what is the main goal of literature review

by Diana Ridley

by Dave Harris

Conducting your literature review 

by Susanne Hempel

The purpose of a literature review

Conducting a literature review is a means of demonstrating the  author’s knowledge  about a particular field of study, including vocabulary, theories, key variables and phenomena, and its methods and history. Conducting a literature review also informs the student of the  influential researchers and research groups  in the field (Randolph, 2009).

Literature reviews:

• report on  knowledge and ideas  that have been established on a particular topic, including their  strengths and weaknesses  while they allow you to discover the agreed academic opinion on the topic while at the same time letting you find out the disagreements on the same subject.
• position your research project within the body of literature and thereby  provide perspective  for the reader.
• demonstrate  your knowledge  of the subject area.
• determine what each source contributes to the topic.
• understand the  relationship between the various contributions , identify and (if possible) resolve contradictions, and determine gaps or unanswered questions.
• justify your  choice of research design ; for instance, your choice of qualitative over quantitative approaches, or your method of data analysis.
• clarify how your work fills a  gap  in the scholarly literature.

Writing a literature review also allows you to:

• gain expertise in the ability to scan the literature on a particular topic efficiently, and
• hone your skills in identifying and analysing unbiased and valid data on various topics or fields of study.

Source: Randolph, J.J. 2009.  A guide to writing the dissertation literature review .  Practical Assessment, Research & Evaluation . 14 (13): 1-13.

A literature review is meant to help you to ...

Source: Hart, C. 1998. Doing a literature review: releasing the social science research imagination.  London: Sage, p 27.

S helf No: 300.72 HART

Video clips from the Internet

Click on the  links  below for video clips on how to write literature reviews:

• Honours & Postgraduate Diplomas workshop - Writing the Literature Review - Dr Thuli Shandu Phetla (Unisa)
• Literature Review: step by step guide to writing an effective literature review
• How to write a Literature Review in 30 minutes or less 
• How to Write a Literature Review in 3 Simple Steps
• Literature Review in 5 mins
• Literature Review & Theoretical Framework - Dr KS Malatji

Books on writing a liteature review

Doing a systematic literature review in legal scholarship 

by Marnix Snel and Janaína de Moraes

340.072 SNEL

Doing a literature review in nursing, health and social care 

by  Michael Coughlan & Patricia Cronin

610.73072 COUG

7 steps to a comprehensive literature review : a multimodal & cultural approach

by Anthony J. Onwuegbuzie & Rebecca Frels

001.42 ONWU

Writing the literature review : a practical guide 

by Sara Efrat Efron & Ruth Ravid

808.02 EFRO

• << Previous: Literature review process
• Next: Evaluating sources >>
• Last Updated: Apr 30, 2024 1:19 PM
• URL: https://libguides.unisa.ac.za/literature_review

Review Articles (Health Sciences)

• Finding Review Articles
• Goals of a Literature Review
• Select Citation Management Software
• Select databases to search
• Track your searches
• Conduct searches
• Select articles to include
• Extract information from articles
• Structure your review
• Find "fill-in" information
• Other sources and help
• Systematic Reviews
• Other types of reviews

Keeping these goals in mind throughout your project will help you stay organized and focused.

A literature review helps the author:

• Understand the scope, history, and present state of knowledge in a specific topic
• Understand application of research concepts such as statistical tests and methodological choices
• Create a research project that complements the existing research or fills in gaps

A literature review helps the reader:

• Understand how your research project fits into the existing knowledge and research in a field
• Understand that a topic is important/relevant to the world and persuade them to keep reading your project
• << Previous: Literature Reviews
• Next: Select Citation Management Software >>
• Last Updated: May 8, 2024 1:19 PM
• URL: https://libguides.usc.edu/healthsciences/reviewarticles

Want to create or adapt books like this? Learn more about how Pressbooks supports open publishing practices.

The Research Proposal

83 Components of the Literature Review

Krathwohl (2005) suggests and describes a variety of components to include in a research proposal.  The following sections present these components in a suggested template for you to follow in the preparation of your research proposal.

Introduction

The introduction sets the tone for what follows in your research proposal – treat it as the initial pitch of your idea.  After reading the introduction your reader should:

• Understand what it is you want to do;
• Have a sense of your passion for the topic;
• Be excited about the study´s possible outcomes.

As you begin writing your research proposal it is helpful to think of the introduction as a narrative of what it is you want to do, written in one to three paragraphs.  Within those one to three paragraphs, it is important to briefly answer the following questions:

• What is the central research problem?
• How is the topic of your research proposal related to the problem?
• What methods will you utilize to analyze the research problem?
• Why is it important to undertake this research? What is the significance of your proposed research?  Why are the outcomes of your proposed research important, and to whom or to what are they important?

Note : You may be asked by your instructor to include an abstract with your research proposal.  In such cases, an abstract should provide an overview of what it is you plan to study, your main research question, a brief explanation of your methods to answer the research question, and your expected findings. All of this information must be carefully crafted in 150 to 250 words.  A word of advice is to save the writing of your abstract until the very end of your research proposal preparation.  If you are asked to provide an abstract, you should include 5-7 key words that are of most relevance to your study. List these in order of relevance.

Background and significance

The purpose of this section is to explain the context of your proposal and to describe, in detail, why it is important to undertake this research. Assume that the person or people who will read your research proposal know nothing or very little about the research problem.  While you do not need to include all knowledge you have learned about your topic in this section, it is important to ensure that you include the most relevant material that will help to explain the goals of your research.

While there are no hard and fast rules, you should attempt to address some or all of the following key points:

• State the research problem and provide a more thorough explanation about the purpose of the study than what you stated in the introduction.
• Present the rationale for the proposed research study. Clearly indicate why this research is worth doing.  Answer the “so what?” question.
• Describe the major issues or problems to be addressed by your research. Do not forget to explain how and in what ways your proposed research builds upon previous related research.
• Explain how you plan to go about conducting your research.
• Clearly identify the key or most relevant sources of research you intend to use and explain how they will contribute to your analysis of the topic.
• Set the boundaries of your proposed research, in order to provide a clear focus. Where appropriate, state not only what you will study, but what will be excluded from your study.
• Provide clear definitions of key concepts and terms. As key concepts and terms often have numerous definitions, make sure you state which definition you will be utilizing in your research.

Literature Review

This is the most time-consuming aspect in the preparation of your research proposal and it is a key component of the research proposal. As described in Chapter 5 , the literature review provides the background to your study and demonstrates the significance of the proposed research. Specifically, it is a review and synthesis of prior research that is related to the problem you are setting forth to investigate.  Essentially, your goal in the literature review is to place your research study within the larger whole of what has been studied in the past, while demonstrating to your reader that your work is original, innovative, and adds to the larger whole.

As the literature review is information dense, it is essential that this section be intelligently structured to enable your reader to grasp the key arguments underpinning your study. However, this can be easier to state and harder to do, simply due to the fact there is usually a plethora of related research to sift through. Consequently, a good strategy for writing the literature review is to break the literature into conceptual categories or themes, rather than attempting to describe various groups of literature you reviewed.  Chapter V, “ The Literature Review ,” describes a variety of methods to help you organize the themes.

Here are some suggestions on how to approach the writing of your literature review:

• Think about what questions other researchers have asked, what methods they used, what they found, and what they recommended based upon their findings.
• Do not be afraid to challenge previous related research findings and/or conclusions.
• Assess what you believe to be missing from previous research and explain how your research fills in this gap and/or extends previous research

It is important to note that a significant challenge related to undertaking a literature review is knowing when to stop.  As such, it is important to know how to know when you have uncovered the key conceptual categories underlying your research topic.  Generally, when you start to see repetition in the conclusions or recommendations, you can have confidence that you have covered all of the significant conceptual categories in your literature review.  However, it is also important to acknowledge that researchers often find themselves returning to the literature as they collect and analyze their data.  For example, an unexpected finding may develop as one collects and/or analyzes the data and it is important to take the time to step back and review the literature again, to ensure that no other researchers have found a similar finding.  This may include looking to research outside your field.

This situation occurred with one of the authors of this textbook´s research related to community resilience.  During the interviews, the researchers heard many participants discuss individual resilience factors and how they believed these individual factors helped make the community more resilient, overall.  Sheppard and Williams (2016) had not discovered these individual factors in their original literature review on community and environmental resilience. However, when they returned to the literature to search for individual resilience factors, they discovered a small body of literature in the child and youth psychology field. Consequently, Sheppard and Williams had to go back and add a new section to their literature review on individual resilience factors. Interestingly, their research appeared to be the first research to link individual resilience factors with community resilience factors.

Research design and methods

The objective of this section of the research proposal is to convince the reader that your overall research design and methods of analysis will enable you to solve the research problem you have identified and also enable you to accurately and effectively interpret the results of your research. Consequently, it is critical that the research design and methods section is well-written, clear, and logically organized.  This demonstrates to your reader that you know what you are going to do and how you are going to do it.  Overall, you want to leave your reader feeling confident that you have what it takes to get this research study completed in a timely fashion.

Essentially, this section of the research proposal should be clearly tied to the specific objectives of your study; however, it is also important to draw upon and include examples from the literature review that relate to your design and intended methods.  In other words, you must clearly demonstrate how your study utilizes and builds upon past studies, as it relates to the research design and intended methods.  For example, what methods have been used by other researchers in similar studies?

While it is important to consider the methods that other researchers have employed, it is equally important, if not more so, to consider what methods have not been employed but could be.  Remember, the methods section is not simply a list of tasks to be undertaken. It is also an argument as to why and how the tasks you have outlined will help you investigate the research problem and answer your research question(s).

Tips for writing the research design and methods section:

• Specify the methodological approaches you intend to employ to obtain information and the techniques you will use to analyze the data.
• Specify the research operations you will undertake and he way you will interpret the results of those operations in relation to the research problem.
• Go beyond stating what you hope to achieve through the methods you have chosen. State how you will actually do the methods (i.e. coding interview text, running regression analysis, etc.).
• Anticipate and acknowledge any potential barriers you may encounter when undertaking your research and describe how you will address these barriers.
• Explain where you believe you will find challenges related to data collection, including access to participants and information.

Preliminary suppositions and implications

The purpose of this section is to argue how and in what ways you anticipate that your research will refine, revise, or extend existing knowledge in the area of your study. Depending upon the aims and objectives of your study, you should also discuss how your anticipated findings may impact future research.  For example, is it possible that your research may lead to a new policy, new theoretical understanding, or a new method for analyzing data?  How might your study influence future studies?  What might your study mean for future practitioners working in the field?  Who or what may benefit from your study?  How might your study contribute to social, economic, environmental issues?  While it is important to think about and discuss possibilities such as these, it is equally important to be realistic in stating your anticipated findings.  In other words, you do not want to delve into idle speculation.  Rather, the purpose here is to reflect upon gaps in the current body of literature and to describe how and in what ways you anticipate your research will begin to fill in some or all of those gaps.

The conclusion reiterates the importance and significance of your research proposal and it provides a brief summary of the entire proposed study.  Essentially, this section should only be one or two paragraphs in length. Here is a potential outline for your conclusion:

• Discuss why the study should be done. Specifically discuss how you expect your study will advance existing knowledge and how your study is unique.
• Explain the specific purpose of the study and the research questions that the study will answer.
• Explain why the research design and methods chosen for this study are appropriate, and why other design and methods were not chosen.
• State the potential implications you expect to emerge from your proposed study,
• Provide a sense of how your study fits within the broader scholarship currently in existence related to the research problem.

As with any scholarly research paper, you must cite the sources you used in composing your research proposal.  In a research proposal, this can take two forms: a reference list or a bibliography.  A reference list does what the name suggests, it lists the literature you referenced in the body of your research proposal.  All references in the reference list, must appear in the body of the research proposal.  Remember, it is not acceptable to say “as cited in …”  As a researcher you must always go to the original source and check it for yourself.  Many errors are made in referencing, even by top researchers, and so it is important not to perpetuate an error made by someone else. While this can be time consuming, it is the proper way to undertake a literature review.

In contrast, a bibliography , is a list of everything you used or cited in your research proposal, with additional citations to any key sources relevant to understanding the research problem.  In other words, sources cited in your bibliography may not necessarily appear in the body of your research proposal.  Make sure you check with your instructor to see which of the two you are expected to produce.

Overall, your list of citations should be a testament to the fact that you have done a sufficient level of preliminary research to ensure that your project will complement, but not duplicate, previous research efforts. For social sciences, the reference list or bibliography should be prepared in American Psychological Association (APA) referencing format. Usually, the reference list (or bibliography) is not included in the word count of the research proposal. Again, make sure you check with your instructor to confirm.

An Introduction to Research Methods in Sociology Copyright © 2019 by Valerie A. Sheppard is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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• Research article
• Open access
• Published: 29 July 2022

Shared understanding of resilient practices in the context of inpatient suicide prevention: a narrative synthesis

• Siv Hilde Berg 1 , 2 ,
• Kristine Rørtveit 3 , 4 ,
• Fredrik A. Walby 5 &
• Karina Aase 1  

BMC Health Services Research volume  22 , Article number:  967 ( 2022 ) Cite this article

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The prevailing patient safety strategies in suicide prevention are suicide risk assessments and retrospective reviews, with emphasis on minimising risk and preventing adverse events. Resilient healthcare focuses on how everyday clinical practice succeeds and emphasises learning from practice, not from adverse events. Yet, little is known about resilient practices for suicidal inpatients. The aim of the study is to draw upon the perspectives of patients and healthcare professionals to inform the conceptual development of resilient practices in inpatient suicide prevention.

A narrative synthesis was conducted of findings across patients and healthcare professionals derived from a qualitative case study based on interviews with patients and healthcare professionals in addition to a systematic literature review.

Three sub-themes categorise resilient practices for healthcare professionals and for patients hospitalised with suicidal behaviour: 1) interactions capturing non-verbal cues; 2) protection through dignity and watchfulness; and 3) personalised approaches to alleviate emotional pressure. The main theme, the establishment of relationships of trust in resilient practices for patients in suicidal crisis, is the foundation of their communication and caring.

Clinical practice for patients hospitalised with suicidal behaviour has characteristics of complex adaptive systems in terms of dynamic interactions, decision-making under uncertainty, tensions between goals solved through trade-offs, and adaptations to patient variability and interpersonal needs. To improve the safety of patients hospitalised with suicidal behaviour, variability in clinical practice should be embraced.

Trial registration

https://doi.org/10.1136/bmjopen-2016-012874

Peer Review reports

Introduction

Our understanding of patient safety for patients hospitalised during a suicidal crisis is limited [ 1 ]. In a systematic review of the literature, Thibaut et al. found [ 2 ] few peer-reviewed empirical studies on patient safety and suicidal behaviour. The literature drawing on the interdisciplinary field of safety science in suicide prevention is particularly thin. Safety science has provided us with the key message that different models affect our understanding of adverse events and thereby have a vast impact on learning and to where we direct our safety measures [ 3 , 4 , 5 ].

According to Hollnagel, the traditional view of safety, referred to here as safety-I is defined by the absence of accidents and incidents [ 6 ]. Consequently, the focus of safety management and research has been on learning about unsafe systems while minimising the number of adverse events [ 7 ]. Methods such as root cause analysis, incident reporting and checklists to reduce healthcare professionals’ (HCPs’) errors are examples of the traditional approach to patient safety [ 7 , 8 ]. Likewise, in a scoping review of patient safety strategies in psychiatry, Svensson found that these measures are mainly intended to prevent adverse events by focusing on failure and ensuring compliance to procedures [ 9 ]. Across countries, clinical practice guidelines on suicide prevention include restricting lethal means, assessing evidence-based suicide risk factors and suicidal intent along with recommended treatment and post-intervention recommendation [ 10 ]. Nevertheless, while the clinical field is moving in the direction of a systematic suicide management system [ 11 , 12 , 13 ], patient safety strategies in suicide prevention have been criticised as excessively focused on harm reduction (e.g. suicide risk assessment) [ 14 , 15 , 16 ].

Retrospective reviews of suicide incidents have focused on deficiencies in the interface between healthcare professionals (HCPs) and patients [ 14 , 17 , 18 ]. In hindsight, suicide investigations have often concluded that an improved risk assessment could have led to a different outcome [ 14 , 17 , 18 ]. Nonetheless, suicidal outcomes cannot be predicted at the individual level [ 19 , 20 , 21 ]. The fallacies of perceiving HCPs in the sharp end of the system as the main causes of the patient suicide are abundant; HCPs are the secondary victims of patient suicides; learning outcomes at the system level are limited; and the complexity of making the decisions regarding suicide risk, and the flexibility required for HCPs to adapt treatment to patients is ignored [ 14 , 17 , 18 ].

A safety-I approach narrows the gap between what HCPs do in practice and their procedures for that practice [ 6 ]. Patient safety in psychiatry has emphasised improving staff compliance to safety-I procedures [ 9 ]. At the same time, there is no single means of preventing inpatient suicides, and practice is characterised by uncertainty and complexity. The lack of a solution relates to the aetiological heterogeneity of suicidal patients, and the need to understand and approach each patient differently [ 22 ]. Uncertainty is also related to the ethical challenges of assigning suicidal patients to a control non-treatment condition to determine whether specific interventions, such as constant observation, have a preventive effect [ 23 ]. As such, no study has examined whether being under observation reduces the number of suicide attempt or deaths [ 24 ]. Clinical decision-making regarding suicide risk involves a high degree of uncertainty. Despite considerable research, instruments used to assign patients to high-risk groups do not enable HCPs to predict which of those patients will die by suicide [ 19 , 25 , 26 ]. There are therefore many limitations to the safety-I approach in the face of healthcare practices.

The field of resilient healthcare (RHC) has sought insight into healthcare practices and the ways in which everyday clinical practice succeeds [ 27 , 28 , 29 ]. Hollnagel [ 6 ] has defined safety-II as ‘the ability to succeed under expected and unexpected conditions alike, so that the number of intended and acceptable outcomes (in other words, everyday activities) is as high as possible’ (Hollnagel, 2014, p. 134). RHC draws on theories from safety science in which healthcare is recognised as a complex adaptive system (CAS) [ 27 , 28 ]. Wiig et al. [ 30 ] describe resilience in healthcare as ‘…the capacity to adapt to challenges and changes at different system levels to maintain high-quality care’ (p. 6). Adaptation is thus seen as the central tenet of RHC and might come in many forms and at multiple levels, for example as HCPs’ capacity to adjust their reasoning and clinical measures based on patient conditions and/or work-related conditions.

Mental health services have been conceptualised as a CAS by Ellis, Churruca and Braithwaite [ 31 ], in which patients and HCPs interact across care levels, and constantly adjust practice to the patient, caregivers, policies, research and standardised and evidence-based treatment. Although most RHC studies have used HCPs as the main source of data on healthcare resilience, patients and family may also be sources [ 32 , 33 ]. Quinlivan et al. [ 34 ] emphasise the importance of patient perspectives when applying an RHC approach to suicide prevention to better grasp the patient vulnerabilities and the individual differences specific to this field. However, patients have not been used extensively as sources of knowledge in RHC [ 35 , 36 ]. Furthermore, few empirical studies have adopted RHC perspectives to suicide prevention [ 37 , 38 , 39 ], and none have incorporated patients’ perspectives. This synthesis of an in-depth qualitative case study applying RHC to suicide prevention can fill this gap. Therefore, the aim of this study was to draw upon the perspectives of patients and healthcare professionals to inform the conceptual development of resilient practices in inpatient suicide prevention.

A narrative synthesis was conducted of findings across two embedded units of analysis: the experiences of patients and the experiences of HCPs (Table 1 ) [ 40 ]. The original data consisted of three samples collected through a multi-method case study approach [ 40 ] consisting of a systematic review of 20 peer-reviewed articles published between 1999 and 2016 on patient experiences of being hospitalised in a psychiatric ward or facility during a suicidal crisis (sample 1) [ 41 ]; individual interviews with 18 patients hospitalised during a suicidal crisis (sample 2) [ 42 ]; and focus group and individual interviews with 35 HCPs responsible for the care of suicidal patients (sample 3) [ 43 ]. The methods of the case study are described in a published study protocol [ 44 ] and the first author’s PhD thesis [ 45 ]. Interview guides have been previously published, see supplemental file 2 in Berg et al. 2020a [ 46 ] and additional file 1 in Berg et al. 2020b [ 47 ].

The literature review (sample 1) followed a systematic approach according to the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses [ 48 ]. Systematic searches were conducted in the MEDLINE, Academic Search Premier, CINAHL, SOCINDEX and PsycINFO databases, identifying 20 qualitative studies on suicidal patients and their psychiatric in-patient care experiences. These studies were systematically reviewed according to PRISMA, subjected to quality appraisals, and synthesized by using thematic analysis [ 49 , 50 ]. The included studies had a total of 311 patients (see Table 2 ).

All individual interviews followed a semi-structured interview guide and were conducted by SHB face to face in a room close to the hospital ward. Focus groups were conducted with a moderator (SHB/KR) and a co-moderator (SHB/MA). Sample 3 followed a sequential triangulation, with the first data set (focus groups) informing the nature of the second (individual interviews) [ 51 ]. All interviews were audio-recorded, transcribed verbatim, coded and followed the systematic qualitative analysis methods of thematic analysis [ 50 ] and content analysis [ 52 ], with a phenomenological hermeneutical approach [ 53 ].

The setting for the empirical studies (sample 2, sample 3) was a university hospital in Norway. We used purposeful sampling to recruit suicidal patients and HCPs working in open or locked wards in specialised mental healthcare facilities for adults. Participants were recruited from nine wards. Locked wards specialised in affective disorders ( n  = 2) or acute care ( n  = 2) while open wards specialised in rehabilitation ( n  = 3) or short-time stabilisation during a crisis ( n  = 2). Fifty-three individuals (patients and HCPs) participated in the empirical studies. All patient participants had active suicidal ideation during inpatient care, nine had recently attempted suicide prior to admission to mental healthcare, see Table 2 (sample 1 and 2).

The HCPs sample included both novices and experienced participants from all professional groups, see Table 3 (sample 3).

Two patients who were invited to participate declined because of their mental state. No HCPs refused to participate. None dropped out. Five patients had follow-up interview within a week of the first interview, which followed the same interview guide.

The Norwegian suicide context

Preventing suicides during inpatient care is a high priority for patient safety in mental health. In Norway, the national guidelines for the prevention of suicides in mental healthcare [ 54 ] outline practices that managers and HCPs in specialised mental healthcare are required to follow. In addition, checklists have been used in the management of suicide risk [ 55 ]. Suicide rates have remained relatively stable in Norway, with approximately 12.1 suicides per 100 000 inhabitants in 2020 [ 56 ], which is slightly higher than the global suicide rate (11.4 per 100 000 inhabitants in 2020 [ 57 ]. Approximately 650 individuals die from suicide in Norway each year [ 58 ], and there are approximately 3500–7500 suicide attempts annually [ 59 ]. Walby et al. [ 60 ] found that 67% of the individuals in Norway who died by suicide within a year of last contact with mental health services had been hospitalised at least once in the year preceding their death. On average, 25 suicides (SD = 4,9) occurred during inpatient care each year in Norway in the period 2008–2015. This is a relatively low proportion (13%) of the total number of suicides conducted by patients receiving specialised mental healthcare services, meaning that most suicides occur in the outpatient care [ 60 ].

Ethical considerations

The case study was approved by the Western Regional Ethics Committee of Norway (REC 2016/34). All participants provided voluntary informed and written consent. Patients were interviewed during hospitalisation and all of them were under the care of specialised HCPs. None of the researchers had a role as a clinician or manager in any of the seven units included in the study or had prior established relationships with the participants. Participants were informed of the rationale for the research: to get insight into safe clinical practices for suicidal patients.

A narrative synthesis was conducted across methods and samples to find common themes reflecting both patients’ and HCPs’ perspectives, using the four stages of data synthesis as proposed by Whittemore and Knafl [ 40 ]. The narrative synthesis was a re-analysis of the work presented in the first author’s PhD thesis [ 45 ]. In the first stage, the primary sources were divided into two subgroups: patients and HCPs. In the second stage, the main findings related to perspectives on resilient practices were extracted from the primary sources and coded inductively. In the third stage, tables were used to display the codes to visualise patterns and relationship within and across primary data. Categories relating to both the patients’ and the HCPs’ perspectives were constructed by compiling codes with shared meaning. In the fourth stage, data were organised into meaningful patterns with themes and sub-themes under an overarching main theme.

This narrative synthesis synthesised patients’ experiences and the HCPs’ experiences in the context of inpatient suicide prevention. The main theme, relationships of trust in resilient practices for patients in suicidal crisis, is the foundation of their communication and caring. The main theme was described by three sub-themes which illuminate three sets of relationships: interactions capturing non-verbal cues, protection through dignity and watchfulness, and personalised approaches to alleviate emotional pressure. Table 4 depicts the main theme, the three sub-themes and categories related to the patient and HCPs perspective and how the three samples form the three themes.

The main theme, relationships of trust in resilient practices for patients in suicidal crisis reflected that resilient practices depended on trust between patients and HCPs, and that HCPs need alliances to establish trusting relationships with the patients. Trust is a precondition for resilient practices to adapt protection, treatment, and care to the needs of suicidal patients.

Suicidal patients experienced the relationship to the HCPs as essential for a feeling of safety during inpatient care. They felt safe when they met someone who cared, validated their feelings and respected them as human beings. Trusting and familiar relationships with HCPs gave them predictability in terms of how their suicidal behaviour would be understood and treated. Trust is relevant to findings involving patients in vulnerable situations: being externally controlled, talking about suicide and relieving emotional pressure.

HCPs experienced personal uncertainty in working with patients in suicidal crisis. They feared losing a patient to suicide while under their care, and they feared being held responsible by the health authorities and the hospital management. HCPs noted that their colleagues’ trust and support were necessary to manage uncertainty in clinical practice. HCPs formed and adapted their informal networks in response to the lack of formal support systems. Without support that could help HCPs cope with the uncertainty of working with suicidal patients, HCPs resorted to fear-based defensive practices to avoid blame and responsibility, which took time and focus away from the personalised activities with patients. However, social support and clinical supervision helped to counteract the impact of personal uncertainty in the patient contact.

As such, resilient practices did not merely depend on strengthening the HCPs’ ability to establish trusting relationships with the patients, but also on ensuring that HCPs had reliable support systems.

Interactions capturing non-verbal cues

The resilient practice interactions capturing non-verbal cues described the interaction between the patient and the HCPs in the detection of suicidal crisis. Suicidal crisis was apparent not only in what patients did and did not say, but also in their body language and affect, as exemplified in Table 5 .

Many of the patients expressed a struggle to communicate suicidal ideations during suicide risk assessment and acute suicidal crisis in the ward. They also experienced being recognised by HCPs who were attentive to their body language and to changes in their mental state. Patients noted that when their HCPs took a genuine personal interest in them, they were less likely to attempt suicide during inpatient care (sample 2).

HCPs attended to multiple sources of information to make sense of suicidal behaviour including the non-verbal cues. The more experienced HCPs claimed that the formal procedures for assessing risk were not helpful during risk assessment, as the list did not take the context-sensitive and non-verbal behaviour into account. They improved their understanding by establishing relational contact with the patient and triangulating several sources of information, including the patients’ verbal and non-verbal cues, mental state, diagnosis and their own ‘gut feeling’. Expertise increased the complexity and the number of information sources that were considered to clarify the picture. Furthermore, HCPs improved their situational awareness of the patients’ suicide risk by seeking other perspectives, which involved reflecting with the patient, bringing other HCPs into conversations with the patient and discussing the case with more experienced colleagues and with doctors on call (sample 3).

Interactions capturing non-verbal cues were grounded in relationships of trust. Patients described a trusted HCPs as someone who connected with them and understood their verbal and non-verbal cues of suicidal crisis (sample 2). When trusted HCPs were unavailable, patients in suicidal deterioration felt unsafe and vulnerable (sample 2). HCPs used experience and emotionally based competence to anticipate suicidal acts, and they perceived this process was strengthened by developing bonds of trust with the patient (sample 3).

Protection through dignity and watchfulness

The resilient practice protection through dignity and watchfulness described the physical protection of patients with suicidal behaviour as a relational and interacting practice, depending on adaptations to ensure that each patient was physically protected, yet connected, as exemplified in Table 6 .

Suicidal patients expressed a need for a safe balance among multiple needs for protection. Findings reflected that suicidal patients needed to be physically protected from death during suicidal crisis while feeling connected with the HCPs during observation. Lack of connection during observation made some patients feel unsafe and thereby intensified their suicidal behaviour (sample 1).

Furthermore, patients’ need for protection during suicidal crisis changed in the course of hospitalisation and depended on a) their ability to establish relations with their HCPs and verbalise their needs; b) their need to withdraw from and master stressors in the outside world; c) their need for closeness to or distance from the HCPs; and d) their need for external control (e.g., locked doors) or internal control (e.g,. impulse control). Thus, resilient practices were experienced when protection of the individual balanced his or her multiple needs (sample 2).

HCPs were adjusting protection of the patient through dynamic trade-offs between under- and over-protection. While the formal procedure described observation as either constant or intermittent (5-, 10-, 30-min) intervals of observation, HCPs were constantly adjusting the observation practice towards the patient. Instead of watching the patients from a distance, they engaged with them, treated them with dignity, but kept an eye on them. Furthermore, HCPs were constantly balancing the physical protection of the patient from suicidal impulses with the risk of over-protection while increasing the patient’s sense of independence at the risk of under-protection. Thus, safe levels of protection were trade-offs between short- and long-term goals in care (sample 3).

Protection through dignity and watchfulness was rooted in relationships of trust. The link between feeling safe and being safe was vital for suicidal patients; their physical safety could not be guaranteed if they felt vulnerable (sample 1). Lack of support from HCPs when patients were under constant observation made patients feel alienated and objectified, their suicidality worsened, and it supported their perception of worthlessness and the sense that no one cared about them (sample 1). Trust that HCPs were acting in the patients’ best interest was a prerequisite for patients’ feelings of safety when they were under external control (sample 2). Likewise, HCP adapted their approaches to protection to ensure patients understood they were acting in their best interest through explaining why doors were locked, and why they had to give away some personal belongings (sample 2) and treating patients with dignity during observation (sample 3).

Personalised approaches to alleviate emotional pressure

The resilient practice personalised approaches to alleviate emotional pressure described the adaptation of treatment and safety procedures that are made to meet individual patients’ needs. Patients experienced less emotional pressure and their suicidal impulses diminished as a result (Table 7 ).

Patients emphasised that regaining a sense of control through coping with symptoms and difficulties was vital when they were having a suicidal crisis. Perception of control through gaining insight, coping with underlying difficulties and symptoms, and being prepared for discharge were essential for suicidal patients’ feeling of safety during inpatient care (sample 1).

Personalised approaches to treatment addressed patients’ underlying mental health issues and stressors. This kind of treatment relieved their emotional pressure, whether it involved medications and physical protection to reduce psychotic symptoms or resolving financial issues to instill hope and a sense of relief from depression. These strategies helped suicidal patients feel safe from suicidal impulses through strengthening their sense of internal control. Talking about suicide also alleviated patients’ individual stressors, symptoms, or emotional pain. When conversations about suicide opened with standard questions and answers about suicide risk, they lost their therapeutic benefit and could evoke feelings of shame and hopelessness. Patients achieved a sense of control in a variety of ways. In the acute phases of their suicidal crisis, some patients wanted external control over their suicidal impulses because physical protection convinced them that they could not harm themselves (sample 2).

HCPs targeted underlying issues by creating individual clinical pathways for suicidal patients. HCPs considered individualised approaches to be important in conversations about suicidal ideations; however, they experienced competing goals between documenting risk and understanding patients as individuals in practice (sample 3).

Personalised approaches to alleviating emotional pressure are rooted in relationships of trust. Seeking help and talking about suicide place a suicidal patient in a highly vulnerable position. If they could not trust their HCPs, some patients withdrew from talking about suicidal ideations and stopped seeking help (sample 2). Likewise, HCPs perceived trusted relationships as a condition for honest responses in suicide risk assessment and described setting aside checklists and forms to prioritise making a trusting bond, a safe atmosphere and engaging with the patients in a dialogue when talking about suicide (sample 3).

We identified three sub-themes categorising resilient practices for patients hospitalised with suicidal behaviour and HCPs: interactions capturing non-verbal cues, protection through dignity and watchfulness, and personalised approaches to alleviate emotional pressure. All three are grounded in relationships of trust in resilient practices for patients in suicidal crisis. These resilient practices outline a safety-II perspective in inpatient care of suicidal patients, which is based on culturally situated knowledge which cannot be generalised to all inpatient settings [ 61 ]. However, theoretical conceptualisation can be made regarding the understanding of safety for the suicidal patient, from a resilience perspective [ 61 ]. Above all, the perspective of resilience provides insight into the system complexity of suicide prevention, and how patients and HCPs cope with challenges and changes [ 28 , 62 ].

The complexity of clinical practice for patients hospitalised with suicidal behaviour

The shared understanding of resilient practices offers insight into clinical practice for patients hospitalised with suicidal behaviour. This clinical practice has the characteristics of a CAS [ 27 , 28 , 63 , 64 ], which has been previously presented in the first author’s PhD thesis [ 45 ].

Interactions capturing non-verbal cues of suicidal inpatients reflect uncertainty in clinical decision-making. The findings correspond with previous studies suggesting that caring for suicidal patients involves uncertainty [ 65 , 66 , 67 ] and expand the literature by showing that making sense of suicidal behaviour requires the comprehension of information ‘beyond the spoken word’, using intuition along with other sources of information (e.g. diagnosis, mental state, medical journal, individual risk factors) [ 68 , 69 ]. To attempt anticipating suicide, and to adapt and respond to the suicidal crisis of patients in the wards, HCPs apply multiple sensemaking strategies to improve their situational awareness [ 70 , 71 ]. The complexity and ambiguity of the cues involved in making sense of suicidal behaviour highlight that it is difficult to standardise screening questions or limit a set of cues to look for (proximal risk factors) in the setting of inpatient suicide prevention with high specificity [ 72 ]. Furthermore, suicide prediction models are imprecise [ 21 ], the evidence does not support the use of risk scales in suicide risk assessment [ 20 , 73 ], and there is no support for the use of clinical intuition as the sole source of suicide prediction, which leaves HCPs with limited support for their clinical decision making. This study supports that ‘work as done’ of suicide risk assessments involves multiple strategies to make sense of uncertainty, which is a characteristic of decision making in complex high-risk and ambiguous work settings [ 70 , 74 , 75 , 76 ].

Protection through dignity and watchfulness, and personalised approaches to alleviate emotional pressure emphasise that there is no one-size-fits-all approach to the protection and treatment of suicidal patients. Instead, practice relies on interpersonal and context-sensitive adaptations to ensure protection is safe [ 28 , 30 , 31 , 77 ]. Furthermore, clinical practice for suicidal patients is characterised by multiple conflicting goals which must be resolved by making trade-offs between higher- and lower-level goals [ 78 ], e.g., preventing immediate harm and working towards long-term health goals. Dynamic interactions and adaptations to ensure safe work are characteristics of a complex adaptive system [ 27 , 28 , 63 , 64 ].

Relationships of trust in resilient practices for patients in suicidal crisis reflect that the complexity in clinical practice is characterised by the establishment of psychological and relational safety, which is only created through personalised and trusted relationships. Personalised relationships are the core characteristic of mental healthcare as a complex adaptive systems [ 31 ].

In a CAS there will be unpredictable consequences of standardised patient safety interventions due to the need for adaptations in clinical practice to ensure safe outcomes. For those designing patient safety interventions at the blunt end of the system, deviations from the procedure may be perceived as an error to be corrected [ 6 ]. However, while errors arise from approximate adjustments of procedures, it is also why everyday work in complex adaptive systems is safe [ 6 ]. To improve safety in complex adaptive systems, variability should be embraced, not erased [ 79 ]. This means that flexible and relationally based patient safety measures should be developed alongside the currently more standardised approaches. Protocols, procedures, and guidelines could for example form a starting point for reflections on how a certain practice might entail variability that go beyond these standardised measures and how the variability should be acted on.

The CAS perspective of clinical practice in suicide prevention also has implications for learning. To learn from variability, it is necessary to move from simple linear models (e.g., root cause analysis) to systemic models (e.g., resilience, CAS) focusing on why practices vary, succeed or fail at the clinical level, hospital management level and at the health system macro level [ 9 , 30 , 77 ].

Supporting resilient practices

This study describes resilient practices which outline complexity in the clinical work in suicidal inpatient care. Some generic lessons regarding how to approach patient safety and suicide prevention at the micro level of the system are drawn based on the RHC perspective.

In a CAS, it is impossible for the HCPs to anticipate all of the consequences of adjustments of procedures and trade-offs [ 80 , 81 ]. Feedback systems are needed to acquire knowledge of how to adapt and its outcomes [ 82 ]. This implies that, systems in mental healthcare need to collect feedback on everyday clinical practice to learn what fosters success under various conditions (Safety-II), not merely from retrospective views of suicide incidents [ 6 , 9 , 14 ]. Suicidal patients provide valuable feedback on what makes them feel safe or unsafe, identify conditions for successful treatment, and those that may cause adverse events. All of this corresponds to findings in other domains of healthcare [ 83 , 84 ]. Collecting patient feedback should be considered essential to support resilient practices for suicidal patients.

Furthermore, suicidal patients’ experiences should inform the development of patient safety measures. This study finding corresponds with the literature that identifies trust as fundamental for hospitalised patients’ feelings of safety [ 85 , 86 ]. The relational component of patient safety is the most vital aspect of care from the patients’ perspective, and HCPs can strengthen the sense of safety in those patients by respecting them as human beings, validating their feelings and ensuring that they know that people care about them. A sense of safety is also linked to a sense of control. HCPs may strengthen patients’ sense of control by addressing underlying issues and mental illnesses during hospitalisation and adapting suicide risk assessments and therapeutic approaches to suicidal behavior to meet each patient’s needs. An intervention which may support resilient practices is the collaborative assessment and management of suicide risk (CAMS) that involves the exploration of the suicidal patients’ individual drivers, warnings signs along with addressing the patient’s pain and suffering [ 87 , 88 ]. Furthermore, dialectical behavior therapy, which aims to improve patients’ emotional and practical coping skills is relevant [ 89 , 90 ].

This study implies that HCPs apply sensemaking strategies to improve their situational awareness of suicidal behavior. These strategies are enacted to gain a fuller meaning of the information they have obtained and a sense of what is going on in complex and ill-defined situations [ 75 , 76 , 91 ]. Since obtaining feedback from the healthcare team is essential in the creation of situational awareness [ 74 , 75 , 76 ], training in suicide risk detection can benefit from multidisciplinary training involving HCPs who regularly interact as a team to establish a shared vision, values and mental models [ 92 , 93 ]. HCPs need to be able to discuss their clinical judgement in everyday clinical practice with a team of colleagues [ 75 , 76 ]. In dialectical behavior therapy, and evidence-based treatment for borderline personality disorder with a specific focus on suicidal behavior, discussion of clinical assessment with colleagues is an integral part of the intervention [ 89 , 90 ]. Furthermore, the results indicate that opening a collaborative dialogue with the patient may also help HCPs’ sensemaking of suicidal behavior [ 87 ]. In this regard, sensemaking is concerned with supporting strategies that create a more comprehensible understanding that enables action [ 94 ]. Future studies are needed to develop complex interventions to improve HCPs’ shared situational awareness, non-verbal communication and relational skills in the patient contact, and may include the development of simulation training interventions for suicide risk assessment [ 95 ].

Following the literature, this study highlights the importance of having experienced HCPs [ 96 ], who are fully therapeutically engaged with the patient [ 97 , 98 ] who balance the exertion of control and the building of the therapeutic relationship during observation [ 99 ]. Observation of patients at suicide risk is a resilient practice that entails watchfulness and sensitivity to cues of a patient’s mental state along with engaging with the patient and establish bonds of trust. The findings are in accordance with research depicting prevention of suicides in constant observation as intertwined with forming connections and regaining hope [ 97 , 100 , 101 ]. The finding supports that observation demands resilient strategies from the individual HCPs and required adaptations and the balancing of multiple goals in care [ 28 , 30 , 77 , 102 ].

Lastly, this study implies that resilient practice should not rely solely on HCPs’ capacity to adapt without formal support systems. Without reliable sources of trust, the system is brittle. HCPs’ adaptive capacities may be overstretched and threaten the adaptive capacity of the system [ 103 , 104 , 105 ]. The findings also follow the literature finding that HCPs may distance themselves from suicidal patients’ emotions to protect themselves from emotional discomfort which may erode patients’ trust in their HCPs [ 106 , 107 , 108 ]. HCPs need to know they are supported, and thus they favour formal arenas for collegial trust, support [ 65 , 109 ], supervision and training to ensure they can keep working with suicidal patients [ 66 , 97 ]. Support systems are currently not considered a vital part of clinical guidelines for inpatient suicide prevention [ 10 ]. However, to support resilient practice, HCPs’ capacity to handle daily stress needs to be nurtured after incidents and on a daily basis. Clinical guidelines and patient safety policies related to inpatient suicide prevention need to include psychosocial support system and clinical supervision of HCPs.

Strengths and limitations

The ability to judge the quality of qualitative research rests on four characteristics: credibility, dependability, confirmability and transferability [ 110 ]. Triangulation of data sources (patients and professional groups), methods (focus groups, individual interviews and systematic review of literature) and the use of several researchers enhance the credibility of this synthesis: the confidence in the accuracy of the data and ensures that the research investigates what it intended to investigate. Credibility was strengthened by including a sample with sufficient information power [ 111 ], that covered significant variations and had relevant experiences with the phenomenon under study [ 112 ]. A sample size of 18 participants was considered adequate to ensure such information power when studying a heterogenic group of patients with suicidal behaviour [ 111 ]. A sample size of 18 and 25 HCPs was considered adequate to ensure variability across care settings (locked/open wards), diverse specialities (psychologists, nurses, medical doctors), gender, experience, expertise and patient diagnosis [ 111 ].

Dependability is strengthened in this synthesis by the provision of clear, detailed descriptions of all procedures and methods in the first author’s PhD thesis [ 45 ], the original studies [ 41 , 42 , 43 ], and by providing transparency through the published protocol [ 44 ], This allows for appraisal without the need to arrive at the same results [ 113 ].

Confirmability is the degree of neutrality and researcher bias [ 110 ]. Confirmability was strengthened through the sharing of the researchers’ backgrounds, preconceptions and pre-understandings to interpret the data [ 114 ]. This study adopted an inductive approach to analysis and curiosity about the experienced reality to describe resilient practices in this context, which reduces researcher bias through approaching data with sensitivity and openness [ 53 ].

Transferability is the extent to which the findings can be transferred to other settings, context or groups [ 113 ]. Qualitative data produce culturally situated knowledge which cannot be generalised to all inpatient practice settings [ 61 ]. The resilient practices described here are part of the processes of clinical practice, not linked to specific outcome measures (e.g., suicidal behaviour, symptoms). We therefore cannot draw conclusions on the effect of such practices related to suicidal behaviour and they should not replace current evidence-based system approaches to suicide prevention (e.g., [ 11 , 12 , 13 , 22 , 115 , 116 , 117 , 118 , 119 ]) However, the findings of this study can be conceptualised at a theoretical level and used to arrive at a deeper insight into the ontology of safety for suicidal patients [ 120 ]. This study focused on hospitalised patients who survived a suicidal crisis and resilient practices in mental health wards, as experienced by these patients and their HCPs. As such, the study conclusions do not pertain to patients dying from suicide or to patients who were not admitted to hospital wards during their suicidal crisis.

Resilient practices for patients hospitalised with suicidal behaviour are experienced by those patients and their HCPs using three practice types: interactions capturing non-verbal cues, protection through dignity and watchfulness, and personalised approaches to alleviate emotional pressure. All of these practice types are grounded in relationships of trust.

These practices inform the conceptual development of resilience in inpatient suicide prevention. The prevention of inpatient suicide is characterised by complexity related to changing, interrelated and variable patient needs in clinical practice and to the unpredictability of suicidal threats. Thus, inpatient suicide prevention demands adaptations and high levels of sensitivity towards the patient. To improve patient safety in this context, variability in clinical practice must be embraced. It is important to acknowledge the uncertainty in clinical decision-making regarding suicide risk and to avoid concluding that HCPs have performed an unsuccessful suicide risk assessment as the root cause of patient suicides. It is not possible to eliminate all uncertainty of suicide risk at the individual patient level. Nevertheless, it is possible to reduce emotional demands placed on HCPs by acknowledging the complexity and challenges involved in clinical decision-making regarding suicide.

Strategies should strengthen feedback systems that foster communication between HCPs and between HCPs and their patients, and reinforce systems such as clinical supervision that ensure support for HCPs. This synthesis was limited to the suicide inpatient care at the micro level of the healthcare system. Future studies should include the roles of family, carers, and ward management.

Availability of data and materials

The datasets generated and/or analysed in this study are not publicly available due to ethical concerns and the sensitivity of the data, but non-identifiable data are available from the corresponding author on reasonable request.

Abbreviations

Healthcare Professional

Resilient Healthcare

Complex Adaptive System

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Acknowledgements

We would like to thank all the participants who took part in the primary studies and the ward managers who supported and helped with recruitment. We would like to thank consultant clinical psychologist Marie Anbjørnsen (MA), who participated as a co-moderator in the focus group study and helped recruit HCPs for the focus groups. We would also like to thank the advisory panel members for this study, who contributed feedback on the recruitment strategies, the interview guides and manuscripts for the original studies: Dag Lieungh (patient experience consultant), Målfrid J. Frahm Jensen (patient experience consultant), Gudrun Austad (inpatient and community suicide prevention; mental health nurse), Kristin Jørstad Fredriksen (consultant psychiatrist), Liv Sand (consultant clinical psychologist) and Sigve Dagsland (consultant clinical psychologist).

This study received financial support from the Western Norway Regional Health Authority, grant number 911846. No funding source had any role in the design or conduct of the study.

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SHB planned the study and the design of the work with substantial contributions from KAA, FW and KR. SHB conducted the patient interviews and moderated/co-moderated the focus groups. KR moderated two of the focus groups. SHB coded and systemised the data. SHB, KR, and KAA read the transcripts. SHB drafted the analysis of the primary studies and the synthesis. KR and KAA discussed and revised the analysis work through all phases of the analysis. FAW contributed substantially to the analysis of primary studies and the synthesis. SHB drafted the manuscript, and all authors made critical revisions to the intellectual content. The authors read and approved the final manuscript.

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SHB (PhD) is associate professor at the Centre for Resilience in healthcare, University of Stavanger with a background in safety science. She is a clinical psychologist. Her occupation and role during data collection was as a PhD scholar. KR (PhD) is a professor in nursing at Stavanger University Hospital and University of Stavanger, with a background in mental health nursing. Her role during data collection was as a researcher. FAW (PsyD) is a consultant clinical psychologist and suicide researcher at the National Center for Suicide Research and Prevention at the University of Oslo. KAA (PhD) is a professor in patient safety at the Centre for Resilience, University of Stavanger with a background in safety science and health services research.

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Berg, S.H., Rørtveit, K., Walby, F.A. et al. Shared understanding of resilient practices in the context of inpatient suicide prevention: a narrative synthesis. BMC Health Serv Res 22 , 967 (2022). https://doi.org/10.1186/s12913-022-08282-x

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Health-related quality of life and clinical outcomes of adults with heart failure in nigeria: a review of current literature, ganiyu a amusa.

Background: Heart failure (HF) is a major public health problem due to its high prevalence, nature of morbidity and consequent socio-economic burden on individuals and societies. The established aims of the management are the prevention of disease progression and improving health-related quality of life (HRQoL). HF is a chronic illness known to have a negative impact on HRQoL with consequent adverse clinical outcomes. While there has been progress in reducing HF progression globally, not much has been achieved in improving RQoL, particularly in Nigeria and other low-resource countries. Methods : The available literature on the topic from PubMed, Medline, Google Scholar and other relevant internet sites were accessed, reviewed and inferences made. Conclusion : Heart failure has a significant negative impact on HRQoL with consequent poor clinical outcomes. Periodic assessment of HRQoL, HRQoL goal setting and adherence to guideline-directed medical therapy (GDMT) are recommended as standard care for individuals with HF in Nigeria and across the world

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Barriers and outcomes of therapeutic communication between nurses and patients in Africa: a scoping review

• Susanna Aba Abraham 1 ,
• Frederick Nsatimba 2 ,
• Dorcas Frempomaa Agyare 1 ,
• Joyce Agyeiwaa 3 ,
• Rita Opoku-Danso 1 ,
• Jerry Paul Ninnoni 4 ,
• Patience Fakornam Doe 1 ,
• Benjamin Osei Kuffour 1 ,
• Benjamin Kofi Anumel 1 ,
• Gifty Osei Berchie 2 ,
• Christian Makafui Boso 1 ,
• Andrews Agyei Druye 1 ,
• Christiana Okantey 1 ,
• Gifty Owusu 2 ,
• Paul Obeng 4 ,
• Mustapha Amoadu 4 &
• Isaac Tetteh Commey 2  

BMC Nursing volume  23 , Article number:  362 ( 2024 ) Cite this article

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Metrics details

Therapeutic communication (TC) promotes effective patient care, emotional wellbeing, and improves patient outcomes. The purpose of this review was to synthesise evidence on barriers and outcomes of TC between nurses and patients in Africa and to inform future studies and systematic reviews.

Search for the records was done in four major databases including PubMed, Science Direct, PubMed CENTRAL, and JSTOR. Additional searches were done in Google Scholar and Google. Results and findings from published studies and grey literature were included. A total of 16 articles met the eligibility criteria and were included in the review. This scoping review followed the guidelines by Askey and O’Malley.

Barriers associated with TC were grouped under five main themes: sociodemographic factors, patient-related factors, nurse-related factors, environmental and health service-related. Age, and religious beliefs were the main sociodemographic factors that hindered TC while stress and inadequate knowledge and skills were identified among the nurse-related barriers to TC. Extreme weather conditions and mosquito infestation were environmental factors while lack of access to TC educational programmes on TC was a health service-related factor that interfered with TC. Both positive and negative outcomes of TC were also identified.

Continuous professional development on TC is necessary to improve nurses’ attitudes and update their skills to enable them to render culturally competent nursing care to patients.

Peer Review reports

Introduction

Therapeutic communication (TC) is fundamental to health service delivery [ 1 ]. TC includes the usage of communication and the development of a professional relationship between the nurse and the patient which may lead to positive patient outcomes that promote healing and recovery [ 2 ]. Therapeutic communication has evolved significantly within the nursing profession, reflecting an increasing understanding of its importance in patient care [ 1 ]. Initially rooted in basic communication principles, TC has matured to encompass a holistic approach that considers patients’ emotional needs, cultural backgrounds, and individual preferences [ 2 ]. Over time, nursing knowledge has recognized TC as not just a tool for relaying information but as a means to establish trust, empathy, and a supportive environment conducive to healing [ 3 ]. This evolution has been marked by a shift towards patient-centered care models, where nurses actively engage in dialogue, active listening, and empathetic responses to better address patient concerns and foster collaborative relationships [ 2 , 3 ]. As nursing continues to advance, TC remains a cornerstone, adapting to new technologies, diverse patient populations, and emerging healthcare challenges to ensure the delivery of compassionate and effective care.

Therapeutic communication, when practised consistently and effectively, has the potential to promote effective patient care, emotional wellbeing, and improve patient outcomes [ 3 ]. Bright and Reeves claimed that the art of TC entails prioritising patients’ needs and fostering a supportive environment in which care can be provided and accessed [ 4 ]. It also involves employing various interpersonal skills such as empathy, understanding and active listening which aims at establishing a meaningful connection with patients [ 5 ].

Navigating through the health system can be a daunting task for most patients and clients who may experience uncertainty and a sense of vulnerability [ 6 ]. In spite of this challenge, nurses are in a central position to create a supportive and welcoming atmosphere for these patients. A positive nurse-patient interaction is said to contribute to positive patient experiences and satisfaction, and better treatment outcomes [ 2 , 7 ]. Thus, nurses who spend longer times with patients are required to maintain a therapeutic relationship with clients and apply therapeutic communication to explore their physical and emotional well-being [ 8 ].

However, following decades of research on TC, there is a lack of review study that has mapped evidence on outcomes and barriers to effective TC [ 9 ]. This is typical of Africa where inadequacies are reported in the utilisation of TC which impacts negatively on the provision of nursing care [ 9 , 10 ].

It is argued that medical errors and patient injuries can be decreased with effective use of TC [ 4 ] which may also promote the psychosocial wellbeing of the client [ 11 ]. This review will fill this gap by synthesising the evidence on barriers and outcomes of TC between nurses and patients in Africa. The purpose is to inform future studies and systematic reviews. Additionally, this review aims to furnish substantiated evidence that has the potential to enrich the creation of policies and the integration of approaches geared towards enhancing therapeutic communication within nursing education and practice.

This scoping review is conducted using the guidelines by Arksey and O’Malley [ 12 ]. The steps include specifying the research question, identifying relevant literature, selecting studies, mapping out the data, summarising, synthesising, reporting of the results and including expert consultation. The reporting of the review follows PRISMA-ScR specifications [ 13 ].

Research questions which formed the basis for the review included: (1) What are the barriers of TC among nurses and patients in Africa (2)? What are the outcomes of TC between nurses and patients in Africa?

The inclusion and exclusion criteria for the review are presented in Table  1 .

Medical Subject Headings (MeSH) terms were used for the search in PubMed and subsequently modified for search in other databases (Science Direct, PubMed CENTRAL, and JSTOR). Table  2 shows the keywords and MeSH terms used for the strategic search in PubMed.

Additional searches were conducted in Google Scholar and Google for relevant materials. Records were exported into a Bibliographic Manager (Mendeley) and duplicates removed. Articles which were not relevant to the subject matter were also excluded. Reference check and institutional repository search also revealed some records which were screened by the team. Furthermore, reference lists of all eligible articles were carefully checked for potentially relevant full text articles. Complete articles that met the eligibility criteria for the review were finally saved in Mendeley for data extraction and charting.

Data extraction was conducted independently by two groups comprising six members each. To retrieve relevant studies, FN, JA, DFA, ROD, SAA, ITC, BKA, BOK, independently extracted the data for analysis. Details such as authors, the countries in Africa where the study was conducted, the purpose of the study, study design, population, sample size, study findings, and conclusions were extracted. Data were compared and inconsistencies that were detected from the charting reconciled by independent team members (MA, FN, JA, DFA, ROD, SAA, ITC, BOK). Thematic analysis and data synthesis were carried out using the method proposed by Braun and Clarke (2006) and the results presented according to the research questions. Authors acquainted themselves with the data that was extracted, and codes were assigned to the data to aid in the content's description. The gathered data was then examined by the authors for patterns and themes. The developed themes were then examined, described, and identified, and the outcomes presented. The review started on June 13 and ended with the last search on August 18, 2023.

Search results

A total of 7,755 records were retrieved. Sixteen records were retrieved from additional search in other databases (Google Scholar and Google). A total of 3,000 duplicates were removed. Following title and abstract screening, 37 full-text records remained after excluding 4734 records. The excluded records at this phase were not relevant to the topic under review. Checking the reference list of all the full-text records produced four records while consultation with a digital librarian also produced 2 records. A total of 16 records were finally included in this review. Reasons for excluding full-text records were provided. Details of search results and screening process are presented in Fig.  1 .

PRISMA Chart

Study characteristics

Most reviewed studies used a qualitative design followed by cross-sectional designs with a few using mixed method (see Fig.  3 ). Majority of the reviewed studies were conducted in three countries in Africa including Ghana, Egypt and Ethiopia. See Fig. 2 for details. Also, most of the studies were conducted in 2019. Figures  3 and 4 present the years in which the studies were published and study designs respectively.

Map showing countries from which reviewed studies were conducted

The years in which the studies were published

Study designs of reviewed studies

Findings were reported according to research questions (Barriers associated with TC and outcomes of TC).

Barriers associated with TC were grouped into sociodemographic factors, patient-related factors, nurse-related factors, environmental and health service-related. The outcomes were grouped under positive and negative outcomes of TC (Table  3 ).

Sociodemographic barriers

The studies reviewed indicated that the age of patients affected TC. Older and younger age of patients were observed to influence the effectiveness of TC between nurses and patients [ 14 , 15 , 16 , 18 ]. For instance, communicating with children requires the use of different words and strategies compared to adults since children cannot think in abstract terms. Emishaw also found that younger males preferred female nurses and vice versa [ 16 ].

Other studies reported that religious beliefs and tenets of both patients and nurses acted as barriers to effective TC in health facilities [ 14 , 15 , 16 ]. For instance, Muslim males preferred to be cared for by male nurses and vice versa [ 14 ]. In relation to gender, some studies found that therapeutic communication was effective when male patients were nursed by female patients and vice versa [ 15 , 16 ]. Cultural differences and practices between nurses and patients also affected effective TC [ 14 , 15 ]. For instance, beliefs that older dying patients had witchcraft affected TC between nurses and older patients [ 15 ]. Given that different cultures use language differently, language differences between nurses and patients were found to affect TC [ 16 , 17 , 19 ]. Therefore, ongoing validation is important in a therapeutic relationship to confirm interpretation of words. Another socio-demographic characteristic that impacted effective TC was education. Formal education on the part of patients was found to negatively affect the practice of TC in healthcare facilities [ 17 ]. Limited literacy of patients [ 23 ] was reported to affect TC. In addition, all-knowing attributes of some patients were more likely to impact negatively on TC between nurses and patients [ 14 , 15 ]. Furthermore, a review study found that marital status and being unmarried was a barrier to TC [ 16 ].

Nurse-related barriers

Evidence from the review showed that stress among nurses was a barrier to TC [ 20 , 21 ]. Also, a few years of work experience of the nurses negatively influenced TC [ 19 ]. Another study having more years of experience affected TC practice [ 22 ]. Inadequate knowledge and skills of TC [ 14 , 15 , 16 , 17 , 19 , 21 , 23 ] was found to be a barrier. The use of technical terms and jargons [ 17 , 19 ], and the inability of the nurses to explain technical terms [ 15 ] were also identified as barriers to TC. The review found that negative nurses’ attitudes and behaviours [ 15 , 20 , 26 ], lack of empathy [ 15 ], oppressive and judgemental attitudes [ 23 ] hindered TC between nurses and patients. Also, dissatisfaction and lack of love for the job [ 27 ], resistance and reluctance of the nurses to communicate with patients [ 19 ] impeded TC. The review found that the personality and/or mood of nurses hindered TC [ 23 ]. Furthermore, a study reported that the lack of professional decency and urgency of nurses was a barrier [ 15 ]. In addition, the unwillingness of nurses to work in poor working environments affected their communication with patients [ 28 ].

Patient related barriers

Evidence from this review suggested that, negative attitude of the patient towards the nurse was a barrier to TC [ 19 ]. In addition, the negative attitude of patients’ relatives hindered TC [ 15 , 26 ].

Patient’s dissatisfaction with nurses was reported by [ 14 , 15 ] as a hindrance to TC. Idleness on the part of the patient was identified as a barrier [ 14 ]. Also, patients’ misconceptions about nurses [ 14 ], stereotyping, lack of empathy, lack of respect from the nurses [ 15 ], and bad nursing care experience [ 23 ] were all found to affect TC between patients and nurses. The review also reported that pain [ 14 , 16 , 17 , 19 , 23 ], anxiety [ 15 , 19 ], and physical discomfort of the patient [ 19 ], deafness [ 26 ], patient condition [ 20 ] and patient mood swings [ 27 ] were all identified as barriers to TC. Lack of confidentiality was identified as a barrier to TC [ 19 ]. Additionally, patients’ family interference with care also affected TC [ 16 , 17 , 20 ]. Cubaka et al. reported that power imbalance weighing on the provider’s side was reported to affect TC [ 23 ].

Environment-related barriers

The reviewed studies reported that anxiety related to new environments [ 14 , 19 ] and long stay in health facilities [ 14 , 15 ] negatively impacted TC between nurses and patients. Also, extreme weather events such as very hot and cold wards affected TC [ 14 , 19 ]. Furthermore, noisy environments [ 14 , 15 , 16 ], distracting environments in relation to the light and fan [ 14 , 19 ], and the busy nature of the ward environment [ 16 , 19 ] also hinders the practice of TC. Also, mosquito infestation [ 14 , 15 ] and poor environment of the health facility [ 28 ] also impacted TC between nurses and patients.

Health facility related barriers

In relation to health facility factors, shortage of nursing staff [ 16 , 21 ] and high workload [ 14 , 17 , 19 , 20 , 21 , 22 , 23 , 28 ] were identified as hindrances to TC. Additionally, lack of access to therapeutic educational programmes [ 17 , 18 , 23 , 24 , 25 ], lack of medical facilities and drugs and lack of continuous TC opportunities [ 16 ] were reported as barriers to TC. Other impediments to TC identified from the reviewed studies were poor information on ward routines [ 21 ] and ineffective health insurance system [ 16 ].

Outcomes of therapeutic communication

The outcomes of TC between nurses and patients were grouped into positive and negative.

Positive outcomes

This review found that effective TC resulted in adherence of patients to treatment [ 21 , 27 ]. Furthermore, effective TC improved patients’ satisfaction with treatment protocol [ 25 ], communication with nurses [ 22 ], instructions and acceptance of guidance from nurses [ 27 ]. Another study reported effective TC fostered patients’ trust and improved recovery [ 18 ]. Successful TC also resulted in improvement in nurses’ skills in TC and the quality of nursing care [ 24 ] protection of patients’ rights [ 22 ].

Negative outcomes

A reviewed study showed that ineffective TC contributed to poor treatment compliance, medical errors, patient dissatisfaction with care and inefficient use of resources [ 20 ]. Also, negative TC reportedly resulted in non-supportive management [ 21 ].

The aim of the scoping review was to map evidence on the barriers impacting the practice of effective TC and its outcome. Findings from this review suggest that there are numerous obstacles to effective TC between nurses and in-patients in Africa. These hindrances were clients’ sociodemographic characteristics such as age and religious differences, limited experience of nurses, patients’ negative attitudes, bad experience of nursing care, and physical discomfort. Other obstacles to TC which were identified in the review related to the environment, climate and the working conditions. These included; hot and noisy ward environments, lack of access to therapeutic educational programmes, shortage of staff and ineffective health insurance system. From the review, it was found that one of the barriers that negatively impacts TC is the shortage of nurses who provide direct patient care to in-patients [ 16 , 21 ]. Nursing staff shortage could result in high workload for nurses who remain at work and therefore impede the ability to effectively communicate with patients. Consequently, this review also found high workload as an obstacle for effective TC between nurses and in-patients [ 14 , 15 , 16 , 17 , 20 , 22 , 23 ]. Furthermore, the review indicated that job-related stress among nurses served as a catalyst for ineffectiveness of TC as the emotional and social elements of communication are lost [ 29 ]. There is therefore the need for healthcare administrators and nurse managers to address these healthcare related factors that impede TC between nurses and patients. Kwame and Petrucka suggest a thorough examination of how this could be addressed [ 9 ].

Furthermore, this review found negative nursing attitudes such as lack of empathy hindered effective communication with admitted patients [ 15 ]. Sharafkhani et al. reported that nurses’ inability to express empathy and accept their own emotions produces gaps in therapeutic communication [ 30 ]. This is unfortunate as empathy is central to effective TC in healthcare settings. Consequently, this lack of empathy can result in increased patient anxiety, hostility and poor clinical outcomes [ 31 ].

Another barrier to TC found by this review was limited practical experience of nurses [ 19 ]. A similar finding. Also, ineffective TC by trained nurses may serve as a negative reinforcement for preservice nurses and thus, cause the problem to become institutionalised [ 32 ]. There is the need for supportive supervision by nurse managers and supervisors to ensure that TC is appropriately practised during nursing service delivery.

Cultural beliefs and practices such as the notion that older dying patients were witches and wizards caused reluctance among nurses in effectively communicating with older dying patients [ 14 , 15 ]. Most of these cultural barriers are compounded by the language differences that affect the effective communication of needs and expectations between nurses and patients [ 9 , 14 ].

The inadequate knowledge and skill of nurses with regard to TC can have a profound impact on the quality-of-care patients receive and their overall outcomes [ 8 ]. TC is an essential element in the nursing profession that entails proficient engagement and interaction with patients to foster recovery, confidence, and comprehension [ 2 ]. The absence of the requisite knowledge and skills in this domain among nurses may result in various limitations and consequences including fatal medical errors. Access to training opportunities in TC for nurses plays a pivotal role in the development and enhancement of therapeutic engagement with patients [ 15 , 19 ]. In turn, this can substantially ameliorate patient care and overall healthcare outcomes. The inability of nurses to explain technical terms and the use of medical jargon can equally have a significant impact on TC with patients [ 33 ]. Effective communication in healthcare requires clear and understandable dialogue between healthcare providers and patients. If nurses opt to employ intricate medical terminology that may not be comprehensible to patients, it may impede effective TC [ 14 ].

This review also identified positive outcomes of effective TC between and patients in Africa. Evidence suggested that successful TC leads to patient adherence [ 21 , 27 ] and satisfaction [ 25 ] to treatment protocol these is in agreement with Sherrill et al. who reported that effective TC enables healthcare workers to actively explain and listen to patients and their families making it easier for them to understand their specific needs, preferences and concerns. The results are also similar to that of Abrams et al. who reported that families of patients are very satisfied with the communication made by nurses [ 34 ]. In addition, effective TC also leads to patients understanding instructions and guidance from nurses [ 27 ]. Risna & Fauzia reported that nurse TC had a positive effect on the cooperative behaviour of patients with mental disorders [ 35 ]. Hence, the patient developed trust which eventually leads to improved outcome [ 18 ]. Finally, the reviewed studies found that effective communication is essential in preventing medication errors [ 2 , 8 , 36 ].

Limitations of the review

A significant majority of the included studies were qualitative and non-experimental. Included studies relied on self-report measures. This introduces biased responses from participants which may affect the generalisation of their findings. This situation may affect the generalisation of findings of this review.

Furthermore, the literature search was restricted to peer-reviewed articles and papers published in English. This situation may have affected the number of included studies and the depth of information presented in this review. Although the study focused on Africa, the majority of the papers were conducted in sub-Saharan Africa (SSA). This may be another limitation to generalising the findings to cover the entire African continent.

There could be papers unpublished on TC in languages other than English which may help understand TC’s importance and barriers in creating a safe and healthy work environment for healthcare delivery. However, this review focused primarily on papers published in English. This may reduce the number of included studies conducted on the subject matter in Africa.

Though there were limitations to the study findings, the review article is still relevant to nurses -patients relationship regarding TC.

Recommendations for future research

Reviewed papers on TC mainly conducted in Africa were included in this study. Most of these papers were conducted using a qualitative approach with much attention on sub-Saharan Africa. Quantitative designs may be needed to understand the concept of TC in nursing care.

Additionally, present literature on the subject matter focuses on nurses and patients. Hence, studies that seek to explore views of physicians, surgeons, clinical psychologists, pharmacists, laboratory technicians and other auxiliary staff in healthcare facilities are needed.

Moreover, the direct impact of TC on nursing care may need further exploration. More studies would also be required to explore the strengths and weaknesses of TC in health care delivery in Africa. Finally, understanding TC through the experiences of other health workers in the health facilities will be of significant benefit for patient care.

Implications for nursing practice, education and policy

The barriers for effective TC between nurses and patients in health care settings are numerous and require a comprehensive strategy to address them. Nurses who lack skills to practise TC might struggle to engage the patients at an emotional level. Hence, it leads to lower patients’ satisfaction levels. Also, TC must be integrated in all aspects of the nursing curricula to enhance nurses’ ability to effectively communicate with patients, families and healthcare teams. Policies to institutionalise supportive supervision on nurses practice of TC while interacting with patients should be established and implemented.

Cultural differences also hinder TC and affected nurses’ willingness to provide care to older dying patients. This means that geriatric patients may suffer neglect in health facilities while on admission. This may result in missed opportunities to provide comfort to dying patients, exacerbate patient anxiety and negatively impact patient care experience. Strategies to incorporate cultural competency and reflective practice in nursing practice should also be enforced.

Furthermore, shortage of nurses providing direct patient care results in increased workload. This could invariably cause stress among the nurses and affect the practice of effective TC negatively. When this is not resolved, it has the potential to impact preservice nurses who see these nurses as role models and mentors and serve as an avenue for negative learning. Health service managers must ensure the appraisal of nursing tasks and responsibilities and recruit more nurses to enhance opportunities for the implementation of effective TC.

Lack of access to educational programmes on TC may result in ineffective practice of TC such as using jargon and technical terms while communicating with patients. This could result in failure to effectively educate patients and families, and fester misunderstanding, anxiety and confusion. Nurse managers and health services administrators must invest in continuous professional development for nurses providing direct patient care to enhance their knowledge and skills.

In conclusion, this comprehensive review illuminates the multifaceted nature of therapeutic communication (TC) within nursing practice and its pivotal role in patient care outcomes across diverse healthcare settings in Africa. The analysis underscores a myriad of barriers spanning sociodemographic, nurse-related, patient-related, environment-related, and health facility-related domains, all of which significantly impede the effective exchange of information, empathy, and support between nurses and patients. Notably, the shortage of nursing staff, high workload, and limited access to educational programs emerge as critical impediments to nurturing meaningful therapeutic relationships. Moreover, the review underscores the nuanced interplay of cultural beliefs, patient attitudes, and environmental factors that shape the landscape of TC, underscoring the imperative for culturally sensitive and patient-centered approaches in nursing care delivery. The findings also highlight the imperative for robust policies, comprehensive nursing education curricula, and supportive supervision mechanisms to foster a conducive environment for effective TC practices. Moving forward, there is a compelling need for future research endeavors to delve deeper into the quantitative dimensions of TC, explore diverse healthcare stakeholders’ perspectives, and elucidate the direct impact of TC on patient outcomes. Ultimately, by addressing the identified barriers and embracing a holistic approach to TC, nursing practice, education, and policy can collectively pave the way for enhanced patient satisfaction, improved treatment adherence, and optimized healthcare delivery across the African continent.

Availability of data and materials

All data generated or analysed during this study are included in this published article (and its supplementary information files).

Abbreviations

• Therapeutic communication

Medical Subject Headings

Sub-Saharan Africa

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Acknowledgements

We are grateful to Dr. Kodua-Ntim of the Sam Jonah Library, University of cape Coast, for his immense support during the data search and screening process.

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MA, PO, SAA, ROD, DFA, AAD, GOB conceptualised the study. FN, JA, DFA, ROD, SAA, ITC, BKA, BOK, retrieved relevant studies and data extraction. MA, JA, DFA, ROD, FN, SAA, ITC, BOK conducted the thematic analysis and data synthesis. GOB, CMA, CO, GO, JPN, PO, PFD, MA, ITC, SAA, FN, DFA, JA, ROD drafted the manuscript. All authors read and approved the final draft.

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Abraham, S.A., Nsatimba, F., Agyare, D.F. et al. Barriers and outcomes of therapeutic communication between nurses and patients in Africa: a scoping review. BMC Nurs 23 , 362 (2024). https://doi.org/10.1186/s12912-024-02038-0

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