Facilitators of Professional Communication Between Nurse and Opposite Gender Patient: A Content Analysis

Abstract

Introduction: Caring for a patient of the opposite gender is followed by many challenges. Hence, making an appropriate professional communication between the patient and the nurse is of great importance in order to provide a high-quality care to the patient and reduce tensions. Identifying positive factors in the formation of an appropriate professional communication can play an important role in preventing such challenges.

Materials and methodology: The current study aimed to identify the facilitators of professional communication between nurse and opposite gender patient in Iran. A qualitative method and a conventional content analysis approach were used. A total of 25 nurses were included in the study by purposive sampling. Data were collected through unstructured and semi-structured interviews in hospitals of three provinces of Northwestern Iran, and were analyzed by Graneheim and Lundman method.

Results: The results included seven categories and three main themes: prevention of misunderstanding, non-violation of therapeutic relationship boundaries, and observance of the socio-individual context.

Discussion: Despite accepting the difficulties of nursing care for an opposite gender patient, the results of the present study showed that paying more attention to, and carefully watching, the mentioned factors could enhance the chance to establish a proper professional communication between a nurse and an opposite gender patient, which is crucial in providing a high quality care, also improving nurses’ comfort in their work environment. Therefore, it is recommended to consider these factors in academic and in-service training of nurses.

Keywords:communication, nurse, opposite gender, qualitative study.

INTRODUCTION

Communication is an essential issue in all areas of nursing practices, including prevention, treatment, rehabilitation, education, and health promotion. It represents the exchange of thoughts, ideas, and information through writing, talking, body language, and gestures that is made consciously or unconsciously to affect others (1). Through professional communication, the nurse tries to maximize the use of his/her skills to learn more about each patient’s behaviors in order to help improve his/her health status (2). The adequate nurse-patient communication creates hope, increases compliance with a care plan and treatment regimen, and improves treatment response (3). However, the lack of proper nurse-patient communication can lead to patients’ tension, distrust, and dissatisfaction with nursing and health care practices (4).

Gender difference is one of the barriers to professional nurse-patient communication (5-7). The general and old premise assumes that female nursing care is appropriate to the patient of any gender, but a review of studies has indicated that female nurses are also faced with challenges in professional communication and care for a male patient (8-10). However, if the nurse is male and the patient is female, the communication is more challenging compared to that of a female nurse and male patient; in this regard, a review of studies has suggested that male nurses face various reactions such as refusal of care and even sexual assault during providing care for female patients (5, 11). Due to the nature of nursing work, nurses may enter the patient’s private domain during nursing care, which may cause difficulties if they fail to build a proper professional nurse-patient communication (12). During the process of a proper nurse-patient professional communication while caring for a patient of opposite gender, the nurse should try to make the patient feel comfortable and satisfied with the provided care. Also, the nurse should consider his/her own personal realm and professional position. Hence, establishing an appropriate professional nurse-patient communication while caring for a patient of opposite gender is of great importance (13).

The results of related studies in Iran showed that nurse-patient gender differences are one of the barriers to proper communication between nurses and patients, which affects nursing care (3, 4, 14). The relationship between men and women in Iran, like other Muslim countries, has many limitations, according to traditional and religious beliefs, so that Iranian (Muslim) women should cover their entire body, except wrists and face. On the other hand, touching patient’s body for therapeutic purposes is not allowed, except in emergency cases, which is done by wearing gloves (14). Muslim women, due to religious beliefs, are unwilling to spend time with men who are not members of their family and they tend to accept care from same-gender nurses (6, 24).

Nurses’ successful experiences in caring for opposite-gender patient can provide effectual information to help create a good professional communication between the nurse and the patient of opposite gender. Therefore, the present study aimed at identifying facilitators of Iranian nurses and opposite gender patients’ professional communication using a qualitative method.

METHODOLOGY

Design

The present study was performed using a qualitative method with conventional content analysis approach (18), which enabled us to obtain a subjective interpretation of textual data content as a regular process to identify codes, categories, and themes (19). Our study aimed at achieving a comprehensive description of the explored phenomenon as well as an analysis of themes and classes that described the phenomenon (20).

Sampling and study settings

Participants were included into the study by purposive sampling. Sampling and data analysis continued simultaneously, until data saturation was achieved. The study was conducted in different hospital wards (i. e., emergency, intensive care, cardiovascular, pulmonary, hemodialysis, and gastroenterology units) in the capital cities of three provinces (Hamedan, Kermanshah, and Kurdistan), from December 2018 to June 2019, using the following inclusion criteria: willingness to participate in the study, having at least one year of work experience in a clinical setting, and having the experience of care for an opposite gender patient.

Participants

Participants included 25 nurses (14 males and 11 females) working in wards with mixed gender patients, including 22 clinical nurses, two clinical supervisors, and one wound nurse with Bachelor (n= 19) and Master of science degree (n=6). The mean age of participants was 33 years and their clinical experience was nine years.

Data collection and procedures

Data were collected using interviews and field notes. Interviews were started with a general unstructured question:

1. Please express your experiences in taking care of opposite gender patients.

2. How do you establish a professional communication with an opposite gender patient?

3. What factors contribute to the establishment of a good professional communication between you and an opposite gender patient?

4. What factors do you avoid in communication with an opposite gender patient?

5. How do people`s characteristics influence the way you communicate with them?

Other questions were asked based on each participant’s answers to obtain more detailed information. Interviews were conducted in a quiet room based on participants’ opinions (i. e., nurses’ workplace after working hours, or researcher’s office at the nursing faculty). All interviews were audio-recorded. Each interview lasted for 35-45 minutes. Interviews were continued until data saturation, so that the last two interviews had no new data.

MAXQDA, version 10, was used for data management. MAXQDA is a world-leading software package for qualitative and mixed methods’ research that analyzes all kinds of data, from texts to images and audio/video files, websites, tweets, focus group discussions, survey responses, and much more. In the present study, textual data were entered into the software and analyzed until abstraction and main themes were achieved.

Ethical considerations

The present manuscript was derived from a PhD dissertation in nursing. Required permissions were obtained from the hospitals’ authorities. Study objectives were explained to all participants, who signed an informed consent, so that interviews were recorded by their permission; also, anonymity and confidentiality of information for every participant was ensured.

Data analysis

Content analysis was performed according to the approach proposed by Graneheim and Lundman (18). This process comprised six steps:

1. Transcribing data, reading and re-reading documents, and perceiving initial ideas

2. Creating original codes; coding verbatim and line by line

3. Searching for themes; contracting codes into potential themes

4. 4. Reviewing themes; relating them with each other, with extracted codes and entire data set

5. Defining and naming themes; ongoing analysis, distillation of themes, creating apparent definitions and names for each theme

6. Producing the report; final analysis, moving between transcripts and themes, selection of vivid stories for each theme, conducting the report.

Trustworthiness

The Lincoln and Guba criteria were used to ensure the accuracy of data quality (21). To increase data credibility and dependability, member check was conducted with participants and a peer check was done with two nursing professors. Moreover, participants were selected from different geographical locations, including three Western provinces of Iran (Hamedan, Kurdistan, and Kermanshah), and from various clinical wards. Their age ranged between 24-49 years. All subjects had clinical records (1 to 27 years). Their level of education was bachelor and master of sciences and their religions were Sunni or Shi’a. Private or public hospitals were included in the study, which increased its credibility and transferability. To enhance dependability at study onset, limited review of the literature was conducted to avoid researchers’ bias in data collection and analysis processes, and participants’ statements were used in presenting codes and categories. To increase data confirmability, the researcher tried to ignore personal thoughts and assumptions in data collection and analysis as much as possible.

RESULTS

There were 530 initial codes during the data analysis process. This was clustered into seven categories and three themes, including “prevention of misunderstanding”, “non-violation of the therapeutic relationship boundaries”, and “observance of the socio-individual context” (Table 1).

Prevention of misunderstandings

- Patient awareness

According to participants’ experiences, introduction of the nurse to the patient, getting patient’s permission before attempting to care and before entering the room, awareness of the treatment process, awareness of the necessary conditions for better performing the procedures, explaining the reason for the need to wear the hospital cloths and describing the consequences of not allowing the care in need of emergency measures, all could help the patient to better understand and accept the conditions, and be aware of the nurse’s real intention and cause of the nursing care. Therefore, informing the patient can prevent misunderstandings in nurse-patient relationship and may help to create a better relationship.

• When I want to take care of an opposite gender patient, or if I need to make a physical contact, I ask for permission; I explain what I want to do; this prevents any misunderstandings (p. 10).

- Care with the presence of a third person

Participants stated that they avoided a private nurse-patient physical environment as much as possible. Allowing the presence of a patient’s companion, attending a nurse, nursing assistant or nursing student while providing care that involves interference with patient’s privacy as well as offering non-privacy care in front of other patients makes the patient feel more comfortable with nursing care. These measures make sure that the nurse’s goal of physical contact with the patient is merely providing nursing care, excluding any suspicion of sexual misconduct.

• I try to have at least one of the companions during the patient’s care, especially for young patients, in order to prevent uncomfortable feeling in the patient or companion, and even myself; that is very effective (p. 17).

- Trust building

Participation experiences indicate the important impact of verbal and non-verbal behaviors such as applying respectful and formal literatures, avoiding vague and suspicious behaviors such as laughing and non-therapeutic conversations with the patient, responding appropriately to the patient’s request for help, apologizing in case of errors while taking care or delivering treatment to the patient, employing specialized knowledge in caring, having proper attire, and avoiding arrogance, all these approaches increase trust in the nurse. By doing so, the patient trusts the nurse, helping to build a better relationship between them.

• I was very busy and had a lot of work, so at that moment I could not fully listen to the patient. I apologized and came back to him, which made the patient understand my working conditions and not feel dissatisfied with not paying enough attention to him. He understood that I am thinking of taking care of him and resolving his problem, so he trusted me more and a good communication was created between us (p. 15).

Respect for the therapeutic communication boundaries

- Minimum possible entry to the patient’s privacy

Behaviors such as not leaving the patient’s body to be exposed more than the need for care, avoiding unnecessary physical contact and look, keeping patient’s secrets, avoiding private care in crowded places, observing patients’ privacy, avoiding non-therapeutic questions in order not to interfere with patients’ personal lives, avoiding abusive behavior if patients’ privacy is exposed, avoiding the proposal of emotional/sexual relationship, and observing the coverage of patients who are unable to maintain their coverage are included in this category. Respect for the patient’s privacy and personal beliefs prevents stress and discomfort in nurse-patient relationship and provides the basis for a proper relationship between them.

• When I go to a female patient’s bedside, I cover her body with a bedsheet or blankets to prevent her discomfort and provide her with a more appropriate coverage (p. 21).

- Maintaining nurse’s personal realm

Nurses said they have always tried to maintain their professional position and privacy while communicating with the opposite gender patient in order to respect his/her privacy. Behaviors such as not speaking about one’s personal life, not allowing the patient to enter nurses’ physical privacy (the rest room or nursing station), not responding to patient’s curiosity in nurses’ personal lives and avoiding to consider nursing as an insignificant profession, all maintain nurses’ privacy and enhance patients’ respect towards nurses. Determining the nurse’s personal domain reduces the likelihood of disrespect and improper patient interference in nurse-patient relationship and helps building more respect in their relationships.

• Since a patient might misunderstand my personal life information or such information may negatively affect his/her attitude toward me as a nurse, I try to communicate with him/her just as a professional nurse; this helps me to more conveniently establish a professional communication and also prevent the possibility of excessive communication from the patient (p. 14).

Observation of the socio-individual context

- Observation of religious-cultural values

Participants pointed to the importance of observance of such issues as respecting the patients’ religious beliefs, theological reference to divine appreciation in the creation of illness and treatment because of the serious people’s beliefs in the role of divine and God’s powers in creating and resolving problems, respecting the patient’s mother tongue and accent, avoiding constant eye contact, using gloves in touching the patient, understanding the sensitivity of patient’s family while communicating with an opposite gender nurse and avoiding a negative reaction to them can greatly help to better communicate with female patients. Respecting the patient’s culture and religion is a sign of respect for the patient and ensures an easier way for him/her to accept the caring process.

• I know that it is difficult for families to see that an opposite gender nurse takes care of their patient due to their religious attitudes; so, I tried to reduce the contact, wear gloves, and use both verbal and non-verbal literature, such as saying a religious statement of “faith in God”, just to insinuate them that I believe in God and adhere to religious beliefs. This helped the patient feel to have more in common with me and accept me easier (p. 24).

- Attention to individual differences

Participants’ experiences showed that a better nurse-patient communication, in addition to religious-cultural background and flexibility, could be helpful in terms of individual differences and clinical conditions. Nurses consider that issues such as caring for same gender patients in private nursing care, if the opposite gender nurse is not accepted, especially in very religious patients, a female care should be assigned to such patients if possible, and experienced nurses ought to be selected to provide care for younger patients, not insisting on providing elective care if the patient does not allow nursing care and waiting for a same gender nurse. Nurses’ attention to these differences makes it easier for nurses to relate to patients because patients may have differences.

• Since patients show different degrees of sensitivity to opposite gender nurses, some of the private cares are assigned to a same gender nurse just to prevent any problems and we do the rest of practices. Also, when the patient does not allow for a particular practice, I do not persist on doing it by myself; this way, I can perfectly manage my communication with opposite gender patients (p. 23).

DISCUSSION

One of the important pillars in the establishment of a proper communication is that the concept of the message in the sender’s mind is similar to that obtained by the receiver (22). Prevention of misunderstanding was one of the main themes of the study, acting as a positive factor in the establishment of a professional communication between the nurse and an opposite gender patient. Informing the patient was also one of the main categories in the prevention of misunderstandings in the professional communication between the nurse and an opposite gender patient in the present study. Nurses believed that providing the necessary and timely information to the patient made their purpose of verbal and non-verbal measures clear to the patient, thus preventing any patient’s misunderstandings. A review of studies revealed that providing information to patients could reduce their anxiety and help to straighten cooperation with nurses (3, 23, 24). Nursing practices such as touching the patient without prior knowledge may increase the risk of misinterpretation by the patient, leading to a negative reaction towards the nurse; as much as the communication between alien men and women is restricted in a community, patients’ awareness of the nursing practices, such as touching and observing, seem more necessary. Considering the religious restrictions on the relationship between men and women in Islam, it seems that the communication between the nurse and an opposite gender patient is closer from the context of the male-female communication in society. Therefore, explaining the purpose of the behavior and getting the patient’s permission can have a positive impact on the acceptance of nurse by the patient and the formation of a professional communication.

Proving care with the presence of a third person is another important category in the study. The presence of an opposite gender nurse alone on the patient’s bedside, and touching and looking at the patient, although being done according to nursing practice and for therapeutic purposes, given that the nurse of opposite gender is an alien, especially in younger patients, may generate patient’s misunderstanding. The nurses in the current study tried to provide care for opposite gender patients in the presence of a third person. The study by Xiang et al. has also pointed to the attempt of male nurses to take care of female patients in the presence of another nurse in order to reduce the risks of sexual accusation in nurses (10). Due to the numerous tasks assigned to nurses and their high workload, it is not always possible to have two nurses simultaneously on a patient’s bedside. Therefore, in the present study, in addition to this case, caring in the presence of patient’s companion, nursing assistant, nursing student, and even other patients were mentioned as a successful experience. On the other hand, the presence or observation of a third person can make the patient more confident that the nurse does not intend to abuse her/him, being only focused on caring practices; this makes the patient trust the nurse more and better cooperate with her/him.

Trust is the basis for nurse-patient communication (25). Among our findings, trust building was one of the main categories. The successful experiences of participants in building trust in the opposite gender patient showed a range of verbal and non-verbal behaviors as well as specialized knowledge. In reviewing studies, providing patient with information about disease and treatment, allocating sufficient time to the patient, and nurse’s specialized knowledge are generally referred to as factors contributing to building patient’s trust towards the nurse, but in particular, no item is addressed to building trust with opposite gender patient (26, 27). Important factors in patients’ viewpoints to trust in a nurse, although similar, can vary according to the background and underlying conditions (27). It can be argued that gaining an opposite gender patient’s trust is more difficult for nurses compared to same gender patient; it even gets harder owing to the restrictions on communication with the opposite gender in Iran like other Muslim countries. Given the religious-cultural context in Iran, women are more likely to trust men with formal appearances and verbal and behavioral patterns that reflect adherence to their common religious beliefs. Since the nurse is in fact a stranger for the opposite gender patient at the beginning of professional communication, the appearance and verbal features of opposite gender nurse might have a great impact on patient’s trust in him/her.

The minimum breaching of a patient’s privacy was one of the facilitator categories in the present study. Patients often accept that parts of their body are exposed to the nurse’s eyes due to care and treatment procedures, but they complain of unnecessary presences and observations and consider it as a violation of their privacy (28). A review of studies suggested that observing a patient’s privacy creates a sense of safety in him/her, consolidating trust in the nurse (29, 30). In Iran, given the religious-cultural sensitivity to cover body from the eyesight of opposite gender aliens, it is very important for patients and such issues are being seriously considered. This ensures a greater positive effect on patient satisfaction and leads to an increased willingness to cooperate with nurses. Therefore, if nurses observe patients’ privacy and minimize a female patient’s privacy breach, in addition to giving a feeling of safety and comfort and lack of discomfort and complaints about violence by patients, it helps them to more clearly understand that the purpose of opposite gender nurse’s physical observation and contacts is just to take care of her and establish a professional communication.

Beliefs, values, ideas, language, and group norms are important indicators in defining the culture of a society (31). The results of the present study showed that respect for community values and considering them in verbal and non-verbal communication with opposite gender patients plays a pivotal role in establishing a professional communication between nurses and opposite gender patients. Leininger’s culture care theory also considers respecting cultural beliefs and values of patients as prerequisites for successful nursing care (32). There are religious- cultural beliefs in different societies as well as different constraints in relation to communication with opposite gender, but in Muslim countries such as Iran, such restrictions are much tighter than in many other countries, so that in the communication between stranger men and women, eye and physical contacts should be prevented. Given the Islamic beliefs of Iranian people, restricted communication between men and women is emphasized; hence, it can be said that in a professional communication, when a nurse is caring for an opposite gender patient, respecting the community values greatly affects the opportunity to build an appropriate professional communication. In spite of the difficulty and impossibility of observing all of these restrictions with regard to the necessary conditions for nursing care, the maximum effort of nurses to comply with such norms is accepted by the patients, which leads to the establishment of an appropriate professional communication between nurses and opposite gender patients.

Patients, despite their religious-cultural commonalities, may have different personal characteristics that affect communication with them (33). Nurses’ experiences in the present study showed that paying attention to individual patients’ differences by nurses had a significant role in building an appropriate professional communication and providing care to opposite gender patients. A review of previous studies highlighted the important role of patient-centered care in this realm; in other words, patients’ personal values should be considered as much as possible by nurses while providing care and establishing a communication with them (33-35). Therefore, it can be said that observing each patient’s personal beliefs and norms can positively affect the building of a professional communication. In the current study, owing to the underlying factors such as opposite gender of patients, facing care for opposite gender patients within a wide age range, different contexts in upbringing and family beliefs, and religious diversity in Iran reflects the importance of nurse’s flexibility while establishing a professional communication with an opposite gender patient based on her/his personal characteristics. Some patients in Iran are more restrictive than the average of the community while communicating with opposite gender nurses due to more serious religious beliefs, and nurses have facilitated the process of communication with them by increasing understanding and flexibility in communication and care provision for such patients.

CONCLUSION

Despite obstacles in communication between nurses and opposite gender patients, the results of the present study provided successful experiences that had a significant role in the establishment of a proper professional communication, indicating a wide range of factors that were affecting this issue. So, nurses’ adequate professional communication with patients of the opposite gender requires showing respect not only towards individual patients in general but also for personal realm.

Study limitations: Limitations of the present study included the lack of examination of patients’ experiences in this regard. Since patient-nurse communication is naturally a mutual situation, it is suggested to consider patients’ experiences and perspectives in further studies.

Conflict of interests: none declared.

Financial support: none declared.

TABLE 1.

Flow chart of methodology