Background
The global shift towards outpatient cancer care has been driven by economic pressures and advances in treatment [1]. Due to this trend, effective communication between patients and nurses in time-constrained settings has become increasingly vital [2]. Although cancer remains a significant burden, with an estimated 19.3 million new cases recorded in 2020 [3], he shift to outpatient care presents unique communication challenges that warrant further investigation. This is particularly relevant considering the cancer burden in the United States, with over 1.9 million new diagnoses anticipated in 2023 [4].
In oncology care, open and clear communication is paramount, especially for outpatients who face the emotional burden of their diagnosis and treatment [5]. Nurses play a crucial role in fostering open communication and enabling patients to express concerns, regain agency, and actively participate in treatment [6]. This not only improves patients’ coping mechanisms and adherence to treatment plans but also enhances their overall quality of life and satisfaction [2, 7].
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However, in outpatient oncology settings, communication barriers pose significant challenges, potentially leading to confusion and distress among patients [8]. Unmet needs related to side effect management and psychosocial support can increase the risk of unplanned hospitalizations, highlighting the critical importance of addressing patients’ emotional well-being and empowering them to manage their treatment effectively [9]. With a growing number of cancer diagnoses worldwide, the role of communication in providing comprehensive psychosocial care, which is now recognized as the sixth vital sign in cancer nursing practice, cannot be overstated [10].
Despite the growing recognition of effective communication and psychosocial support as integral components of comprehensive cancer care [5], significant barriers to optimal communication persist within outpatient oncology settings. Limited appointment duration and brief nurse-patient interactions restrict opportunities for in-depth communication [2]. Patient reluctance to disclose concerns, coupled with nurses’ challenges in recognizing subtle cues or managing emotional distress, further intensifies communication difficulties [10].
Furthermore, while effective communication is recognized as a critical component of high-quality oncology care [11, 12], the majority of research in this area has focused on the perspectives of healthcare providers, often neglecting the nuanced communication needs and experiences of patients, particularly in outpatient setting [2]. This gap is particularly evident in studies involving Iranian cancer patients receiving outpatient treatment, in which cultural and systemic factors may uniquely influence communication patterns [13] While previous research has identified communication barriers in this population [13, 14], there remains a lack of understanding regarding their specific emotional responses, informational needs, and communication preferences.
The present study aimed to address this gap by investigating how Iranian cancer patients perceive communication with nurses in outpatient oncology clinics. Specifically, we aim to elucidate their emotional responses, informational needs, and communication preferences. A comprehensive understanding of these factors is crucial for tailoring interventions that enhance communication and optimize care experience in this patient population.
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Methods
Study design
We employed a qualitative descriptive study design to gain a comprehensive and detailed understanding of the phenomenon under investigation [15]. Qualitative descriptive approaches to nursing and healthcare research provide broad insights into particular phenomena and require researchers to remain close to the data [16]. Findings from qualitative descriptive studies on healthcare have the potential to describe the experiences of patients, families, and health providers, inform the development of health interventions and policies, and promote health and quality of life [17]. This study was conducted to explore the communication experiences of Iranian cancer patients with nurses in the outpatient oncology clinic of Urmia University of Medical Sciences, which is a major hospital in the province. This study aimed to gain a comprehensive understanding of the dynamics and challenges in patient-nurse communication in this setting.
Setting and participants
Fourteen adult cancer patients (18 years and older), undergoing outpatient treatment (chemotherapy, radiotherapy, or follow-up) and fluent in Persian or Turkish were recruited using purposive sampling. This sampling strategy maximized variations in age, cancer type, treatment modality, and time since diagnosis to capture a broad spectrum of communication experiences. Data saturation was achieved in 14 participants because no new themes emerged in subsequent interviews. The sociodemographic and clinical characteristics of the participants are detailed in Table 1.
Table 1
Sociodemographic and clinical characteristics of the study participants
Variables | N (%) | Mean ± SD |
|---|---|---|
Age, years | 40.2 ± 8.7 | |
Gender, Female | 8(57.2) | |
Working status | ||
Housewife | 6(42.8) | |
Working | 8(57.2) | |
Marital status, married | 12(85.7) | |
Education level | ||
Illiterate | 4(28.5) | |
Primary school | 3(21.5) | |
High school | 4(28.5) | |
University | 3(21.5) | |
Diagnosis period, years | 2.64 (± 1.21) | |
Clinical diagnosis | ||
Colon cancer | 2(14.3) | |
Breast cancer | 3(21.4) | |
Gastric cancer | 1(7.2) | |
Lymphoma | 3(21.4) | |
Lung cancer | 2(14.3) | |
AML | 3(21.4) | |
Religion | ||
Shia Muslim Sunni Muslim | 11(78.6) | |
3(21.4) | ||
Data collection
Individual interviews were conducted to enable an in-depth exploration of the participants’ experiences. The semi-structured interview guide (Table 2), based on a comprehensive literature review, was developed and refined through discussions within the research team, which consisted of experienced oncology nurses and qualitative researchers. The research team engaged in regular discussions and reflexivity throughout the six-month data collection and analysis process, allowing for the ongoing refinement of the interview guide and data collection strategies based on emerging insights.
Table 2
Semi-structured interview guide
1. Can you describe your communication with the nurses during your outpatient visits? |
2. What aspects of communication with nurses are considered most important? |
3. What are your expectations regarding communication with the nurses at the oncology clinic? |
4. What information or support did you hope to receive from the nurses? |
5. What specific actions or words were most impactful to the nurses? |
6. Have you ever felt hesitant in sharing your concerns or asking questions? If so, why? |
7. What are the consequences of good communication with nurses? |
8. Tell me about your overall healthcare experience with nurses. |
Interviews were conducted face-to-face in a private clinic setting, ensuring participant confidentiality and comfort. The first author (AA) audio-recorded the interviews between October 2023 and April 2024. Interviews lasted between 45 and 60 min and included the collection of sociodemographic and clinical data. The interviews began with general questions designed to understand the patient’s overall communication experience. These questions explored the nurses’ initial interactions, clinic environment, and expectations regarding communication and support. Throughout the interviews, probes and follow-up questions were used to encourage participants to elaborate on their responses and provide specific examples. This approach enabled a comprehensive understanding of the participants’ communication experiences and perceptions within the outpatient oncology setting. With participant consent, interviews were audio recorded and transcribed verbatim for analysis.
Qualitative content analysis, adhering to Graneheim and Lundman’s framework, was employed to analyze the transcripts. This analysis involved systematically summarizing the information shared by the participants in a way that accurately captured their experiences and perspectives [18]. The data analysis process occurred concurrently with data collection, allowing for ongoing refinement and exploration of emerging themes. The transcribed interviews were read multiple times to gain a comprehensive understanding of the content. Meaningful units related to patient-nurse communication were identified, and codes were developed iteratively based on both semantic similarity and the underlying meanings conveyed by the participants. The codes were then organized into categories and subcategories, reflecting the relationships and patterns within the data. Two researchers (AA and SO) independently coded the data, engaging in continuous discussion and reflection with the broader research team throughout the analysis process to ensure accuracy and depth of interpretation. To enhance rigor and reliability, their individual analyses were then systematically compared. Any discrepancies were identified and resolved through thorough discussion and consensus, ensuring the robustness of the final findings. MAXQDA software was used to manage and code the data.
Trustworthiness
The authors aimed to ensure trustworthiness by adhering to Lincoln and Guba’s criteria and the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [19, 20]. Prolonged engagement with the research setting and participants was employed, ensuring an in-depth understanding of their experiences. The purposive sampling strategy, encompassing a diverse range of participants, further strengthened the credibility of the findings. Reflexivity was actively engaged in throughout the research process, acknowledging the potential influence of the researchers’ backgrounds on data collection and interpretation. The research team held regular debriefing sessions with co-authors to obtain reflective feedback, confirm the accuracy of the primary data, and hold frequent discussions throughout the study to document their decisions and reflections. The use of semi-structured interviews allowed for flexibility and in-depth exploration of participant experiences. Additionally, the researchers shared preliminary findings with participants to confirm their accuracy (participants were offered the opportunity to review the thematic map with quotes). To enhance transferability, the study provides detailed descriptions of the research context, participants, and data collection and analysis methods. The use of verbatim quotes strengthens the link between the data and the interpretations presented, thus supporting the findings (Supplementary Material 2).
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Results
Fourteen patients with confirmed cancer diagnosis (mean age: 40 years) participated in the study. The qualitative analysis yielded three main categories: communication dynamics, barriers to communication and effective communication outcomes. Each category was divided into several subcategories, as detailed in Fig. 1.
Fig. 1
Patients’ experience of communication during their course of treatment in an oncology outpatient clinic
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Communication dynamics
Effective communication between cancer patients and nurses in outpatient oncology clinics is crucial for ensuring positive patient experiences. This study explored various aspects of communication dynamics. Cancer patients defined communication with nurses in three subcategories: verbal communication, emotional support and patient education.
Verbal communication
Participants emphasized the significance of verbal communication with nurses during outpatient visits. Patients expressed a desire for nurses to engage in meaningful dialogs, providing a safe space where patients can express their emotions and concerns. Active listening by nurses to patient anxieties, fears, and questions was also highlighted.
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“We’re with our nurses more than our doctors, so we appreciate it when they chat with us, even for a few minutes. It helps us feel heard, especially when things are tough.” (P3).
“Meaningful communication is when a nurse understands our pain and allows us to openly share our experiences.” (P7).
Emotional support
In addition to verbal communication, patients emphasized the significance of emotional support provided by nurses. Nonverbal gestures, such as hand-holding, expressions of affection and sympathy, and the provision of comfort, were highly valued. Patients expressed the need for nurses to address their holistic well-being, which encompassed physical, spiritual, and emotional aspects, and acknowledge them as individuals deserving of compassion. The positive influence of a nurse’s cheerful demeanor, kindness, and professionalism was also highlighted. One patient stated, “During painful procedures at the clinic, my nurse’s kindness sometimes provided a welcome distraction. Patients can sense everything from a nurse’s looks and demeanor.” (P4).
Patient education
Patient education emerged as a pivotal component of the nurse-patient relationship. Participants emphasized the importance of comprehensive education regarding disease etiology, prognosis, treatment modalities (e.g., chemotherapy), and self-management strategies for side effects. Patients expressed a desire for information regarding nutritional optimization and other aspects of self-care.
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One patient stated, “Cancer isn’t like catching a cold. There are so many questions swirling around in your head, but sometimes we hesitate to ask them.” (P5).
Another participant expressed a preference for specialized nurse educators: “I wish they would hire a nurse solely responsible for teaching patients. We have many questions about treatment, side effects, nutrition, and nurses need time to explain them thoroughly.” (P12).
Barriers to communication
Participants identified multiple barriers to effective communication between patients and oncology nurses. These barriers were categorized into four subcategories: negative nurse behaviors, challenging work conditions for nurses, patient-specific factors, and logistical and environmental challenges.
Negative nurse behaviors
Patients reported that certain aspects of nurse-patient communication negatively impacted their experiences. They perceived a lack of warmth and engagement in some interactions, citing instances of inattentiveness, nonverbal cues such as frowning, and a perceived lack of investment in their well-being as contributing factors. One participant stated, “The nurse in the chemotherapy clinic seemed distant and uncaring, which was distressing. It made it difficult for me to open up and communicate.” (P8).
Another participant noted, “Being sick is hard enough, but having a nurse who is not nice makes it even worse. It leaves a bad taste in your mouth and can mess with your healing.” (P3).
Challenging work conditions for nurses
Participants identified the challenging conditions experienced by nurses, including staff shortages and time constraints. These factors, such as heavy workloads, heightened stress, fatigue, and insufficient time, were reported to impede effective communication. Participants specifically cited instances of poor communication due to nurses’ high workload, often feeling that their concerns or questions were not adequately addressed. One participant noted, “The nurses here are clearly overworked. Their limited numbers make it difficult for us to feel fully confident in our care. They are constantly rushing between patients, and we sometimes worry that they are too overwhelmed to provide the attention we need. We have so many questions, but it’s hard to find a moment to ask when they’re so busy.” (P6).
Patient-specific factors
Patient-specific barriers to effective communication with nurses included preferences for gender-concordant care, language barriers, and cultural or religious beliefs. Female patients, in particular, expressed a desire for same-gender nurses, especially during interactions involving physical touch. Cultural and religious practices, such as those related to touch within the Islamic faith, were also identified as potential communication barriers. One patient noted, “Close contact, like holding hands, can be comforting, but our religion (Islam) does not allow it.” (P9).
Language barriers between Kurdish-speaking patients and predominantly Turkish-speaking nurses presented an additional challenge. A Kurdish-speaking patient explained, “Communicating with the nurses here is difficult because most are Turkish and do not understand me.” (P4).
A female patient expressed, “I prefer a female nurse for the comfort of physical touch and care. I don’t feel the same connection with male nurses.” (P2).
Furthermore, patients acknowledged that individual characteristics, such as introversion and difficulties in verbal expression, could hinder effective communication.
Logistical and environmental challenges
Logistical challenges in the clinical setting also impeded nurse-patient communication. These included high patient-to-nurse ratios, overcrowding, and insufficient bed availability, all of which limited nurses’ time and capacity for meaningful patient interactions. As one patient noted, “There aren’t enough nurses for the number of patients here, so they cannot speak with everyone.” (P6) Furthermore, some patients perceived a deficiency in communication skills training within nursing education. They suggested that inadequate emphasis on the importance of patient communication may contribute to the under-prioritization of some nurses. In the words of one patient, “some nurses do not seem to understand how crucial communication is. Perhaps they haven’t received enough training and do not prioritize it.” (P7).
Outcomes of effective communication
This study identified several positive outcomes linked to effective communication between nurses and cancer patients in outpatient oncology clinics. These benefits include commitment to treatment, coping with illness, stress reduction, and patient satisfaction.
Commitment to treatment
Patients reported that effective nurse communication, including comprehensive education regarding treatment options, potential adverse effects, and self-care strategies, significantly enhanced their motivation to adhere to the treatment plan. This increased engagement was evident in improved medication adherence, consistent attendance at follow-up appointments, and an overall sense of empowerment in managing patients’ health. One patient shared, “When the nurses actively listened and explained everything clearly, I felt they genuinely cared about my well-being. This motivated me to follow the treatment plan and take ownership of my health, making informed decisions with confidence.” (P10).
Coping with illness
Participants emphasized the vital role of communication in facilitating patient adaptation to cancer diagnoses and treatment-related challenges. Open and effective communication was perceived as empowering patients, fostering coping skills and providing essential support and guidance throughout the treatment trajectory.
“The nurses were my lifeline during a tumultuous time. Through their communication, they helped me not only understand my illness but also develop the tools to cope with its challenges. Their guidance and support empowered me to navigate my health journey with confidence and a sense of control.” (P3).
Stress reduction
Stress reduction was identified as a significant benefit of effective patient-nurse communication, as evidenced by participant feedback. One patient aptly expressed, “Being able to talk openly with my nurse helps me to feel less stressed. When I can share all the things I’m worried about or curious about, it calms me down and makes me feel better about my treatment overall.” (P11).
This highlights the crucial role of clear and open communication in mitigating patient stress. By fostering an environment in which patients feel comfortable expressing their concerns and seeking information, nurses directly contribute to patients’ emotional well-being and overall treatment experience.
Patient satisfaction
The experiences of cancer patients highlight the critical role of nurse-patient communication in fostering patient satisfaction. Patients reported that active listening, engaging in meaningful conversation, and feeling heard and valued throughout their clinic visits significantly impacted their overall satisfaction, even more so than the specific medical interventions they received.
One patient put it perfectly, saying, “I’m so much happier with the clinic and the care I get when I feel like the nurses really listen to me and we have a good chat. It makes a huge difference in my experience.” (P1).
Discussion
In outpatient oncology settings, effective nurse-patient communication is crucial for optimizing patient experiences and treatment outcomes. This qualitative study of 14 cancer patients illuminated the multidimensional nature of this communication. Patients emphasized the significance of clear verbal communication, empathetic emotional support, and comprehensive patient education. However, several barriers were identified, including negative nurse behaviors, high workloads, individual patient preferences and language barriers, staffing shortages, and perceived nurse training deficiencies. Despite these challenges, effective communication led to increased treatment adherence, improved coping mechanisms, reduced stress levels, and enhanced patient satisfaction. These findings underscore the critical role of communication in oncology care and highlight the need for targeted interventions to foster positive nurse-patient interactions.
Patients consistently emphasized the value of verbal communication with oncology nurses, expressing a preference for meaningful dialog and active listening [21]. This finding aligns with existing literature that highlights the importance of open and empathetic communication in addressing the complex needs of individuals with cancer [22]. Establishing a safe and supportive environment where patients can express their emotions, concerns, and questions is paramount in oncology care [23]. Clear, honest, and empathetic communication fosters trust and empowers patients to actively participate in their care journey.
The current study highlighted the paramount importance of emotional support in oncology nursing care. Patients frequently valued simple, compassionate gestures, such as hand-holding, touch, and expressions of empathy, above clinical interventions. The profound influence of nonverbal communication on patient well-being underscores the necessity for healthcare systems to prioritize emotional care alongside medical treatment. Patients expressed a desire to be treated holistically, with nurses attending to their physical, spiritual, and emotional needs [23]. These findings emphasize the emotional dimension of nursing care as a cornerstone of patient satisfaction and overall well-being in oncology settings.
Comprehensive patient education emerged as a pivotal factor in cultivating effective nurse-patient relationships. Study participants consistently emphasized the necessity of education encompassing disease trajectory, therapeutic options, adverse event management, and self-care strategies. These findings align with prior research that identified unmet informational needs as a significant concern for patients with cancer [21]. Clear communication and acknowledgment of the emotional burden of cancer were intrinsically linked to successful patient education [24]. The desire for specialized nurse educators underscores the importance of allocating resources to this critical aspect of oncology care [23].
Excessive workloads and limited time were identified as substantial barriers to effective nurse-patient communication [25, 26]. The participants noted that overburdened nurses encountered difficulties in providing individualized care and maintaining positive interactions. Additionally, instances of nurses’ lack of empathy further hindered communication [23]. These findings underscore the need for comprehensive interventions to address these complex challenges.
Patient-related barriers, such as language discordance and cultural beliefs, significantly influenced nurse-patient communication. Previous studies have documented negative attitudes toward care providers of opposite genders and the importance of cultural and religious considerations in oncology care [27, 28]. In this study, the communication challenges experienced by Kurdish-speaking patients interacting with predominantly Turkish-speaking nurses underscore the need for healthcare systems to provide culturally and linguistically appropriate services to diverse patient populations.
Logistical challenges, such as suboptimal nurse-to-patient ratios, overcrowding, and bed shortages, significantly impede effective communication within oncology care settings [29]. These limitations underscore the critical need for healthcare institutions to prioritize adequate staffing levels and optimize resource allocation to foster environments conducive to meaningful patient-nurse interactions.
The present study emphasizes that building supportive nurse-patient relationships, marked by open dialogue and active listening, is crucial for enhancing patients’ motivation, commitment, and ability to make informed decisions. These elements lead to better adherence to treatment plans and reduced emotional distress. The importance of effective communication between oncology nurses and patients in encouraging adherence to cancer treatment plans is supported by existing literature [30‐32].
Open and effective communication was identified as a critical factor that facilitate the coping processes of cancer patients. Nurses were described as a primary source of emotional and practical support, highlighting the importance of their communicative role [21]. Empowering patients with information and resources to navigate their treatment trajectory enhances adaptation to illness and promotes a sense of autonomy [22, 23]. This empowerment has been associated with improved coping strategies and decreased psychological distress in this patient population [33].
Open communication with oncology nurses helps reduce patient stress. The patient testimonials emphasize the importance of open dialog in mitigating emotional distress, which is consistent with previous research that demonstrated the role of communication in alleviating anxiety and promoting emotional well-being in individuals with cancer [21]. Empathetic communication from nurses fosters a supportive environment, which contributes to stress reduction, whereas clear and honest communication is associated with decreased patient anxiety and uncertainty [23]. The emotional support provided through open communication allows patients to express concerns, seek information, and experience reduced stress levels [26].
Effective communication in oncology care is associated with increased patient satisfaction. Active listening and meaningful dialogue were identified as crucial elements valued by patients, highlighting their significant impact on the overall patient experience. The importance of emotional support and clear communication throughout the cancer trajectory is consistent with existing literature [21, 22]. The emphasis patients place on feeling heard and valued aligns with findings that underscore the significance of empathy, a patient-centered approach, and shared decision-making in oncology care [23].
This study’s limitations include a small sample size from a single outpatient oncology ward in Iran, potentially limiting generalizability. The study design may have introduced selection bias, as participants may have been more likely to volunteer if they had positive experiences. Additionally, data collection at a single time point during chemotherapy could be influenced by patients’ transient moods or circumstances. Despite these limitations, the qualitative methodology allowed for an in-depth exploration of patient perspectives, and the semi-structured interviews facilitated open sharing of experiences. This study contributes to the growing body of research on patient perceptions of nurse-patient communication in Iranian outpatient oncology settings.
Conclusions
Findings from this study highlight the essential role of nurse-patient communication in optimizing oncology care. Open communication, emotional support, and comprehensive patient education were identified as facilitators of improved patient wellbeing, treatment adherence, and clinical outcomes. Barriers to effective communication, such as high nurse workloads and cultural discordance, were also observed. The findings of this study underscore the need for a comprehensive strategy to optimize the communication between oncology nurses and patients. Robust educational programs should equip nurses with technical expertise, emotional intelligence, and cultural competence to navigate sensitive conversations. Healthcare systems must prioritize adequate staffing levels and manageable workloads to foster meaningful nurse-patient interactions. Care delivery should be tailored to the cultural and linguistic backgrounds of diverse patient populations, and emotional support services should be integrated into routine oncology care. Comprehensive patient education initiatives should empower patients to actively participate in their care, and logistical barriers to communication must be addressed. Tailoring communication approaches to individual patient preferences enhances patient satisfaction and engagement. Finally, advocating policies that prioritize communication within oncology care settings can lead to systemic improvements, ultimately enhancing patient experiences and outcomes.
Acknowledgements
Thank you to all the patients who participated in this study for their selfless sharing.
Declarations
Ethics approval and consent to participate
The study was approved by the ethics committee (IR.UMSU.REC.1402.247). All participants provided voluntary written informed consent before their participation in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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