Journal of Advanced Nursing, 1997, 26, 93100

Understanding nurses communication with

patients in accident & emergency departments
using a symbolic interactionist perspective
Geraldine Byrne RGN BA RNT PhD
Principal Lecturer, Adult Nursing (South) Division, University of Hertfordshire, Hatfield

and Robert Heyman BA PhD

Professor of Health Social Research, Institute of Health Sciences, University of
Northumbria, Newcastle Upon Tyne, England

Accepted for publication 10 June 1997

Journal of Advanced Nursing 26, 93100

Understanding nurses communication with patients in accident and
emergency departments using a symbolic interactionist perspective
Much research has examined the nature and duration of nursepatient
communication. However, few studies suciently acknowledge the extent to
which communication is influenced by the meanings and perceptions of those
involved or the social context in which it occurs. This paper reports on a study
which used in-depth interviews with 21 nurses in two accident and emergency
departments to explore how their perceptions of their work and patients
influenced communication and the way in which patients anxieties were
addressed. A grounded theory approach was used to guide the process of data
collection and analysis, and interpretation of findings discussed with reference
to a symbolic interactionist perspective. The core category was identified as
Defining the role of the accident and emergency department nurse. This
category illuminates the nurses perception of their role and purpose as being
primarily concerned with dealing with emergencies and providing urgent
physical care. Two other categories, Nurses priorities and patients anxieties
and Keeping the department running smoothly, delineate the impact this view
had on the organization and delivery of nursing care in accident and emergency
departments and its e
ect on nursepatient communication.

BYRN E G. & H EYMA N R. (1997)

Keywords: accident and emergency, nursepatient communication, symbolic

interactionism

I NTRODUCTI ON
Much research has examined the nature of nursepatient
communication has been examined. However, many early
studies (Faulkner 1979, Wood 1979, Macleod Clark 1982,
Bond 1982) do not suciently acknowledge the extent to
which communication is influenced by the meanings and
Correspondence: Geraldine Byrne, Principal Lecturer, Adult Nursing
(South) Division, Wright Building, University of Hertfordshire, College
Lane, Hatfield AL10 9AB, England.

1997 Blackwell Science Ltd

perceptions of those involved and the social context in

which it occurs.
This paper reports on a study which used in-depth interviews with 21 accident and emergency (A & E) department
nurses to explore how nurses perceptions of their work
and patients influence communication, and the ways in
which patients anxieties are addressed. The process of
interviewing and analysis followed the principles
described by Strauss and Cobin (1990) to generate a
grounded theory. Interpretation of data was guided by a
symbolic interactionist perspective.
93

G. Byrne and R. Heyman

Dealing with patients emotional responses to their illness

and to the experience of hospitalization is a crucial and
unique aspect of the nurses role (Wilson-Barnett 1980). In
the UK, the emphasis on the nursing process and nursing
models reflects the concern that nurses should view their
patients holistically and value their uniqueness and individuality (Sundeen et al. 1994). The benefits to patients of
having nurses who will talk with them and address their
anxieties are well reported (Hayward 1975, Thompson
1989), yet research findings seem consistently to report a
lack of attention to providing open and informative communication by nurses (Faulkner 1979, Macleod-Clark
1982, Bond 1982). However, these early studies have been
criticised for failing to consider the social context in which
communication occurs (May 1990) and for ignoring the
patients contribution ( Jarrett & Payne 1995). As Heyman
and Shaw (1984) indicate, nursepatient communication
is influenced by a complex range of factors including
the distribution of inter-professional power, the requirements of large bureaucracies and the influence of social
status, such as social class and gender, as well as by the
communication skills of those involved.

common finding that nurses interaction with patients is

brief, predominantly task-centred and concerned with
physical care. Nurses appeared to restrict their contact
with patients to those interactions which were necessary
for the patients progress through the department. Wood
used only a small sample of 20 patients with minor injuries, and used a pre-coded structured checklist to classify
the types of interaction which occurred. This approach,
however, provides no contextual detail, making it dicult
to explain the reasons for the limited communication
observed.
Some researchers have suggested that poor communication in A & E may arise from di
erences in perception
between nurses and patients about the nature and urgency
of the patients problem or the patients informational
needs. For example, Calnan (1984) found that patients
were more likely to classify an injury as urgent than
nurses. Others point to di
erences in identifying patients
informational needs. For example, Clarke (1982) compared
definitions of health teaching needs of patients and nurses
in A & E and found they held di
erent priorities. Patients
rated reassurance and explanation the most highly. Nurses
were more concerned with teaching preventive measures,
an aspect which patients rated as of low importance.

Cultural factors

Sociological studies

A number of studies have explored the influence of cultural factors on nursepatient communication. Melia
(1987) found that student nurses had diculty communicating with patients because they lacked the necessary
knowledge and authority to answer patients questions.
Melia also suggests that students communication with
patients was constrained by cultural definitions of what
constituted nursing work. The real work was physical
labour and talking with patients was seen as not pulling
your weight. Peterson (1988) found that qualified nurses
are also influenced by the prevailing culture within a
hospital setting.
Peterson reports that groups of qualified nurses on three
medical floors developed norms and values which influenced behaviour patterns, beliefs and attitudes on each
floor. She describes these interactions as cool, ecient
and rushed on one unit, casual, warm and somewhat
superficial on the second unit and brusque and
businesslike on the third. Smith (1991) also found the
emotional climate on a ward was central to creating an
atmosphere in which the emotional labour of caring for
patients could e
ectively occur. Smith found that the ward
sister or charge nurse was the person most influential in
making the emotional care visible to, and valued by,
nurses.
Little research has examined nursepatient communication in A & E departments. However, a small study by
Wood (1979), using structured observation, supports the

Sociological studies have examined how social factors may

influence communication with and treatment of patients
in A & E. Roth (1972) and Je
ery (1979) describe the attitudes of sta
to deviant patients, for example drunks,
overdoses and tramps. They suggest that these patients
are perceived by sta
as having a low social value and
that this perception influences their treatment. Thus, sta

can make judgements about their patients on the basis of
social stereotypes and such judgements have an impact on
the quality of communication and physical care.
The present study has used a symbolic interactionist
perspective to explore how nurses perceptions of their
work and patients may influence the nature of nurse
patient communication and the extent to which nurses
deal with patients anxieties in A & E. Symbolic interactionism allows the perceptions of those involved in any
situation to be explored in detail, and the meaning they
attach to events to be considered. Using this approach may
help to explain the nature of nursepatient communication
with reference to the context in which it occurs. It also
provides insight into some of the factors influencing
nursepatient communication in A & E, an area which has
been little studied.

LITERATURE REVIEW

94

SYM BOLIC INTERACTIONISM

A symbolic interactionist approach aims to understand the
social group studied by exploring the relationship between

1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 93100

Communication with patients

social structure and the meanings by which individuals
interpret and create their social world. The perspective
originated from the work of George Herbert Mead (1913,
1924, 1934, 1964). Meads work has had a profound e
ect
on sociological and psychological thought, although there
are wide variations in the way in which his theories have
been interpreted and propounded (Stryker 1981).
However, as Meltzer et al. (1975) point out, all symbolic
interactionists take as basic premises that humans act
toward things on the meaning those things have for them,
that meanings emerge from social interaction and that
meanings are modified and dealt with through an
interpretative process. Using symbolic communication
involving gestures and language, individuals interpret
social situations and respond in a way they deem appropriate. This action, in turn, is designed as a stimulus to
others involved in that interaction to draw from them the
desired response (Burkitt 1991).
For Mead self and society exist in a dialectical relationship. Individuals are born into a symbolic social world
which defines their identity and concept of self, but actively
interpret and modify these definitions. Individuals are seen
as actively creating the social world in which they participate, as well as being shaped by it. Symbolic interactionists perceive the social world, therefore, as a social
process in which social situations are constantly being
changed and reorganized by those involved in them.
Stryker (1981) argues that it is the concept of role which
serves as the point of articulation the bridge between
social structure and the individual. Mead describes how
individuals reconstruct the past, according to problems or
conflicts they must solve in the present, in order to create
a better future. A role is the function an individual performs in this activity of adaptation (Burkitt 1991). As the
social world and process of adaptation are constantly
changing, so are the roles of individuals. At the same
time, individuals are seen as playing an active part in
constructing new roles.
In the present study, understanding how nurses in A &
E interpreted their role was central to understanding how
they organized their work and interacted with patients.
Nurses viewed their role as one which was predominantly
concerned with providing urgent physical care. This conception of their role led them to view patients who
attended with old or trivial injuries as time wasters.
However, this view would be interpreted within the context of their interaction with each individual patient and
some would negotiate a more favourable response. For
example, parents who attended the department with young
children seemed to elicit sympathy, even when the injury
was very minor. On the other hand, nurses were reluctant
to be too helpful to drunks and regulars who used the
department as this might encourage them to attend more
frequently. Nurses were clear that dealing with drunks
and regulars was not a proper part of their role.

Social interaction also occurs within a social context

whereby members of a group influence and are influenced
by each other. Symbolic interactionism stresses the continuing nature of socialization throughout adult life. While
recognizing the unique views of participants, symbolic
interactionism is concerned to explore how interactions
with other group members may contribute to the individuals learning sets of beliefs, attitudes and behaviours
which are held in common. Thus the nurses view of the
A & E department and the role of the nurse in it, is influenced by information received during professional training, and by further socialization which occurs in the work
setting. Nurses, therefore, both create and are influenced
by a culture which defines their work and attitudes
towards patients.
Symbolic interactionism provides a valuable perspective from which to study social interaction in the A & E
department and allows the complex processes by which
participants understand, interpret and create their world
to be explored in detail. In order to explore these processes
a qualitative approach to research is usually preferred.
Direct observation, interviewing, life-histories, letters and
diaries may all be useful in exploring aspects of social life
(Blumer 1969). The study reported here relies on the
accounts of nurses gathered through in-depth interviews
to explore their views of their work and patients.

THE PRESENT STUDY

The aims of the study were:
$

To investigate nurses perceptions of their work and

patients in two A & E departments and explore how
these influenced their practice.
To explore nurses views of their role in dealing with
patients anxieties.

Research design
The research formed part of a wider study looking at
patient anxiety and nursepatient communication in A &
E (Byrne 1992). Two A & E departments, within the same
health authority, were used for the study (department A
and department B). The two departments were studied
concurrently. The research was divided into three stages.
Stage one involved structured interviews with patients to
identify the sources of anxiety for patients in A & E. Stage
two consisted of in-depth interviews with nurses in each
department to explore their perceptions of their work and
patients. Stage three was an observational study which
examined the nature of nursepatient communication in
A & E. This paper reports on the interviews with nurses
conducted during stage two of the research and discusses
the three categories generated which elaborate the nurses
perceptions of their work and patients and how they

1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 93100

95

G. Byrne and R. Heyman

influenced nursepatient communication. The way in
which they defined their role and its impact on how
patients anxieties were addressed is explored.

The interviews
Sampling
In-depth interviews were conducted with all the qualified
nurses working in the two departments (apart from those
working permanent night duty). The purpose of the interviews was explained and none of the nurses refused to
take part. This resulted in 13 interviews in department A
and eight in department B. Of the sample, three were male,
and 10 female. Six were at sister/charge nurse grade, two
were enrolled nurses, and five were sta
nurses.

Procedure
The interviews took place in the sisters oce in each
department. In both departments this was a room which
was quiet and predominantly free from interruptions. The
interviews took place at a time convenient to the nurses,
early in the morning in department A, and in the middle
of the afternoon in department B. Only one or two interviews were conducted each day. As data analysis took
place concurrently the interviews were conducted over a
period of several months.
At the beginning of each interview, the purpose was
again explained, and permission to tape record obtained.
The researcher explained that although there was a list of
topics which she wanted to cover, this was not rigid and
nurses could raise other relevant issues. Respondents were
reminded that the interview would be treated as confidential. Interviews started with a discussion of general topics,
such as how long the nurses had worked in A & E, where
they had worked before, and what their impressions had
been on coming to work in the department. These questions provided useful background information, as well as
a starting point for other lines of enquiry. The interviews
progressed in the form of a purposeful conversation
(Burgess 1984). Such an approach allowed the interview
to proceed in a natural and spontaneous way which
enabled the meanings and interpretations of the nurses to
be explored. The interviews lasted between 40 minutes
and 1 hour, during which time the nurses talked in a way
which seemed unconstrained about their attitudes towards
their work and patients, perceptions of their role, the
everyday rewards and demands they encountered in their
work and the strategies they used to achieve their ends.
The process of interviewing and analysis followed the
principles described by Strauss and Corbin (1990) to generate a grounded theory. Using this method, themes arising
in early interviews were used to direct the focus of those
conducted later. For example, in the early interviews,
nurses were asked about their work, and tended to describe
aspects which they found most and least rewarding. In
96

later interviews reasons underlying these preferences and

their influence on practice were explored. Many views
were held in common. When unusual views were
expressed, individual motivations and experiences could
be probed.

Analysis
Interview transcripts were transcribed verbatim by the
researcher, and analysed using the constant comparative
method (Chenitz & Swanson 1986). Significant themes were
pursued as they emerged, and each transcript was examined
in detail and the data grouped according to identifiable
themes. This early coding is described as open coding
(Strauss & Corbin 1990) and is concerned with the naming
and categorization of the data. Once identified, these themes
were then compared with those arising in subsequent interviews, and used to direct further enquiry. Thus, a theme
elaborating the contrast between the nurses experience of
A & E work and their expectations arose in the first interview. Exploring this issue in subsequent interviews proved
fruitful. Initially, 22 themes were identified covering a wide
range of nurses experiences of working in A & E. With
continued scrutiny and comparison, relationships between
themes were recognized.
This process of identifying associations and relationships between themes is described as axial coding, and
leads to the merging of related themes to form categories.
In the present study, themes which outlined the contrast
between nurses expectations of working in A & E and the
reality of doing so, factors which influenced job satisfaction and nurses perceptions of the purpose of A & E were
found to share a number of common elements. Each was
concerned with how nurses defined the role of the A & E
nurse. These three themes were therefore merged to form
this category.
Strauss and Corbin (1990) describe the process of
developing a grounded theory as one which results in a
storyline which explicates the central meaning of the
phenomenon. The final stage of coding is identifying the
core category of the theory. Other categories should be
systematically related to and integrated with the core
theory. In the present study Defining the role of the A &
E department nurse was identified as the core category.
This category illuminates the nurses perceptions of their
role and purpose as being primarily concerned with dealing with emergencies and providing urgent physical care.
The other two categories delineate the impact this view
had on the organization and delivery of nursing care in A
& E and its e
ect on nursepatient communication.

Category one: defining the role of the A & E

department nurse
The first category was generated initially from the nurses
responses to the question of why they had chosen to work

1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 93100

Communication with patients

in A & E. A striking element of the accounts was the
number of nurses who had been attracted to working in A
& E because of the excitement and drama they believed
such work would involve. However, they discovered that,
in reality, much of their work was not of this nature. As
one nurse states, I thought it would be loads of major
things and you just dont realise the amount of tripe that
comes through the door. The above statement illustrates
the contrast between this nurses perceptions of what it
would be like to work in A & E and what, in reality, she
found the work to involve. Many of the nurses interviewed
described this contrast.
Despite their relative rarity, caring for major trauma
patients was an aspect of their work which was valued by
almost all of the nurses. As one nurse reported, Most
nurses who work in casualty like the excitement of, you
know, you get a lot of minor stu
but its the major stu

that keeps peoples interest. Only one, older, nurse commented that, having spent years working in A & E, she had
now less interest in major trauma and increasingly found
caring for other patients, particularly the elderly, more
rewarding. An important feature of major trauma patients
was, as one nurse states, that they allowed nurses to exercise certain practical, often technical, skills, When I say
major trauma I include MIs [myocardial infarctions]. To
me an acute MI is part of, its not strictly major trauma but
I class it as such. Its where you know your skills are going
to be called on. A second nurse comments, Its what I
think were here for, whilst another describes how major
trauma patients really do need you.
The importance nurses attached to these patients can be
understood using a symbolic interactionist perspective. In
addition to allowing nurses to demonstrate their technical
skill, caring for major trauma patients contained an
emotional component of the relationship. The nurses felt
needed by these patients, which they found satisfying. The
major trauma patients therefore provided nurses with an
opportunity to feel both technically expert and rewardingly useful. From a symbolic interactionist perspective, it
is understandable that nurses enjoyed caring for major
trauma patients the most. The emphasis on major trauma
may have contributed towards the limited attention which
Wood (1979) describes as given to minor patients.
In contrast to managing major trauma, caring for
minor patients was generally regarded as less interesting
or, as one nurse described it, as very repetitive and boring.
However, as the nurses commented, major trauma
patients formed only a small part of their work. As one
nurse said Its more sprained ankles than anything else.
Despite this, the nurses definition of major trauma as the
most important aspect of their work appeared to influence
the way in which they organized it. Thus, although these
patients formed only a small part of the workload, the
organization of both departments was geared towards their
care. In many ways, the urgent attention required by these

patients justifies the emphasis placed on them. However,

this view did have an impact on the organization of nursing work and on communication with patients, as the
following two categories show.

Category two: nurses priorities and patients

anxieties
This second category elucidates the way in which nurses
perceived patients anxieties in the accident and emergency department and the factors which influenced how
these anxieties would be addressed. As we have seen, the
nurses saw their priority as the provision of urgent physical care. However, they were also conscious that many
people who attended A & E were likely to be anxious.
Almost all said they thought every patient would have
some degree of anxiety. An interesting theme which
emerged was the types of patients the nurses thought
would be the most anxious. There was general agreement
that those with more serious illnesses and injuries would
be more anxious than those with minor injuries. As one
nurse said:
I think the majority of them probably are [anxious]... I think the
majority of the cabins, I think the cabin patients [i.e. those with
more serious conditions] are probably more anxious. Their injuries or illnesses are more severe and theyre basically the ones who
may have to stay in hospital.

While it is conceivable that certain types of patients may

tend to be more anxious than others, there is a danger
inherent in such assumptions. Relying on such assumptions about the amount of anxiety di
erent types of
patients experience may lead to incorrect assessment of
individual patients. One of the reasons why nurses relied
on these common assumptions about patients was, they
reported, because they had insucient time to deal with
each patient individually. The following extract reveals
the priority they gave to physical care.
If it is busy then all the nice things youve been taught about what
youve got to do and how to look after patients go out of the
window and its just task oriented. Youve got to get this one done
because you know theres another one waiting for you and theres
very little... I think when its quiet then you can look after your
patients, advise them whats going on, but when its busy the
patient as a person thing gets forgotten.

The above extract suggests that the nurses often felt

under constant pressure to complete one task so that they
could progress to the next. Holistic, individualized care
was seen as an impossible ideal. The nurses reported that
even when they were in the process of caring for a patient
they were constantly interrupted and, in any case, were
themselves conscious of other tasks they needed to perform. Attempting to cope with so many conflicting
demands simultaneously made dealing with patients
anxieties a dicult task.

1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 93100

97

G. Byrne and R. Heyman

The way nurses described their experiences was very
much in terms of how they coped. The symbolic interactionist perspective recognizes that individuals direct
their action according to their own means and ends. The
nurses felt that problems arising from the volume of work
they frequently faced and pressure of conflicting demands
being simultaneously made on them were impossible to
resolve adequately. The only way they could cope was by
concentrating on physical care, and developing strategies
to do so in minimal time.
One of the most commonly described ways of achieving
this was by popping in on patients as a means of organizing care. Many nurses described this process. Nurses used
various terms, but the most common were popping in and
out, dashing in and out and nipping in on patients.
Using this strategy meant that nurses could avoid spending
lengthy amounts of time with patients, but feel confident
that any major problems would be identified. It is conceivable that such a strategy may be useful in providing physical care but its value in addressing patients anxieties is
doubtful. The nurses themselves were conscious of the
limitations of this approach as the following comment
indicates:

how they undertook a great number of tasks which were

not necessarily nursing duties in order to fulfil their own
wider aim of keeping the department running smoothly.
A nurse in department B described the diculties they
faced: We only have one domestic, and if you want a
porter you have to ring for one... you cant ring every time
you want a porter, so you end up doing his job. The reason
they do this, she goes on to say, is, To keep the department
flowing, everything ticking over. Thats the main thing.
Keeping the department ticking over when youre busy.
The nurses in department A reported similar actions and
motives. From the above accounts it would seem that
nurses are prepared to take on a variety of non-nursing
duties in order to speed things up.
The importance nurses attached to keeping the department running smoothly is central to understanding the
way in which they organized care. Thus, nurses described
talking to patients as something they did if the routine
allowed, but which was necessarily abandoned when the
department was busy.
I mean often if it was in the curtains [where minor patients are
seen] say, you might call in the patient, and you might send them
to X-ray and then the next time you see them is when youre going

It must be awful when you just go in and do your bit, and then

to strap up their ankle, to tell them that theyre going to fracture

theyre just left. For all you say Ill be popping back and forwards

clinic, and you might have seen them for what, maybe 5 minutes...

and my name is such and such. Shout if you want something, but

Its far easier down in the cabins where its on a one-to-one basis...

Ill be popping back.

Also the times when they need it [psychological support] is when

The strategy of popping in on patients is consistent

with the description of nursepatient interaction given by
Wood (1979) and McCleod Clark (1982). Such an approach
would make it dicult to ensure that the anxieties of
patients were identified and dealt with. Indeed, the strategy of popping in and out would be likely to deter
patients from expressing any worries, or making any
demands of the nurse unless they were urgent. However,
to label it as poor communication is misleading as to do
so fails to recognize that nurses could be consciously using
the strategy. They were also communicating that they were
busy and patients needed to wait. The strategy could also
have a positive value. When the department was busy,
popping in on patients was one way of demonstrating to
patients that they hadnt been forgotten and providing
some contact with a nurse.

Category three: keeping the department running

smoothly
The material in the previous categories has shown that
nurses perceptions of their work and patients influenced
the way in which they delivered care. The present category
elucidates further how the role of the A & E nurse was
developed and maintained. A central aim was defined as
keeping the department running smoothly. The nurses
view of their role was influenced by their concern that the
department should run eciently. The nurses described
98

youre the busiest and thats the time theyre not going to get it.

It is clear, therefore, that nurses felt that it was important

to provide psychological support for patients, but that getting patients through the department quickly was a more
pressing aim. Also, as the above nurse points out, it is
easier to provide support to patients whose condition
requires a degree of continuity of nursing care. Minor
patients, who were likely to be in contact with a number
of di
erent nurses for short periods of time, may be less
likely to have their fears addressed.

DISCUSSION
The symbolic interactionist perspective has provided a
useful framework for understanding some of the complex
processes which influence nursepatient communication
in A & E. Interviews with nurses have suggested that definitions of their priorities and perceptions of their patients
influence the nature and quality of communication. Thus,
a primary concern was keeping the department running
smoothly. Nurses also expressed their sense of constantly
dealing with competing demands and pressures. This perceived constant pressure led to the nurses feeling that the
more time spent with one patient, the less was available
for others. Hence the strategy of popping in on patients
developed as a means of dealing with these competing
demands.

1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 93100

Communication with patients

Such a fragmented approach to care is often defined
as poor communication (Faulkner 1979, Wood 1979,
Macleod Clark 1982). The present study suggests, however,
that such a conclusion is over-simplistic and that there is
evidence that nurses are, in fact, extremely good communicators. Their strategy of popping in on patients was e
ective in conveying to patients that they were busy and
therefore unavailable for unnecessary conversation.
Menzies (1970) suggests that nurses use such techniques
to block dicult conversations in order to prevent their
own feelings of discomfort at having no solution to o
er
to the patients problems. Rather than reflecting poor communication skills, this strategy would allow nurses to control the topics which arose.
Chapman (1983) argues that ritual procedures which
nurses perform may also have a symbolic significance.
Bocock (1974) defines rituals as The symbolic use of bodily
movement and gesture in a social situation to express and
articulate meaning. In the A & E department, popping in
on patients can be seen as a ritual act which provided the
patient at regular intervals with the support of a nurses
presence. Nurses often worked under considerable pressure
and were faced with conflicting demands. Thus, at times
when they were busy and unable to provide more substantial support, the act of popping in may have served to
reassure patients that they had not been forgotten.
The conclusion that poor communication is a problem
to be located with the individual nurse also deserves
further consideration. Practical and cultural factors can
influence the quality and extent of nurses communication
with patients (Melia 1987, Peterson 1988, Smith 1991). In
the present study, individual factors and the culture of the
departments combined to define the aspects of work which
were most important. Thus, nurses were attracted to
working in A & E because of the excitement and variety
they believed this type of nursing would entail. The
emphasis which individuals placed on this aspect, exemplified in their preference for major trauma, was part of
a group culture which emphasized its importance. An
important secondary concern was, keeping the department running smoothly. Nurses felt they must concentrate
on getting patients through the department quickly rather
than spending time talking with them. The ways in which
nurses defined their role, therefore, were central in understanding their interaction with patients.
However, nurses were conscious of the problem of
patients anxieties and attempted to deal with them, within
the constraints of their workload. For example, one reason
nurses gave for the importance they attached to keeping
the department running smoothly was to hasten the
patients progress through the department. The nurses
assumed that patients in the department were likely to be
anxious. An e
ective way of reducing their anxiety was
by shortening the amount of time patients spent in the
department.

Conclusion
This was a small study, conducted by one researcher in
only two departments but it has provided some insight
into how nurses perceptions of their work and patients
may influence communication. The interviews have
allowed only accounts of the nurses motives and actions
to be considered. The larger study included unstructured
and structured observation to examine the nature of nurse
patient interaction and explore the relationship between
nurses views and behaviour. Generally the observational
data support the descriptions of actions reported at interview. A criticism of much research into nursepatient
communication is that the contribution of the patient is
ignored ( Jarrett & Payne 1995). This was partially explored
in other parts of the present study which found that many
patients reported anxiety which was not addressed by
nurses.
The material gathered through interview has emphasized the nurses views but does help to explain some of
the reasons why patients anxieties were not always
addressed. However, in order to gain a more complete
understanding of social interaction the perspectives of all
those involved must be considered and there is a need for
future research to investigate patients perspectives and
experiences further.

References
Bocock R. (1974) Ritual in Industrial Society. Allen and Unwin,
London.
Bond S. (1982) Communication in cancer nursing. In Recent
Advances in Nursing 3: Cancer Nursing (Cahoon M.C. ed.),
Churchill Livingstone, Edinburgh, pp. 330.
Byrne G.S. (1992) The accident and emergency department:
nurses priorities and patients anxieties. Unpublished PhD
thesis, University of Northumbria.
Blumer M. (1969) Symbolic Interactionism: Perspective and
Method. Prentice Hall, Englewood Cli
s, New Jersey.
Burgess R.G. (1984) In the Field. An Introduction to Field
Research. Routledge, London.
Burkitt I. (1991) Social Selves. Theories of the Social Formation
of Personality. Sage, London.
Calnan M. (1984) Functions of the hospital emergency department. Journal of Emergency Medicine 2, 5763.
Chapman G.E. (1983) Ritual and rational action in hospitals. Journal of Advanced Nursing 8, 1320.
Chenitz W. & Swanson J. (1986) From Practice to Grounded
Theory. AddisonWesley, Menlo Park, California.
Clarke E. (1982) Patient health teaching needs. Journal of
Emergency Nursing 10(3), 151155.
Faulkner A. (1979) Monitoring nursepatient communication on
a ward. Nursing Times, Occasional Papers 75(23), 9596.
Hayward J.C. (1975) Information A Prescription Against Pain.
Royal College of Nursing, London.
Heyman R. & Shaw M. (1984) Looking at relationships in nursing.

1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 93100

99

G. Byrne and R. Heyman

In Understanding Nurses: The Social Psychology of Nursing
(Skevington S. ed.), John Wiley, Chichester, pp. 2947.
Jarrett N. & Payne S. (1995) A selective review of the literature
on nursepatient communication: has the patients contribution been neglected? Journal of Advanced Nursing 22,
7278.
Je
ery R. (1979) Normal rubbish: deviant patients in casualty
departments. Sociology of Health and Illness 1(1), 90107.
Macleod Clark J. (1982) Nursepatient verbal interaction: an
analysis of recorded conversations on selected surgical wards.
Unpublished PhD thesis, University of London, London.
May C. (1990) Research on nursepatient relationships: problems
of theory, problems of practice. Journal of Advanced Nursing
15, 307315.
Mead G.H. (1913) The social self. In Selected Writings:
George Herbert Mead (Reck A.J. ed.), Chicago University Press,
Chicago.
Mead G.H. (1924) The genesis of self and social control. In Selected Writings: George Herbert Mead (Reck A.J. ed.), Chicago
University Press, Chicago.
Mead G.H. (1934) Mind, Self and Society. From the Standpoint
of a Social Behaviourist. Chicago University Press, Chicago.
Mead G.H. (1964) On Social Psychology. Selected Papers (edited
by Strauss A.), University of Chicago Press, Chicago.
Melia K. (1987) Learning and Working: The Occupational Socialisation of Nurses. Tavistock, London.
Meltzer M., Petras J.W. & Reynolds L.T. (1975) Symbolic Interactionism: Genesis, Varieties and Criticism. Kegan Paul,
London.

100

Menzies I.E. (1970) The Functioning of Social Systems as a

Defence Against Anxiety. Tavistock, London, Pamphlet No. 5.
Peterson M. (1988) The norms and values held by three groups of
nurses concerning psychosocial nursing practice. International
Journal of Nursing Studies 25(2), 85103.
Roth J. (1972) Some contingencies of the moral evaluation and
control of clientele: the case of the hospital emergency service.
American Journal of Sociology 77(5), 839855.
Smith P. (1991) The Emotional Labour of Nursing. Macmillan,
London.
Stockwell F. (1972) The Unpopular Patient. Royal College of
Nursing, London.
Strauss A. & Corbin J. (1990) Basics of Qualitative Research.
Grounded Theory Procedures and Techniques. Sage, London.
Stryker S. (1981) Symbolic interactionism: themes and variations.
In Social Psychology: Sociological Perspectives (Rosenberg M.
& Turner R.H. eds), Basic Books, New York, p. 20.
Sundeen S.J., Stuart G.W., Rankin E.A. & Cohen S.A. (1994)
NurseClient Interaction. Implementing the Nursing Process 5th
edn. C.V. Mosby, St Louis.
Thompson D. (1989) A randomised controlled trial of in-hospital
nursing support for first time myocardial infarction patients and
their partners: e
ects on anxiety and depression. Journal of
Advanced Nursing 14, 291297.
Wilson-Barnett J. (1980) Anxiety for hospitalised patients. Royal
Society of Health Journal 101, 118122.
Wood K.M. (1979) NursePatient Communication in an Accident
Department. Unpublished MSc thesis, Manchester University,
Manchester.

1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 93100