A Person, L Finch
advanced practice nurse behavior, advanced practice nurse caring, advanced practice nurse communication, bedside manner, bedside manner concept, patient perceptions
A Person, L Finch. Bedside Manner: Concept Analysis and Impact on Advanced Nursing Practice. The Internet Journal of Advanced Nursing Practice. 2008 Volume 10 Number 1.
Bedside manner has received little in-depth evaluation in the literature, especially from an advanced nursing practice perspective. Concept analysis revealed specific provider behaviors that are consistently deemed positive or negative by patients. Positive behaviors include displays of respect, courtesy, and listening ([
Bedside manner is a term with which most medical professionals and lay persons are familiar. A provider’s bedside manner can impact professional reputation in the community, affect the loyalty of patients, and even impact effectiveness (). Once thought to be a “personality trait” or an inherent ability, many medical schools are now attempting to teach bedside manner to prospective physicians (). This trend to provide education on bedside manner may be attributable to patient demands for more personal healthcare (). While the term “bedside manner” may be readily recognizable to both medical personnel and to the public, this concept has received little attention in the literature. In addition to being a poorly described concept, the significance and relationship of bedside manner to the Advanced Practice Nurse ([APN]) is lacking insight. This paper will analyze the concept of bedside manner, determine how bedside manner impacts advanced nursing practice and education, and identify areas for further research.
The purpose of concept analysis is to recognize, define, and clarify phenomena to improve understanding and promote further research. A concept is a phenomenon that occurs in nature or in thought and is derived from certain attributes. Through the process of concept analysis, ideas area broken down and analyzed through identification of key features of the concept. These features include: attributes, which are the characteristics that define a concept and are consistently seen when the concept exists; antecedents, which is what must occur for the concept to exist; consequences, or the results of concept existence; and, empirical referents, which are phenomena that, by their existence, demonstrate the occurrence of the concept ().
The concept of bedside manner warrants analysis and scrutiny because good bedside manner is highly valued by patients, yet bedside manner has received minimal literary attention ([[[[13; 14]]]]). One study showed that patients value good bedside manner and listening skills more than clinical competence (). In addition to patient satisfaction with care, good bedside manner has also been implicated in improving overall health status ([[[[5; 15; 16]]]]). The relevance of practitioner behavior in medical care has been said to be of greater importance to customers than in other service professions. This increased significance has been related to the fact that the customers must bare themselves both physically and emotionally (). While the value of good bedside manner has been established, specific behaviors and actions that dictate and guide this experience have received little attention ().
The term bedside manner dates back as far as 1869. The Merriam-Webster dictionary definition of “bedside manner” is “the manner that a physician assumes towards a patient” (). For further clarification, the term “manner” is defined as “a way of acting”. The term “bedside” literally means “the side of a bed” (). In healthcare, references to “bedside” may have the literal meaning of being by a patient in their bed, or simply imply a personal encounter with a patient.
From these definitions, the assumption can be made that bedside manner is a behavior or group of behaviors. All human behaviors have been theorized to result in a multitude of consequences; intentional and unintentional, positive and negative (). Considering the consequences of human behavior, it can thus be assumed that health provider behaviors, communicated through an encounter designated as bedside manner, result in an experience for patients, one that may be perceived as positive or negative.
Review of Literature
Various provider behaviors have been identified by patients as consistently positive or negative. Verbal communication skills are reported as very valuable when patients assess the performance of their provider ([[[[15; 16; 19]]]]). One study that assessed the value of communication skills found that physicians who where deemed as being good listeners had the best relationships with patients and the least amount of complaints (). A similar study reported that patients related bedside manner and listening skills with the feeling that their clinician really cared about them (). Specific to advanced nursing practice, research has identified communication skills and longer visits as a favorite aspect of APN care (). Non-verbal communication, such as neat appearance and body language, have been said to relay a positive impact on patient’s perceptions of provider bedside manner as well as effectiveness (). Other non-verbal cues associated with a positive experience for patients include eye contact, body position, and tone of voice ().
Humanistic behaviors such as care and concern are also frequently reported by patients as positive and desirable. One study of patients cared for by APNs found a statistically significant correlation between patient satisfaction and the feeling that the nurse practitioner was caring (). Additionally, Finch () questioned patients as to what behaviors and actions were expected from nurses, with “caring” as the most common response. “Caring” was described as concerned, compassionate, genuine, and kind (). In the United Kingdom, a national summit sought feedback from the public of their expectations and desires from primary care services. The findings revealed that the public’s priority was care that was interpersonal, including sympathy and attention (). Findings from a study () that asked patients what made a medical provider “good” reported sensitivity as the most common response. Similarly, Bendapudi and colleagues () asked patients to describe their ideal doctor. The top responses were a provider who was confident, empathetic, humane, personal, forthright, respectful, and thorough ().
The literature also revealed information about provider behaviors deemed negative and related to undesirable and negative patient experiences. Luthy and colleagues () identified good clinicians as being sensitive and bad clinicians as “self-serving”. An article discussing patient satisfaction with medical care cited “bad” providers as being arrogant, rude, dismissive, and indifferent (). Behaviors such as insensitivity, lack of respect, arrogance, disinterest, and impatience were reported when a group of patients were asked to describe their worst experience with a clinician (). Disrespect, distrust, and unavailability where also reported as negative provider behaviors ().
The review of literature revealed that patients typically described clinicians based on interpersonal behaviors with little mention of clinical skills or competence. Bendapudi and colleagues () theorized that patients lack the knowledge to judge their provider’s technical quality. These authors also proposed that most patients view clinical proficiency as an expectation, perhaps limiting focus on clinical competence or expertise. Therefore, providers appear to be judged by what the lay person can readily assess, most often being overt behavior.
From the review of literature, concrete critical attributes of bedside manner do not appear to exist, and further, clear identification of bedside manner attributes has received little study (). The literature did reveal, however, common themes of patient-perceived encounters with positive or negative connotations. Positive provider behaviors were described as empathetic, friendly, listener, effective communicator, courteous, caring, and respectful ([[[[1; 2; 21; 22; 23]]]]). Terms describing bad or negative provider behaviors included rude, arrogant, dismissive, uncaring, and indifferent ([[[[1; 3; 23]]]]). Along with behavior, appearance was found to impact the patient’s impression of their clinician, including neatness and body language ([[[[1; 20]]]]).
In the case of bedside manner, the primary and basic antecedent is an interaction between provider and patient. Bedside manner, or provider behavior, will always exist when there is an encounter with a patient, yielding a positive or negative experience (). These interactions may occur in various settings, including medical offices, community clinics, hospitals, or by telephone. Since provider behaviors may be unspoken, such as body language, a verbal interaction does not have to occur for bedside manner to exist (). Current research also reports that good bedside manner is a skill, inferring that if one does not exhibit it, development and mastery may occur (). While good bedside manner is proposed as a learnable skill, specialized training in bedside manner is not included as an antecedent. According to Merton’s theory of human behavior, which states that all human interactions reveal behaviors with subsequent consequences, providers will exhibit intentional and unintentional behaviors when engaging with patients whether training on this interaction has been received or not ().
Consequences of bedside manner are dependant on each patient’s perception of the encounter and whether the provider’s behavior and the patient’s overall experience are deemed as positive or negative. A multitude of positive consequences of bedside manner have been demonstrated in the literature and are directly related to the patient’s perceptions. Research has shown that patients who feel that their provider has good bedside manner are more compliant with treatment regimens, have more positive health outcomes, and are satisfied with the care that they receive ([[[[5; 6; 7; 8; 24]]]]).
Negative consequences of bedside manner can be as equally dramatic as the positive ones. Patients whom feel their provider has poor bedside manner have been shown to be less compliant with treatment regimens, have poorer outcomes, and are generally less satisfied with the relationship with their provider ([[[[5; 7]]]]). Patients whom report that their provider does not listen to them hold the highest correlation with reports of poor bedside manner and less desirable health outcomes ().
Identification of concrete empirical referents for bedside manner is difficult due to limited research of the phenomenon as well as the subjectivity of the experience. In the presence of the phenomenon of bedside manner, other consequential phenomena will likely occur. Just as providers will always exhibit some sort of behavior toward each patient, the patient will have impressions and perceptions based on the experience. The challenge in universal description of empirical referents, similar to that of the attributes, is that each patient interprets bedside manner and the behavior of others differently ([[[[1; 18]]]]). Further research is indicated in this area to clearly identify those phenomena which coexist with good and bad bedside manner.
Implications For Practice
Literature to date has typically discussed bedside manner related to physicians; however, the number of APNs delivering primary and tertiary care is increasing and expected to continue to rise (). Bedside manner has been shown to occur in every provider-patient contact, and APNs need to be privy to the impact of this interaction. Research has shown that patients are more likely to judge their provider’s ability to communicate as well as interpersonal behaviors, such as expressions of care and empathy, more so than clinical abilities (). Furthermore, concept analysis of bedside manner revealed outcomes-related consequences that may prove vital to the development and maintenance of effective, holistic advanced nursing practice.
The impact of bedside manner on patient compliance is of utmost importance (). Patients who perceive their provider’s behavior as positive have been shown to be more compliant with treatment regimens (). Good bedside manner also improves communication and the professional relationship, and effective relationships have revealed the greatest impact on adherence to education strategies and therapeutic regimens (). Patient compliance is vital to health and wellness, and effective bedside manner is a strategy without cost in which APNs may improve patient adherence. In addition to compliance with regimens, research supports the influence of bedside manner on actual and perceived health status (). Care that is patient-centered and includes the positive attributes of bedside manner has been shown to improve recovery from illness, revealing a link between provider behavior and effective disease management (). As well as increased efficacy of care delivery, bedside manner impacts cost effectiveness (). Decreasing expenditures is relevant since healthcare responsibilities of practicing APNs are expanding, including delivery of cost effective care (). A study by Stewart and colleagues () revealed that patients who felt their provider displayed care, empathy, and effective communication had significant reductions in health care costs. Spared resources were in the form of a 50% decrease in specialist referrals and a 75% decrease in diagnostic tests (). While clinically competent care is of utmost importance, these discoveries support the need for APNs to focus on behaviors as heavily as diagnosis and treatment ().
Implications For Education
An understanding of bedside manner will enhance nurse-patient relationships, lead to more accurate assessments, and thus, promote improvement in patient outcomes. APNs must develop and maintain holistic and caring characteristics inherent to nursing to continue delivery of quality and satisfying nurse practitioner care (). Knowing about bedside manner, both the concept and related behaviors, can be used to develop teaching strategies to be integrated into basic baccalaureate as well as advanced practice nursing programs.
Historically, literature has deemed bedside manner as a “personality trait” or an inherent gift (). Current research, however, regards provider behavior in patient interactions as a skill that may be learned and taught (). Physician education has already begun to embrace both the importance of bedside manner and the need to include this concept in medical training (). Concept analysis has revealed numerous benefits of effective bedside manner, and inclusion of this concept in nursing curriculum warrants consideration. Two increasingly accepted methods of bedside manner education are simulation scenarios and direct supervision of patient encounters ().
Simulation of encounters with “patients”, whom may be faculty, other students, or lay persons, is one strategy for bedside manner education (). One method for utilizing simulation scenarios is through faculty observation of simulated patient encounters. Students receive feedback from faculty regarding responses to simulated patient questions, the manner in which concerns or challenges are handled, and nonverbal communication cues such as body language and eye contact (). Another method of instruction utilizing simulation scenarios includes formal lecture on patient interactions and evaluates learning through student self-report (). Rosenzweig and colleagues () evaluated APN students who received classroom instruction on communication, provider behaviors, and how to deal with various challenging situations. In addition, the students participated in a simulation lab composed of nursing faculty posed as patients. Students reported improved confidence and communication abilities both immediately after the simulation experience as well as 4 months after training ().
Bedside manners may also be evaluated and improved upon by direct evaluation of student interactions with actual patients. In 2006, Boehm () incorporated this method into the clinical experience of 106 medical students. Instruction and evaluation addressed nonverbal communication including proper professional attire, sitting at eye level when speaking to patients, and limitation of distractions such as television or telephones. When speaking with patients, students were encouraged to display care and emotion, using phrases such as “I am so very sorry”. At the conclusion of the rotation, students reported the experience as helpful and recommended that the exercises be incorporated into medical education ().
Indications For Research
Knowledge and study of bedside manner attributes with further clarification of desirable behaviors will help guide APN practice and education. Understanding the patient experience has many potential benefits, such as allowing APNs to shape practice in a way that is more therapeutic, trusting, and satisfying. An appropriate research approach into the bedside manner concept is qualitative research; specifically, phenomenological research. A phenomenological method aims to describe phenomena as they are experienced and lived (). Concept analysis has revealed a high level of subjectivity in perceptions of provider behavior, and subsequently, bedside manner. Thus, a phenomenological approach to study seems most appropriate and likely to further identify themes and shape the gestalt of bedside manner.
A research focus for APN practice should include identification of behaviors and attributes that reflect good bedside manner and the level of impact on patient health outcomes. Furthermore, insight as to which attributes of good bedside manner are seen most in care delivered by APNs versus physicians is warranted. Identification of disparities between the disciplines would be beneficial to both nursing and medical practice and education. Another research area is identification of the most effective method to educate APNs on bedside manner, patient relationships, and communication skills.
The concept of APN bedside manner has received minimal attention in nursing research and literature. While most publications related to provider behaviors discuss physicians, APNs need to be equally as diligent and conscious of behavior when interacting with patients. The impact of patient-provider encounters is evident in the consequences, as bedside manner and provider behaviors have been shown to effect patient satisfaction, compliance, and overall health status ([[[[7; 8]]]]). Further research assessing bedside manner that is specific to advanced nursing is warranted to guide and shape APN practice and curriculum.
Amanda Person, MSN, RN
60 Winding Creek Drive
Oakland, TN 38060