychological outcomes. Mead, Bower,
and Hann (2002) concluded there is a lack of supportive
evidence regarding patient-centered communication,
identifying that there is no clarity over the definition of
patient-centered communication, the optimal methods of
measurement, and the relationship between patient-cen-
tered communication and patient outcomes.
Barriers to communication
Regardless of the style of communication used, there are
always barriers to effective communication. These barriers
originate from both the HCP and the patient. The following
are examples of HCP barriers to communication: (a) insuf-
ficient time, (b) lack of solution to a patient’s health
concerns, (c) discomfort, and (d) lack of knowledge regard-
ing a patient’s health concerns (Alexander, Casalino,
Tseng, McFadden, & Meltzer, 2004). The following are
examples of patient barriers to communication: (a) dis-
comfort, (b) insufficient time, (c) the belief that the HCP
did not have a viable solution, (d) a fear of compromised
quality of care, (e) learning deficits, (f) memory loss or
impairments, (g) hearing deficits, (h) visual deficits, (i)
speech impairments, and (j) primary language of patient is
different from primary language of provider (Alexander
et al.; Rutledge, 2004).
Patient-centered communication can assist the HCP in
overcoming communication barriers. One study noted
that patient barriers to care (such as lack of access to
health care, perceptions about health, and the need for
therapy) and HCP barriers (such as the use of ineffective
communication styles) contribute to the low rates of
hypertension control in individuals of African American
descent (Price & Cooper, 2003). The authors stated,
‘‘Patient-centered communication strategies can help
overcome these barriers and can improve compliance
and outcomes’’ (p. 1330). Little et al. (2001) noted that
when HCPs do not provide a positive patient-centered
approach, patients are less satisfied, are less enabled, have
more problematic symptoms, and have higher rates of
referral.
Styles of communication and patient outcomes
The style of communication that an HCP uses influ-
ences patient outcomes. The outcomes of the interaction
between the HCP and the patient can be either negative
or positive (Anderson, 2002; Beck, Daughtridge, &
Sloane, 2002; Crawford & Makoul, 2003; Cunningham,
2004; Fortin, 2002; Heisler et al., 2003; Horrocks, Ander-
son, & Salisbury, 2002; Little et al., 2001; Lobb et al.,
2004; Price & Cooper, 2003; Roter, 2000; Schrader &
Schrader, 2001; Stewart et al., 2000; Suarez-Almazor,
2004; van Dulmen & Bensing, 2002; Wissow, 2004). The
negative outcomes most frequently mentioned in the
literature are malpractice lawsuits, poor patient adher-
ence to medical treatments, and low patient satisfaction
(Crawford & Makoul; Wissow). Malpractice lawsuits are
the negative outcome most often discussed in the media.
A common cause for malpractice lawsuits is poor patient
communication such as the biomedical style. One study
noted that plaintiffs of malpractice claims rated
C.R. Charlton et al. NPs’ communication styles
383
dysfunctional delivery of information and poor listening
behavior of the HCP as the main reason for suing their
HCP (Beck et al.). Crawford and Makoul stated that the
combination of a bad outcome and patient dissatisfaction
is a recipe for litigation. Patients and families are more
likely to sue the HCP if the HCP is viewed as not caring and
not compassionate. The same authors also noted that
patients who sued their HCP felt rushed and ignored, felt
that their questions were not adequately answered, and
felt that the HCP did not spend very much time with them
(Crawford & Makoul).
Another concern is that when HCPs use the biomedical
style, there may be problems with adherence because
patients do not understand instructions given to them
by the HCP (Schrader & Schrader, 2001). For example,
one study related that when the HCP used the biomedical
style, it contributed to low rates of hypertension control in
individuals of African American descent (Price & Cooper,
2003). Another study showed that patient encounters
with the HCP are stressful, which negatively impacts the
patients’ health (van Dulmen & Bensing, 2002).
When HCPs communicate using the biomedical style,
patients are less satisfied and less able to care for them-
selves (Little et al., 2001). Another study reported that the
HCPs who showed low levels of items identified as atten-
tiveness and empathy had low patient satisfaction (Suarez-
Almazor, 2004). Researchers found that low patient
satisfaction leads to patients communicating poorly with
their HCPs and creates ineffective treatment plans
(Crawford & Makoul, 2003; Fortin, 2002). Negative expe-
riences can be changed into positive ones when the HCP
uses a communication style, like patient-centered com-
munication, to help patients in understanding their health
concerns (Stewart et al., 2000).
The biopsychosocial, or patient-centered, style of com-
munication is often associated with positive outcomes. For
example, a review of the literature reveals that patient-
centered communication leads to better information
gathering and more appropriate treatment, resulting in
better outcomes for patients (Anderson, 2002). Outcomes
that are affected by positive HCP communication, such
as patient-centered communication, include lower rates
of malpractice lawsuits, increased adherence to treat-
ment plans, improved patient health, and increased
patient satisfaction (Suarez-Almazor, 2004). Crawford
and Makoul (2003) noted that good communication skills
are important in building and maintaining a positive HCP–
patient relationship and stated, ‘‘There is no question that
if the relationship is good, patients don’t sue unless the
negligence is extraordinarily egregious’’ (p. 18).
Not only does biopsychosocial communication decrease
the possibility of malpractice lawsuits, but it also affects
other patient outcomes in positive ways. Roter (2000)
reviewed biopsychosocial communication interventions
and found strong supporting evidence linking patient-
centered communication elements with a variety of
patient health outcomes, including emotional health,
symptom resolution, function, physiologic measures
(i.e., blood pressure and blood sugar level), and pain
control. The use of patient-centered communication by
the HCP is associated with enhanced diagnostic accuracy,
improved blood pressure and diabetes control, and
improved patient satisfaction (Fortin, 2002). For example,
positive communication has increased patient adherence
to treatment plans in studies involving breast cancer,
diabetes, and oral contraceptive use (Heisler et al.,
2003; Lobb et al., 2004; Schrader & Schrader, 2001).
Another study stated there is strong evidence that links
patient-centered communication with improvements in
markers of disease control such as hemoglobin A1c and
blood pressure, enhanced reports of physical and emo-
tional health, improved functioning, and better pain con-
trol (Price & Cooper, 2003). When an HCP is able to
positively communicate with a patient and collectively
create a treatment plan, it increases adherence to the
treatment plan and improves the patient’s health.
Another outcome mentioned in the literature is patient
satisfaction and how it is positively influenced by patient-
centered communication. One study noted that when
HCPs used patient-centered communication, patients
reported higher satisfaction and improved outcomes
(Anderson, 2002). Price and Cooper (2003) related that
positive HCP–patient communication leads to improve-
ments in patient satisfaction, compliance, and health out-
comes. Price and Cooper also stated that the highest levels
of patient satisfaction are associated with communication
styles that are characterized by psychosocial exchange and
an equal distribution of HCP and patient talk. These are
defining characteristics of patient-centered communica-
tion. There is little substantive literature on the use of
patient-centered communication by NPs and the effect
that it has on patient outcomes. However, Cunningham
(2004) in a review of outcomes studies stated that when
compared to other HCPs, the care provided by NPs was of
equivalent quality and that NPs are more effective in
providing services that relied on patient-centered commu-
nication. Horrocks et al. (2002) in a review article com-
pared other HCPs working in primary care settings and
related that NPs provide care that leads to increased patient
satisfaction and similar health outcomes. Both of these
review articles agree that NPs are performing more inves-
tigations into patients’ complaints and spend more time
with patients than do other HCPs, which suggests the use
of patient-centered communication by NPs. Therefore, the
purpose of this integrative literature review was to exam-
ine the research regarding NP–patient interaction and to
NPs’ communication styles C.R. Charlton et al.
384
determine the best practice to enhance patient outcomes.
Clinical recommendations will be made based on findings
of the integrated literature review.
Methodology
An electronic search was conducted to identify studies
from 1999 to 2005 in the following databases: Academic
Search Elite, Cumulative Index to Nursing and Allied
Health Literature (CINAHL), Health Source Consumer
Edition, Health Source Nursing/Academic Edition, Med-
line, and PsychInfo. The following search terms were used
for this study: nurse practitioner, communication, styles,
patient-centered, and outcomes. The inclusion criteria
included the search being limited to peer-reviewed
research articles, English language, and patient outcomes
evaluated. A total of 17 articles were found during the
electronic search that met these criteria.
The references from all articles were reviewed. An
additional nine articles from this review were found bring-
ing the total number of articles to 26. Further inclusion
criteria refinement limited the studies to those that ana-
lyzed NPs’ communication styles. Out of the 26 articles
selected, only 7 met the criteria for analysis of NPs using
communication styles and the impact that they have on
patient outcomes.
Findings
A total of seven articles were evaluated; the articles
selected were studies that involved NPs acting as the
primary care provider and discussed the patient out-
comes of those studies (Table 1). Criteria used to evaluate
the seven articles included determining the communi-
cation style implemented in the study, either biomedical
or biopsychosocial as previously identified. Additional
evaluation criteria included (a) an approval rating scale,
(b) and adherence scale, and (c) an improved health
scale.
Communication styles
Communication styles used in the articles were bio-
medical and biopsychosocial (Table 1). Four studies did
not specify a communication style but interactions
between the NP and the patient contained elements that
defined the communication style as biopsychosocial
(Burns & Earven, 2002; Knudtson, 2000; Litaker et al.,
2003; Mundinger et al., 2000). Schrader and Schrader
(2001) evaluated NP communication using a tool to
describe the interaction between the NP and the patient;
from their description, the communication style can be
defined as biopsychosocial. Lawson (2002) showed NPs
using both biomedical and biopsychosocial communica-
tion styles at different times during the same NP–patient
interview. Pinkerton and Bush (2000) did not specify the
type of communication style used by NPs but showed
a positive association between the care provided by the
NP and increased patient satisfaction and improved health
of the patient.
Patient outcomes related to NP communication
The style of communication that an NP uses can posi-
tively or negatively influence patient outcomes. Negative
outcomes were not addressed in the studies analyzed. The
positive outcomes addressed in the articles were increased
patient satisfaction, increased adherence to treatment
plans, and improved patient health. Five articles (Knudt-
son, 2000; Litaker et al., 2003; Mundinger et al., 2000;
Pinkerton & Bush, 2000; Schrader & Schrader, 2001)
evaluated patient satisfaction and showed a positive asso-
ciation between biopsychosocial communication style and
increased patient satisfaction. However, Lawson (2002)
showed no direct association between the provider’s com-
munication style and patient satisfaction. Two articles
(Litaker et al., 2003; Schrader & Schrader) evaluated
adherence to treatment plans and showed a positive asso-
ciation between biopsychosocial communication and
increased adherence. Four articles (Burns & Earven,
2002; Litaker et al., 2003; Mundinger et al., 2000;
Pinkerton & Bush) evaluated patient health and showed
a positive association between biopsychosocial commu-
nication and improved health. In every area, outcomes
were improved by NPs using a biopsychosocial style of
communication.
Three articles evaluated only one outcome of the com-
munication style used by the provider, either patient
satisfaction (Knudtson, 2000; Lawson, 2002) or improved
health (Burns & Earven, 2002). Three articles evaluated
different combinations of two positive outcomes, either (a)
patient satisfaction and improved health (Mundinger
et al., 2000; Pinkerton & Bush, 2000) or (b) patient satis-
faction and increased adherence (Schrader & Schrader,
2001). One article (Litaker et al., 2003) evaluated three
positive outcomes: patient satisfaction, increased adher-
ence, and improved health. None of the seven articles
examined addressed negative outcomes such as malprac-
tice lawsuits, poor adherence to treatment plans, or poor
patient health.
Discussion
There is no literature that adequately addresses the
use of patient-centered communication by NPs. Also
C.R. Charlton et al. NPs’ communication styles
385
Table
1N
Ps’
com
mu
nic
ati
on
sty
les
an
dp
ati
en
to
utc
om
es
Au
tho
r
Stu
dy
de
sig
na
nd
sam
ple
Bio
me
dic
al
sca
leB
iop
sych
oso
cia
lsc
ale
Ap
pro
val
rati
ng
sca
leA
dh
ere
nce
sca
leIm
pro
ved
he
alt
hsc
ale
Bu
rns
&Ea
rve
n(2
00
2)
De
scri
pti
ve
pre
-
an
dp
ost
an
aly
sis
of
NP
(n=
69
9)
No
Yes
(th
eN
Pw
as
con
tin
ua
lly
com
mu
nic
ati
ng
wit
hth
e
pa
tie
nt
an
da
llm
em
be
rs
of
the
me
dic
al
tea
mto
imp
rove
ad
he
ren
ceto
the
tre
atm
en
tp
lan
an
d
toke
ep
ev
ery
thin
go
n
targ
et)
No
No
Yes
(me
asu
red
colle
ctin
gd
ata
da
ily
usi
ng
ast
an
da
rdiz
ed
da
taco
llect
ion
too
l
calle
dth
eB
urn
s
We
an
Ass
ess
me
nt
Pro
gra
m)
Kn
ud
tso
n(2
00
0)
De
scri
pti
ve
de
sig
n
(n=
93
)
No
Yes
(pa
tie
nts
wit
hin
the
stu
dy
we
rem
ost
sati
sfie
d
wit
hth
ein
terp
ers
on
al
asp
ect
so
fN
Pse
rvic
e,
ho
wth
ey
we
retr
ea
ted
by
the
NP,
an
dth
e
inte
rest
an
dre
spe
ct
sho
wn
by
the
NP
)
Yes
(me
asu
red
usi
ng
the
NP
Sa
tisf
act
ion
Inst
rum
en
t)
No
No
Law
son
(20
02
)D
esc
rip
tiv
e
corr
ela
tio
na
l
stu
dy
(n=
12
4)
Yes
(use
dP
rov
ide
r
Co
mm
un
ica
tio
n
Sty
leR
ati
ng
Sca
le)
Yes
(de
term
ine
du
sin
g
the
Pro
vid
er
Co
mm
un
ica
tio
nS
tyle
Ra
tin
gS
cale
)
Yes
(me
asu
red
usi
ng
the
He
alt
hC
are
Clim
ate
Qu
est
ion
na
ire
an
dth
eP
ati
en
t
Sa
tisf
act
ion
Qu
est
ion
na
ire
)
No
No
Lita
ker
et
al.
(20
03
)E
xp
eri
me
nta
l
de
sig
n
(n=
15
7)
No
Yes
(NP
resp
on
sib
lefo
r
de
velo
pin
gtr
ea
tme
nt
reg
ime
ns
tha
tin
corp
ora
ted
pa
tie
nt
pre
fere
nce
sa
nd
for
ass
ess
ing
tre
atm
en
ta
dh
er-
en
ce,
ind
ivid
ua
lb
arr
iers
to
ad
he
ren
ce,
an
dfa
mily
sup
po
rtfo
rtr
ea
tme
nt)
Yes
(me
asu
red
usi
ng
the
Pa
tie
nt
Sa
tisf
act
ion
Qu
est
ion
na
ire
)
Yes
(me
asu
red
usi
ng
the
He
alt
hS
urv
ey
Sh
ort
Form
-12
an
d
the
dis
ea
se-s
pe
cific
Dia
be
tes
Qu
alit
yo
f
Life
qu
est
ion
na
ire
)
Yes
(me
asu
red
usi
ng
the
He
alt
hS
urv
ey
Sh
ort
Form
-12
an
d
the
dis
ea
se-s
pe
cific
Dia
be
tes
Qu
alit
yo
f
Life
qu
est
ion
na
ire
)
Mu
nd
ing
er
et
al.
(20
00
)
Ra
nd
om
ize
d
con
tro
lled
tria
l
(n=
13
16
)
No
Yes
(de
term
ine
du
sin
g
pro
vid
er-
spe
cific
ite
ms
fro
m
ap
ati
en
tsa
tisf
act
ion
qu
est
ion
na
ire
)
Yes
(me
asu
red
usi
ng
ap
ati
en
tsa
tisf
act
ion
qu
est
ion
na
ire
)
No
Yes
(de
term
ine
db
y
colle
ctin
g
ph
ysio
log
ic
me
asu
rem
en
ts)
Pin
kert
on
&
Bu
sh(2
00
0)
Ex
pe
rim
en
tal
de
sig
n
(n=
16
0)
No
tsp
eci
fied
No
tsp
eci
fied
Yes
(me
asu
red
usi
ng
the
NP
Sa
tisf
act
ion
Inst
rum
en
t)
No
Yes
(me
asu
red
usi
ng
the
SF
-20
He
alt
h
Su
rve
y)
Sch
rad
er
&
Sch
rad
er
(20
01
)
Ex
pe
rim
en
tal
de
sig
n
(n=
46
)
No
Yes
(me
asu
red
usi
ng
are
vis
ed
vers
ion
of
No
rto
n’s
Co
mm
un
ica
tor
Sty
le
Me
asu
re)
Yes
(me
asu
red
usi
ng
are
vise
dve
rsio
no
f
No
rto
n’s
Co
mm
un
ica
tor
Sty
leM
ea
sure
)
Yes
(me
asu
red
usi
ng
the
Ora
lC
on
tra
cep
-
tiv
eC
om
pre
he
nsi
on
Qu
est
ion
na
ire
)
No
NPs’ communication styles C.R. Charlton et al.
386
none of the analyzed articles specifically use the term
patient-centered communication to describe or evalu-
ate the communication between NPs and patients.
However, the articles describe the manner in which
the NPs interact with patients, and these descriptions
meet the criteria for the biopsychosocial style of com-
munication or patient-centered communication as dis-
cussed previously.
The use of patient-centered communication by NPs
was shown to improve the following patient outcomes:
(a) patient satisfaction, (b) adherence to treatment plans,
and (c) patient health. Unfortunately, negative patient
outcomes were not discussed or measured in the articles,
which decreases the thoroughness of the articles in
studying the relationship between NP communication
and its effect on patient outcomes, both positive and
negative.
Recommendations
The studies analyzed were not conclusive, partly
because researchers do not use consistent definitions
or outcome measures. However, the results of this
review suggest that patient-centered communication
incorporated into NPs’ practice is associated with
improving patient outcomes by (a) increasing patient
satisfaction, (b) increasing adherence to treatment plans,
and (c) improving patient health. Further research is
needed to fully study the relationship between NPs using
patient-centered communication and its impact on
patient outcomes. This can be performed by specifically
defining patient-centered communication and then by
measuring how patient-centered communication used
by NPs affects patient outcomes such as (a) patient
satisfaction/dissatisfaction, (b) adherence to treatment
plans, (c) improved/decreased patient health, and (d)
malpractice lawsuits.
Conclusions
A review of the literature was conducted to examine
NP–patient interactions and to determine which com-
munication style improves patient outcomes. The bio-
medical and biopsychosocial styles of communication
were identified and described. The biopsychosocial style
of communication was identified as being equal to
patient-centered communication. Seven studies were
then analyzed for NP communication model and the
impact that it has on patient outcomes. The results of
this integrated literature review suggest that patient-
centered communication incorporated into NPs’ practice
is associated with improving patient outcomes. To verify
the results of this literature review, future research
should study the relationship between NPs using
patient-centered communication and its impact on
patient outcomes.
Regardless of the communication style used, it is impor-
tant to involve the patient in the process. If HCPs com-
municate in a clear and effective manner with patients, as
in patient-centered communication, then patient out-
comes will improve (Stewart et al., 2000).
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