Registered nurse– patient communication research: An integrative review for future directions in nursing research

Aim: To explore communication research in nursing by investigating the theoretical approaches, methods, content and perspectives in research on real-time registered nurse (RN)– patient communication. Design: An integrative review of real-time communication between RNs and patients. Data Sources: Empirical research papers were searched in PubMed, CINAHL Plus and Medline. The results from the database searches were supplemented with results from manual searches in reference lists. Review Methods: A total of 1369 articles published between January 1996 and December 2021 were screened, which resulted in the inclusion of 52 articles. Results: The integration of various theories, such as nursing or communication theories, is weak in most of the included studies. RN–


| INTRODUC TI ON
Communication is considered a core principle of nursing practice (Casey & Wallis, 2011).The importance of communication and a well-functioning nurse-patient relationship to provide high-quality care is well known (Caris-Verhallen et al., 1997;Fleischer et al., 2009;Shattell, 2004;Street et al., 2009).The ability to provide effective communication is also emphasized as central for assuring high-quality care and patient safety, as well as detecting important needs, providing support and information and enhancing patient learning (Kwame & Petrucka, 2022).There has also been a strong trend for patient-or person-centred care, which highlights patients' rights to autonomy, information and shared decision-making, in which communication is a key element (Håkansson Eklund et al., 2019).Furthermore, Sundler et al. (2020) have stressed the importance of acknowledging communication skills that can facilitate person-centred care.However, less is known about the actual communication, hereafter called realtime communication, between registered nurses (RNs) and patients.
To the best of the authors' knowledge, there is no recent review on the real-time RN-patient communication, and how such studies are guided by theory.

| BACKG ROU N D
Communication and interaction are complex processes that are central to the exploration and understanding of patients' health conditions (Parker et al., 2020).The terms communication and interaction are often used interchangeably in nursing research and are seldom clearly described or explained (Fleischer et al., 2009).Both interaction and communication are processes and situations involving behaviours that are communicative and convey messages.However, interaction can be seen as a superior term characterized by a mutual and dynamic process, while communication can be seen as a special type of interaction linked to the exchange of information and experiences with the aim of reaching understanding and building a relationship.Communication includes both verbal and non-verbal expressions and is described as something that always happens when people meet, making it a prerequisite for constructive interactions (Fleischer et al., 2009;Watzlawick et al., 1967Watzlawick et al., /2014)).
Communication is a core element of nursing care used as a promoter or tool for interaction and relationship-building, and nursing communication also influences patients' health and well-being (Fleischer et al., 2009).For instance, communication can instil trust, support well-being or self-care actions and strengthen the patient's autonomy.
Interaction and communication are critical for assessing the needs and outcomes of patients, such as increased knowledge, self-care skills, adherence to treatment, trust, high-quality medical decisions, social support and empowerment (Street et al., 2009).
Until now, the number of RN-patient communication studies and reviews in this field is sparse, compared to the number of studies and reviews on physician-patient communication, see, for instance, Beck et al. (2002), Laidsaar-Powell et al. (2013), Zill et al. (2014), Cohen et al. (2017) and Ghosh et al. (2020).There are some previous reviews in nursing, but no recent literature review with a focus on studies using observations (in person, or by audio or video recording) of communication between RNs and patients.Previous reviews have focused on theoretical nursing models and care for older people (Caris-Verhallen et al., 1997); additionally, reviews have observed a unidirectional focus in nurses' communication (Shattell, 2004) or have noted that the concepts of interaction and communication were used interchangeably (Fleischer et al., 2009).In addition, a theoretical perspective was often lacking, except for the use of the cognitive model of social information processing (Sheldon & Ellington, 2008).
Nurses' communication with patients is commonly embedded in everyday activities (Macdonald, 2016;Sundler et al., 2016) and can occur while performing nursing tasks (Fleischer et al., 2009;Shattell, 2004).Nursing care requires an understanding and sensitivity to patients' experiences and emotional concerns.Nurses' relationship-building and communication with patients include the confirmation of emotions (McCabe, 2004).The communication is also important for addressing patients' needs and worries (Höglander et al., 2017;Sundler et al., 2016).Thus, communication and interaction are imperative and can reflect humanistic values of respect, self-determination and empathy (McCormack et al., 2011).
The present review focuses on studies of real-time RN-patient communication.Methods and approaches used to investigate realtime communication vary.To date, observational methods seem to have been less frequently used than other methods when describing or investigating communication.Most studies used retrospective qualitative interviews of nurses and/or patients concerning their communication (Amoah et al., 2019;Chan et al., 2019;Fleischer et al., 2009).It has been suggested that further research using realtime observations in nursing research is needed (Liu et al., 2021;Williams et al., 2017).However, research using real-time observations like audio or video recordings for data collection may be challenging.For instance, data collection involving nurses tends to invade the normal workflow more compared to doctors, while nurses tend to walk around much more, doctors most often meet patients while sitting down.Thus, nursing encounters are more complicated to record with an unmanned camera during ordinary nursing care.There may also be difficulties to manage data collection when the researcher must engage nurses in the recruitment of patients (Sundler et al., 2017).As stressed by Liu et al. (2021)  recording may act in a different way when being recorded.Although no huge differences are being observed (Arborelius & Timpka, 1990;Penner et al. 2007;Pringle & Stewart-Evans, 1990).There may also be challenges to obtain access to the field when recruiting participants, and when obtaining ethical approval concerning the intrusiveness of using recordings in, for instance, home care services when data are collected in a person's own home and with respect to their integrity (Sundler et al., 2017).
RN-patient communication is a hallmark of professional competence in nursing that is sometimes undervalued.There is a need for a current assessment of the state-of-the-art research on real-time

| Aim
The aim of this review was to explore communication research in nursing by investigating the theoretical approaches, methods, content and perspectives in research on real-time RN-patient communication.

| Design
An integrative review was conducted to assess nursing research on real-time communication between RNs and patients.An integrative review is a broad research review that allows the researcher to combine both theoretical and empirical literature and to include a variety of data types and diverse methodologies (Whittemore & Knafl, 2005).The present review followed the process described by Whittemore and Knafl (2005), encompassing problem identification, a literature search, data evaluation, data analysis and the presentation of results.The sources of data were empirical research papers, and no theoretical literature was used.

| Search methods
A systematic literature search strategy was undertaken to identify relevant studies.Article retrieval was performed via database searches and manual searching.The latter involved searching for articles in the reference lists.First, we conducted computerized database searches in PubMed, CINAHL Plus, and Medline with assistance from a librarian.Keywords (based on MeSH terms) of "nurse" and "patient" or "person" and "communication" or "observation" were used in the searches.When scanning the search results, the following inclusion criteria were used: (1) observational studies of real-time RN-patient communication, (2) peer-reviewed studies, (3) studies that were written in English and (4) studies that were published between January 1996 and December 2021.The limitation in the years was based on a previously published literature review that covered articles published before 1996 (Caris-Verhallen et al., 1997).
Articles not available in full text (n = 6) were excluded.
Unpublished manuscripts, abstracts, and dissertations were excluded, as well as studies involving participants younger than 18 years of age.Furthermore, we excluded studies with participants from different professions when it was impossible to distinguish the results on RN-patient communication from other healthcare professional-patient communication.This exclusion ensured that the focus on RN-patient communication was maintained.Articles were excluded if they lacked descriptions of methods (e.g.data collection, analysis or participants) or the study did not include realtime communication; for example, studies with indirect methods used to assess communication, such as interviews.

| Search outcome
An initial broad search of the literature yielded a total of 1369 references.All the references from the search were screened for duplicates.The references were screened by title, after which they were screened by abstract.A second screening of the methods section was performed to verify whether the articles complied with the inclusion criteria.A total of 128 references were read in their entirety by four of the authors.Each author screened a fourth of the references, and joint discussions were enacted to resolve any doubts and to maintain compliance with the inclusion and exclusion criteria.
The second screening was comprehensive, with multiple checks to verify the accuracy of the screenings and to validate that all the inclusion and exclusion criteria were met.After the second screening, additional articles were included through an additional hand search and from the screening of the reference lists (n = 16), which finally resulted in the inclusion of 52 references.The literature search was documented as a Prisma flow diagram, see Figure 1.

| Quality appraisal
For the quality appraisal, we used the Mixed Methods Appraisal Tool (MMAT) version 2018.The MMAT was designed to appraise the quality of empirical studies and permits for appraisal of qualitative research, randomized controlled trials, non-randomized studies, quantitative descriptive studies and mixed methods studies.The MMAT checklist contains two screening questions, and five questions for each of the five different study designs included in the appraisal (Hong et al., 2018).Each study was screened and rated in accordance with MMAT.To ensure consistency among the researchers we discussed our appraisal based on the methodological quality criteria.All the included articles demonstrated high quality (based on the MMAT) and met 75%-100% of the evaluated criteria in the MMAT checklist.

| Data abstraction and synthesis
The following data were extracted from the studies and organized as follows: theoretical approach, aim, methods and design, setting, participants, data collection, analysis and results.The extracted data were compared and analysed for differences and similarities, and similar data were grouped.The analysis followed a constant comparison method, as suggested by Whittemore and Knafl (2005).
With constant comparison patterns, variations and similarities are established.This method is preferable when using a variety of data that are obtained with different methodologies (Whittemore & Knafl, 2005), as was done in the present study.

| Methods and approaches used for examining RN-patient communication
The characteristics of the 52 included studies are summarized in

| The meaning and nature of RN-patient communication
The meaning and nature of RN-patient communication were categorized as (1) the focus and impact of communication, (2) various, more or less person-centred communication styles and (3) the content of patient communication, further described below.

| The focus and impact of communication
The focus of communication was found to influence the relationshipbuilding and interaction between RNs and patients.The focus of the communication could both point to and result from a power imbalance between RNs and patients.
The interaction between RNs and patients changes during encounters and might signify both symmetry and asymmetry (Barrere, 2007).When building a relationship, the roles of RNs and patients could be complementary and facilitate symmetry through a social exchange in the communication such as humour and trust (Lotzkar & Bottorff, 2001) or by including the patient's family members (Reblin et al., 2016).However, psychosocial issues, positive emotions and partner statements usually receive much less attention than physical care information (Ellington et al., 2018).RNs were found to dominate the communication and interaction when they initiated the contact, decided on the topic, or had an instructor role (Duxbury et al., 2010;Ellington et al., 2018Ellington et al., , 2012;;Höglander et al., 2017;Kettunen et al., 2000;Pettersson et al., 2018).RNs' dominance was also observed in consultations in which they talked more than their patients (Ellington et al., 2018(Ellington et al., , 2012)).RNs' contributions to the interaction and communication with patients were sometimes minor compared to other professionals such as physicians (Weber et al., 2007).
A dominant discourse of communication was also described as nonpatient centred (Siouta et al., 2019).The dominant role could increase or decrease, depending on the RN's interaction with the patient (Barrere, 2007;Ellington et al., 2018Ellington et al., , 2012)).If the RNs instead invited the patient to participate in his or her care, it could decrease the asymmetry in the relationship (Bolster & Manias, 2010).
Even if the RNs strived to meet patients' needs, they often focused on nursing routines, for example, tasks regarding nutrition, hygiene, physical examinations or medication administration (Gordon et al., 2009;Macdonald et al., 2013;Prip et al., 2019) as well as on patients' medical conditions and questions (Johnsson, Wagman, et al., 2018;Prip et al., 2019).RNs were often the ones who initiated the gathering of patient information (Duxbury et al., 2010), and the communication became characterized by a focus on treatment, which seldom explored patients' existential and psychosocial concerns (Prip et al., 2019).RNs were reported to be more confident and efficient in communication on medical or physical aspects, rather than in communication on emotional aspects (O'Baugh et al., 2009).
Some studies reported that RNs exhibit poor skills in answering patients' questions (Carlsson & Pettersson, 2018;Collins, 2005; Roche & Jones, 2021), clarifying their doubts or exploring their comments (de Leeuw et al., 2014;Duxbury et al., 2010;Eide, Sibbern, Egeland, et al., 2011;Eide, Sibbern, & Johannessen, 2011;Ernesäter et al., 2014;Ernesäter et al., 2016;O'Baugh et al., 2009).Participants: 11 nurses (9 females/2 males) 25 patients (6 females/19 males) Some nurse-patient interactions during medication activities were found to be consistent with a person-centred care.The nurses commonly initiated and dominated the interactions and provided patients with information.They sometimes missed opportunities for patient participation.The nurses were described to stand beside the patient's bed, making little eye contact with their patient.Only a few nurses sat down during the medication activities.Nurses appeared to be rushed with limited time for the patients and the environment was hectic and demanding for the nurses.Barriers to person-centred care were observed when the care was centred on routines or the nurses' views rather than the individual patient Carlsson and Pettersson (2018) 5 Nurses (all females) 6 Doctors (1 female/5 males) 23 Patients (Sex NS) During consultations, nurses used a language that was more everyday-like, compared to doctors who used a more technical and medical language.
The nurses provided space and responded to patients' views to a larger extent than the doctors did.In consultations with nurses, the patients' problems and concerns seemed to be given more space, while doctors tended to have a more medical point of view.The study concludes that these differences are complementary in their contribution to the individual care of 5 Nurses (4 females/1 male) 58 Patients (49 females/9 males) The consultations in this study had a mean duration time of 36.14 min (range 14.25-52.30).In these, the patients expressed 801 cues and concerns, mostly about pain.The patients expressed more explicit concerns when nurses to a higher extent responded emphatically.When lacking empathic responding there was an association with patients expressing more implicit cues.
The study concludes that the patients with fibromyalgia in the study expressed many expressions contained emotional distress.They more often expressed implicit emotional cues (n = 591) rather than explicit concerns (n = 210).The study suggests that education and skills training may be needed to help professionals to detect expressions of emotional distress and to respond in an emphatic manner Eide, Sibbern, Egeland, et al. (2011), Eide, Sibbern, and Johannessen (2011) 5 Nurses (5 females/0 male) 7 Patients (2 females/5 males) In general, the nurses talked more during the recordings than patients and family caregivers.Nurses used questions in 8% of their talks and provided information advice mainly related to physical care.Their talk was also coded as partnership building (17%) and devoted to emotional responses (8%) and 4% of their statements reflected humour.A large proportion of lifestyle statements were found (23%).
The patients were silent in 11 of the 32 visits.When they spoke, most talks concerned physical care information (31%) or lifestyle statements (19%).Some statements were about psychosocial information (6%), while few questions were asked by the patients (2%).
The study concludes that audio-recorded home hospice nurse visits were feasible, and RIAS was suited to code content of the encounters.The findings showed a wide range of topics and emotions during nurse-patient/family caregiver conversations Tables and     19 nurses (18 females/1 male) 38 patients (24 females/14 males) Affective questions and tentative speech, together with continuers, facilitated active participation by patients.Thus, patients were free to discuss their ideas, concerns, experiences and knowledge with nurses.The findings indicated that nurses were able to establish collaboration and involve patients in their frame of reference.Nurses' affective questions were something that manifested empowering acts from the nurses.Affective questions related to patients' perspectives and views, deal with feelings, experiences, and concerns, participation, options to choose topics and providing space for their wishes, hence empowering the patient.
Patient participation was facilitated when the nurses used affective questions, tentative speech and continuers.In conversations where the nurses allowed patients to freely discuss their experiences, concerns, and views, they were able to establish collaboration and involve patients.There were no significant differences in consultation length.
The nurses had higher levels of overall self-satisfaction regarding the consultations than doctors.Patient satisfaction was significantly related to building a relationship in their talks  Participants: 34 nurses (28 females/6 males) 100 patients (45 females/55 males) Nurses' cue responding was independently related to patient satisfaction.Patients with palliative treatment had higher satisfaction regarding communication than the patients that were curatively treated.
70% of cues signalled worry or concern, 24% of cues mentioned worry or concern, and 6% expressed unpleasant emotion.
Nurses explored 21% of the cues per conversation.24% were acknowledged and 55% had a response using distancing behaviour.3 Nurses (3 females/0 male) 28 Patients (0 female/28 males) There were no significant demographic differences between the telephone and videophone groups.The nurses have a high degree of utterances related to the categories of Data gathering, Building a relationship and Activating and partnership building.The highest number of utterances appeared in the Building a relationship category.
Patient-centred communication strategies were also reported inviting, involving and recognizing patients during communication, and encouraging them to narrate their experiences (Pettersson et al., 2018;Sundler et al., 2020), focusing on their emotions (Hafskjold et al., 2017) and facilitating a mutual interaction (Sundler et al., 2020).Patient-centred communication was more personal and focused on the individual patient's perspective of their situation and everyday life (Johnsson, Wagman, et al., 2018;Collins, 2005).
However, social conversation and partnership building were sometimes less frequently used (Berry, 2009).

| The content of patient communication
Similar to RNs, the patients also used different communication styles, such as storyteller, quiet confirmer, stoic observer, emotional expressor, detail-oriented inquisitor, dominant participator or critical self-observer (Kettunen et al., 2000).Patients' participation during communication and their choice of communicative content or communication style were often affected by how the RNs communicated with them (Eide, Sibbern, Egeland, et al., 2011;Kettunen et al., 2000;Kim et al., 2001); for example, patient participation was affected by how RNs responded (Eide, Sibbern, Egeland, et al., 2011;Kettunen et al., 2000) or if they used professional terminology (Kettunen et al., 2000).Patients became more active when RNs expressed positive emotions, understanding or agreement and used small talk (Kim et al., 2001).
However, some studies reported that patients avoided being explicit about their concerns with RNs (de Leeuw et al., 2014;Eide, Sibbern, Egeland, et al., 2011;Kettunen et al., 2000), whereas one study revealed that patients uttered more explicit concerns when talking to RNs who provided empathic responses, compared to RNs who did not (Eide, Sibbern, Egeland, et al., 2011).No explicit challenges regarding RNs' communication skills were reported in the results, which was surprising because, as previously stated, RNs are frontline healthcare professionals (Kaminsky et al., 2017) who often work independently and care for patients with complex conditions.Hence, it was expected that RNs would face high demands on their communication skills.Communication processes are also described as being complex (Parker et al., 2020), which would also be expected to challenge RNs' communication skills.However, it was observed that RNs could have poor abilities in answering questions or further exploring patients' doubts.It was also found that communication and interaction were used interchangeably similar to the review by Fleischer et al. (2009).This is further supported by the communication theory provided by Watzlawick et al. (1967Watzlawick et al. ( /2014)), which states that all communication includes interaction and is described as a reciprocal and dyadic process that goes beyond a mere sender-receiver relationship.

| DISCUSS ION
The agenda for communication appears to be primarily set by RNs.The patients' communication styles were affected by how the RNs communicated.For example, patients used a more active communication style if RNs were positive, empathetic or prosocial.
Moreover, the patient became more implicit and avoided explicit utterances when nurses were perceived as being less empathic in their communication.It is critical to provide space for patients to address their concerns and ask questions (Höglander et al., 2017).
Communication is fundamental in nursing care; specifically, it is a critical starting point for understanding patients' needs and expectations (Caris-Verhallen et al., 1997).Proper and effective communication could demonstrate symmetry and build trust, which may help to facilitate patient-centred care.When integrating nursing tasks with the patients' views, more patient-centred styles of communication could be beneficial.Effective communication is emphasized to ensure high-quality care that supports and meets the patients' needs (Kwame & Petrucka, 2022).
recordings may influence the actual situation as participants being aware of the K E Y W O R D S communication, integrative review, interaction, patient, registered nurse 13652648, 2023, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15548by University Of Boras, Wiley Online Library on [31/01/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License communication between RNs and patients to identify what is known in this area and what has not yet been researched.More knowledge is needed on real-time communication and on how to apply the best communication practices.

F
Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15548by University Of Boras, Wiley Online Library on [31/01/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 4.1 | Theoretical approaches used in studies on real-time RN-patient communication In general, the theoretical perspectives related to RN-patient communication were implicit.None of the studies used a nursing theory or theorist, and most of the studies had no clear theoretical underpinnings for communication.In some studies, a patient-or person-centred perspective was described as a conceptual framework underlying RN-patient communication and interaction, thus demonstrating an interactional and relationship-based view on collection of real-time RN-patient communication was mainly conducted through audio or video recordings (n = 43) or participatory observations (n = 9).The most commonly used methods for coding data were the Verona coding definition of emotional sequences [VR-CoDES] (n = 8), the Roter interaction analysis system [RIAS] (n = 6) and conversational analysis [CA] (n = 4).Most papers originated from Nordic countries (e.g.Sweden, Norway, Finland and Denmark, n = 22), and some papers were from the United States (n = 8), the Netherlands (n = 5), England/UK (n = 5), Australia (n = 5), and Canada (n = 2).Single papers were from Iran, Indonesia, New Zealand, China and Switzerland.Hospitals and primary care settings were the prevailing settings, followed by home care, hospice and telenursing settings.In most studies, participants were commonly and solely comprised of RNs and patients (n = 41).
patients de Leeuw et al. (2014), the Netherlands Nurse-patient communication in follow-up consultations after head and neck cancer treatment To explore the content and form of nurse-patient communication in follow-up consultations with HNC patients with or without a /3 males) The findings describe that patient cues were found to consist of more vague expressions rather than clear expressions of emotions.Nurses most frequently responded with distancing behaviours to patients' and partners' cues, hence reducing rather than providing space in the communication, however, most informational questions were adequately addressed.Most nurses' conversations contained small talk to keep the conversation going, without further exploration of patients' utterances.The study concludes that adequate cue and question responses remain challenging for nurses.Drevenhorn et al. (2001)sex NS) Patients (numbers and sex NS) Nurses' conversations with patients were found to mostly contain somatic or medical issues.Almost all patients were found to ask questions about medications.Non-pharmacological information was mainly related to diet and physical activity.In 15 out of 63 observations, psychosocial content was observed during nonpharmacological conversations Duxbury et al. (2010), England A structured observation of the interaction between nurses and patients during the administration of medication in an acute mental health unit To describe current practice in the administration 12 females/12 males) 57 patients (sex NS) During interactions nurses often demonstrated warmth, empathy and a diplomatic interpersonal style.In most of the observations, the nurses checked that they had understood the patients' perspectives.The nurses demonstrated active listening skills.This was often shown through affirming nods, eye contact, or expressing caring and concern.There was a good balance of verbal communication in most observations (93%) between nurses and patients.Information giving was initiated more by the nurses than by patients.Solutions to problems initiated by patients were commonly explored.There were situations when the patients' views were not explored, and the nurses did not always ask for patients' views or acceptance of medication TA B L E 1 (Continued) (Continues) 13652648, 2023, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15548by University Of Boras, Wiley Online Library on [31/01/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Efraimsson et al. (2015), Sweden Nurses' and patients' communication in smoking cessation at nurse-led COPD clinics in primary health care To describe smoking cessation communication between patients and registered nurses trained in MI in COPD nurse-led clinics in Swedish primary 11 females/2 males) During the non-smoking consultations, the nurses asked closedended questions, made reflections, and provided information, and they did not adhere to the principles of a motivational interview in the interactions with patients.Patients were mainly neutral or adhered to what nurses said, but there was a limited focus on how the patient could stop smoking Eide, Sibbern, Egeland, et al., 2011; Eide, Sibbern, & Johannessen, 2011, Norway Fibromyalgia patients' communication of cues and concerns: interaction analysis of pain clinic consultationsTo explore the types of concerns and cues patients expressed in an initial consultation with a nurse at a pain clinic, how and who initiated these cues and concerns, and predictors of these expressions text The analysis of the 25 calls found that the telephone nurses made more utterances than the callers, 1439 compared with 1209.During the calls, the nurses mainly asked closed-ended medical questions, and they mainly responded to concern with closeended medical questions while exploration of callers' reasons for concern was sparse.The study concludes that the nurses' reluctance to use open-ended questions and to follow up on callers' understanding might be a threat to concordance and a potential threat to patient safety Fakhr-Movahedi et al. (2011), Iran A qualitative content analysis of nurse-patient communication in Iranian nursing To explore cultural and contextual factors influencing nurse-patient communication according to lived experiences of Iranian nurses and all females) 9 Patients (4 females/5 males) All nurses believed that communication with patients was important.They strived to support and meet the patients' needs.The Nurse-patient communication was influenced by factors such as physician orders and administrative demands, and the nurses communicated with patients unsystematically, according to patients' requests and needs.The present study findings implied that despite the nurses' beliefs in the importance of nurse-patient communication, in practice the role was not running well because of structural and sociocultural factors TA B L E 1 (Continued) (Continues) 13652648, 2023, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15548by University Of Boras, Wiley Online Library on [31/01/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Finset et al. (2013), Norway Patterns in clinicians' responses to patient emotion in cancer care To investigate how patient, clinician and relationship characteristics may predict how oncologists and nurses respond to patients' 17 females/2 males) 5 oncologists (1 female/4 males) Patients (numbers and sex NS) During the consultations, the patients expressed 471 cues and 109 concerns.The nurses were five times more likely to provide space for further disclosure of cues and concerns (according to VR-CoDES definitions) than oncologists in outpatient follow-up consultations were.Nurses gave room for further disclosure to explicit concerns and nurse-initiated cues/concerns, but the effects were smaller than for oncologists Gordon et al. (2009), UK The use of conversational analysis: nurse-patient interaction in communication 2 females/3 males) In this study, the nursing staff started 88% (n = 20) of the opening sequences analysed and 44% of the interactions were related to a nursing task.Five openings (19%) appeared to be 'social' in nature, and not task oriented.Overall, the interactions were asymmetric, with very limited patient contributions.The nursing staff controlled the conversations by choosing the topic and flow of conversations, and patient participation was limited.This study concludes that overall, the nursing staff controlled the conversations around nursing tasksHafskjold et al. (2017), NorwayThe use of supportive communication when responding to older people's emotional distress in home care-An observational study To describe nursing staff's responses to older people's emotional distress, and identify factors that encourage audio-recorded home care visits, 635 expressions of emotional distress among older people were coded.In 48% of nursing staff responses, the content was emotion focused.Expressions with explicit reference to emotion most frequently received emotion-focused responses (60%), whereas more implicit emotions mostly received non-emotion-focused responses (59%).The study concludes that emotion-focused responses by nurses were promoted when nursing staff elicited the emotional expression, and when the patient expression referred to an explicit emotionHakimnia et al. (2014), Sweden Exploring the communication between telenurse and caller-10 females/1 male) 20 Patients (13 females/7 males) The analysis revealed five types of calls: a gatekeeping call, a gendered call, a call marked by impersonal traits, a call with voices of the life world and a counter-discourse call.The dominating patterns in the calls were of gatekeeping and biomedical character.The study concludes that awareness of gender biases and knowledge about callers' different resources to be heard, can improve the inequality in the communication between telenurse and callersHeyn (2013), Norway Talking about feelings and worries in cancer consultations: the effects of an interactive tailored symptom assessment on source, explicitness and timing of emotional cues and concerns To examine the impact of an interactive 471 cues and 109 concerns in clinician-patient consultations (n = 196), with a majority of patient-elicited utterances.Almost half of the utterances of cues and concerns were categorized as hints, and there were more often descriptive cues in the intervention group than in the control group, especially if elicited by the patients.Nurse and patient communication: Cues (78.9%) and concerns (21.1%) were common in consultations with nurses.Patients expressed more descriptive cues and concerns to nurses than to physicians.More utterances were initiated by patients (61.3%) than by nurses (38.7%).Nurses were often provided with explicit responses to patients' cues/concerns and provided space for further disclosure TA B L E 1 (Continued) sex NS) The results describe how nurses communicated with four different voices: a medical voice; a nursing voice; a pedagogical voice and a power voice.The voices were context dependent, and the nurses switched between different voices when changing focus.When nurses can combine their voices in a successful way, and by limiting the power voice, the communication could become more positive for all involved.A successful combination of voices was described to facilitate good nurse-patient-relative communication.To improve patient care and health outcomes the communication used is important for relationship building Johnsson, Wagman, et al. (2018), Sweden What are they talking about?Content of the communication exchanges between nurses, patients and relatives in a department of medicine for older people-An ethnographic study To explore and describe the content of sex NS) Three categories of the content of the communication were described, that was; medical with focus on the patient's medical condition, personal content with focus on the individual patient's life situation and explanatory content related to patient's health and needs.The study concludes that nurses need to be aware of the importance of the communication content and the importance of asking questions.The content used by the nurses in the communication could help enable a more holistic view and facilitate person-centred care Kettunen et al. (2000), Finland Communicator styles of hospital patients during nurse-patient counselling To answer the question of what kind of communicator the Finnish patient is during counselling sessions with a nurse in a seven communicator styles used by patients: Quietly Assenting, Emotionally Expressive, Storyteller, Stoic Observer, Inquisitive of Detail, Dominant and Critical Selfobserver.The communicator styles indicated the ways in which patients participated.Even though the nurses were flexible, a strong tendency was observed that the nurses directed the conversation in a stereotypical manner that restricted the speech of the patient TA B L E 1 (Continued) The study concludes that conversations that emphasized partnership and social and emotional talk were important, and the study advances professional understanding of the patient-centred empowering practiceKettunen et al. (2006), Finland Lifestyle counselling in type 2 diabetes prevention: A case study of a nurse's communication activity to produce change talk To investigate the construction of change talk: how a nurse initiated change talk, how it was received by a patient, and what communication female) Change talk was described based on three categories: rejected, restrictive and expansive change talk.Overall, the nurse's communication was interpreted as patient-centred, when not using change talk that interrupted our inhabited patient's talk.Maintaining professional authority at the same time as having a patient perspective could be a dilemma.Change talk could be demanding and was best produced when the nurses focused on the patient's viewKim et al. (2001), Indonesia Client communication behaviors with health care providers in Indonesia To analyse determinants of active communication acceptable ways for the clients' communication during family planning consultations.These included asking questions, requesting clarification, stating opinions and expressing concerns.In this study, client active communication was found to be associated with the providers' information giving, providers' facilitative communication, providers' expressions of negative emotion, client educational level and province Lam et al. (2020), China Factors affecting the levels of satisfaction with nurse-positive nonverbal cues used by nurses during routine care were visual contact (80.2%) and proximity (75.2%), and for patients visual contact (82.2%) and maintaining attention (63.4%) were common.Negative nonverbal cues, such as ignoring, were rarely seen in nurses TA B L E 1 (Continued) (Continues) 13652648, 2023, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15548by University Of Boras, Wiley Online Library on [31/01/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License33 females/25 males) The discussion about online health seeking was equally initiated by patients and nurses.The results indicate that the internet is becoming integrated in communication during consultations with patients.In these conversations, the nurses used a patientcentred approach and responded by taking patients' online health information-seeking seriously or affirming their beliefs Lotzkar and Bottorff (2001), Canada An observational study of the development of a nurse-patient relationship To identify features of nursepatient interactions (NPI) in the development of a nurse-sex NS) The findings describe the active and complementary roles of nurses and patients when developing a nurse-patient relationship.Moreover, the results highlight the contribution of social exchange, trust and humour in the relationship.Continuity of nursing care is reported as important for relationship building Macdonald et al. (2013), New Zeeland Nurse-patient communication in primary care diabetes management: 10 females/8 males) In this study, the consultations with nurses commonly involved the completion of checklists, physical examination, referral to other health professionals and distribution of written material.The nurses' consultations were commonly longer than consultations with other professionals.The consultations were based on the nurses' clinical agenda more than the patient's perspective.The protocols and checklists used by the nurses both help and hinder communication Mallett and A'Hern (1996), England Comparative distribution and use of humour within nurse-/3 males) Findings describe that the amount and proportion of humour from the patients varied.The findings indicate that humour may be an important facilitator for nurse-patient communication Manias and Williams (2007), Australia Communication between patients with chronic kidney disease and nurses about managing pain in the acute hospital setting To examine communication between patients three themes: complexity of pain, knowledge about pain management, and contextual characteristics of the renal units.The complexity of pain involved the nature of pain and the effects of analgesics on the body.Difficulties to manage pain were related to various causes of the pain.The context involved a perceived urgency of pain communication and environmental stressors TA B L E 1 (Continued) 13652648, 2023, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15548by University Of Boras, Wiley Online Library on [31/01/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Mulder et al. (2014), the Netherlands Quality assessment of practice nurse communication with type 2 diabetes patients To assess if, and how, nurses applied the five key elements of selfmanagement support in standard care assessed current health behaviours and follow-up consultations.The care contained discussions on health behaviours and in less than half of the consultations, the patients got advice to change dietary or physical activity behaviours.Conclusions were that nurses' communication can benefit from using standardized assessments of health behaviours and beliefs as a foundation to support and give advice O'Baugh et al. (2009), Australia Investigation into the communication that takes place between nurses and patients during chemotherapy To explore the verbal and nonverbal communication /5 males) It was common to first provide an overview of the steps that they would follow in the communication.A major amount of the nurses' communication is concerned with conveying information to support patients practically and psychologically.The conversations had the main focus on procedure focused and they rarely clarified patients' doubts.Nonverbal communication involved looking, touching, movements and emotions.The nurses were efficient in their communication regarding physical and medical areas but could hesitate to address and discuss emotional issues Oguchi et al. (2011), Australia Measuring the impact of nurse cueresponse behaviour on cancer patients' emotional cues To explore the impact of nurse responses to 30 females/21 males) 13 nurses (7 females/6 males) Family members Both patients and family members were reported to express cues and concerns during consultations, even if most cues and concerns were expressed by patients.In a third of the answers, 35%, the nurses responded by providing space.Responses from the nurses that provided space for further disclosure were significantly associated with a decrease in patient expressions of cues and concerns Oliver et al. (2019), USA Behind the doors of home hospice patients: A secondary qualitative analysis of hospice nurse communication with patients and families To examine the use of validation communication techniques by hospice nurses during home visits to patients and their family caregivers Qualitative content analysis Home hospice visits by nurses Data gathered from 65 hospice nurse visits Participants: 65 Nurses (59 females/6 males) 8 Patients (3 females/5 males) The nurses used validation communication techniques.For example, paying attention, reflecting back, reading minds, understanding the context, recognizing the valid and showing equality.This occurred at least once during each visit.Findings suggest that nurses use validation techniques in their communication with patients and family caregivers.The use of basic techniques is common and the use of more complex forms of validation is rare Pettersson et al. (2018), Sweden Prepared for surgery-Communication in nurses' /12 males) During the consultations, the nurses talked and introduced new topics: Preparation before surgery, Discovery, Tumour, Operation, Recovery after surgery, and Thrombo-prophylaxis.They used two different approaches to communicating: Talking to and talking with the patient, the latter could be seen as person-centred communication.Talking with patients instead of talking to them, may contribute to increasing the patient's understanding.The use of an open question can contribute to patients' participation and a dialogue between nurses and patients TA B L E 1 (Continued) (Continues) 13652648, 2023, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15548by University Of Boras, Wiley Online Library on [31/01/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License and sex NS) Patients (numbers and sex NS) Three main themes were identified: treatment-centred communication, efficient communication and spatially bound communication.The communication was characterized by the content that was focused on the treatment.The aspects of existential, psychosocial and sexual concerns were rarely explored Roche and Jones (2021), UK A qualitative study of nurse-10 females/11 males) 21 Registered nurses (17 females/4 males).Patients' information needs were not satisfied when RNs sometimes were unwilling or unable to answer questions and provide information.Sometimes the patients were not receptive to the information and had difficulty understanding it Reblin et al. (2016), USA Caregiver, patient and nurse visit communication patterns ) Six communication patterns occurred in two perspectives: (1) who interacts most with the nurse (patient, caregiver, or dyad) and (2) the relatively high or low expressions of distress during the visit.The result contributes to how to organize triadic communication patterns in cancer home hospice visits Sandhu et al. (2009), UK Emergency nurse practitioners and doctors consulting with patients in an emergency department: 24 females/22 males) The nurses focused on patient education and counselling medical condition, or therapeutic regimen compared with the doctors.
was non-person-centred oriented.The alternative discourse person-oriented related to the patient's personal and sociocultural context was identified and showed that nurses could develop a person-centred approach to consultation.They also replicated a traditional biomedical model.The result showed 5 themes: Discursive approaches to the start of the consultation, Discursive approaches to talking about side-effects, Discursive approaches to patient education, Discursive approaches to feelings, worries and concerns, and Discursive approaches to decision making.It's important to give the person the chance to learn and become the one that's competent to make his/her own decisions Sundler et al. (2020), Sweden Attributes of person-centred communication: A qualitative exploration of communication with older persons in home health care To explore attributes of person-29 females/8 males) Person-centred communication was related to approaches that recognize, invite and involve the person.The RNs facilitated mutual interaction and a deep relationship with the person.Attentive communication is important to facilitate personcentred care.The care requires communication skills that make it possible to recognize, invite and involve the person Uitterhoeve et al. (2009), the Netherlands Nurse-patient communication in cancer care: does responding to patient's cues predict patient satisfaction with communication To investigate the relationship between nurses' cue-responding behaviour give compliments and build partnerships were less frequently used by the nurses compared with the videophone.On the telephone they more often gave lifestyle information and approval comments, and, on the videophone, it was more common to use closed-ended questionsTA B L E 1 (Continued) (Continues)13652648, 2023, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15548by University Of Boras, Wiley Online Library on [31/01/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons Licensealso differences in how communication was expressed, that is, verbal or non-verbal communication.The topic for the communication varied, often depending on the situation or context of care.RNs' communication could also be influenced by structural and sociocultural factors (Fakhr-Movahedi

Fewer
studies were reporting on patients' communication, with a focus on patients' expressions of concerns and the content of the patient communication.Patients used different communication styles and their communication were affected by the RNs' communication.
There were also examples of RNs using a mixture of task-oriented and socioemotional communication, as well as RNs using different communication strategies based on situation or context, which may hint at some challenges and complexity of RN-patient communication.Research could benefit by making communication challenges more explicit or emphasizing the knowledge or skills needed by RNs to improve RN-patient communication.This may be related 13652648, 2023, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15548by University Of Boras, Wiley Online Library on [31/01/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License to the complex nature of nursing, where challenges and shortcomings in communication and interaction may be related to how these phenomena often occur naturally during interventions and tasks, in contrast to physician-patient communication in, for example, consultations allowing for information exchanges under different circumstances.The communication practice of nurses is still developing, and the studies in this review had a descriptive or exploratory nature to explore RN-patient communication.However, the results revealed no clear picture of the theoretical underpinnings of RN communication, and the integration of theories in the empirical studies was weak.Similar results were found byFleischer et al. (2009), concluding that nursing theories were rarely used in studies on RN-patient communication.We propose the need for future utilization of empirical RN-patient communication research that is integrated with theory development of RNs' communication, the centring of patients' needs and communication as a core competence for nurses.
Communication was closely linked to relationship building and socializing, and it must focus on more than just instrumental nursing tasks.Routinely, nurses may use more task-oriented communication, which may result in RNs missing opportunities for active listening and patient-initiated topics.However, patients may be vague or unclear in expressions of their concerns.Thus, the communication skills of RNs, such as active listening, being attentive and responding to implicit and explicit expressions during conversations with patients, are important in nursing.This review focused on empirical studies of real-time RNpatient communication.Studies using, for instance, interviews were excluded.Some of the included studies used participatory observations, even if most of the studies used direct observations, such as audio or video recordings.We argue that more studies of real-time communication using audio and video recordings are needed, as there may be gaps between what people report and recall in interviews about nursing care and how this care was delivered.There is a need for studies about RNs' real-time communication and how communication may hinder or facilitate quality and patient-centred care.5.1 | Strengths and limitationsA strength of this review is the clearly defined inclusion of studies on RNs.Thus, this review adds to what is currently known about RNpatient communication and the methods and approaches that have been used within this field.However, the low number of articles that matched our inclusion criteria led to the decision to analyse articles regardless of context or situation, which made the analysis complex and the results broad.The results give an overview of the width and depth of observational research in nursing care and finding such a miscellaneous set of studies was an outcome in itself, which might indicate a less well-grounded field of research.A narrower inclusion could instead have resulted in an even fewer number of articles and risked excluding important research within this relatively unexplored research area.The search strategy may have led to a limitation in eligible articles.Even if databases are perceived as being effective and efficient sources for literature searches,Whittemore and Knafl (2005) point out that an inconsistent search terminology or indexing problem may yield only a 50% search result.This became evident through the addition of articles from other sources that were not found in the initial database searches.However, the addition of articles through additional sources may be considered a strength that allowed for a more comprehensive literature search.6 | CON CLUS IONThis review gives an overview of the width and depth of observational studies on RN-patient communication research.The various set of studies in this area might indicate a less well-grounded field of research, with a need for further research.The relationship between RNs and patients is intertwined with communication, and communication will influence how an interaction develops.Hence, communication is a critical starting point for interaction and its development.It is important that RNs become aware of their communication styles and how their behaviour can affect the communication, otherwise, insensible and unreflective communication can lead to misunderstandings.RNs should understand the significance and meaning of the communication skills that they use, as well as how to facilitate patient-centred communication.The content and styles of communication revealed the use of different communication styles, as well as the fact that communication was multifaceted.Future research is needed on what communication skills are required for RNs to adapt 13652648, 2023, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15548by University Of Boras, Wiley Online Library on [31/01/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

TA B L E 1 Characteristics and summary of included studies Author/year/country Aim Methods/study design Setting and sample Findings/Conclusion
Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15548by University Of Boras, Wiley Online Library on [31/01/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

country Aim Methods/study design Setting and sample Findings/Conclusion
nurses and surgeons gave clear as well as unclear responses to patients' questions.Patients asked more questions if responses from the professionals were unclear.Clear communication was deemed important to help patients manage their recovery and regain controlAuthor/year/ In this study, 801 responses by nurses to patients' expressions of emotional cues and concerns were coded.The nurses most frequently (75%) responded by using minimal encouragement to patients' emotional expressions, with explicit recognition to 13% of expressions and the rest (12%) were responses not within the perspective of the patient.The study suggests that further explorations are needed on the effects of empathic accurate responses of nurses Participants:5 Nurses (4 females/1 male) 58 Patients (49 females/9 males) In the conversations, 54% of the utterances were made by the nurses, 29% by the caregivers, and 17 by patients.The conversations predominantly focused on physical care.Home hospice conversations were predominantly focused on physical care, maintaining a relatively stable focus for the domains of physical and psychosocial/daily life care.A small decrease in emotional expressions was observed over time.Nurses often fail to recognize the critical role of caregivers and to address their concerns about patient care.The study suggests that nurses' communication strategies used could be developed to better support the family 13652648, 2023, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15548by University Of Boras, Wiley Online Library on [31/01/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License driven, with a ratio of tele nurse/caller talk of 1.31 (SD 0.24) in the cases, versus a ratio of 1.28 (SD 0.30) in the controls (p = 0.424).Statistically significant differences were found between the cases and controls: tele nurses used fewer openended medical questions in the cases compared with controls; callers provided tele nurses with more medical information in the controls compared with the cases and tele nurses used more facilitation and patient activation activities in controls, e.g.back-channel responses.In the malpractice-claimed calls, the nurses used closed-ended questioning to a larger extent than in control calls, where more open-ended questions and back-channel responses were used.Such responses, e.g.openended questions of back-channelling allowed for richer medical descriptions and more information from callers.The study concludes that these communicative techniques are important

country Aim Methods/study design Setting and sample Findings/Conclusion
A total of 473 cues and 109 concerns were coded with more utterances of cues/concerns in the intervention compared with the control group and in consultations with nurses.Significant differences in the type of response were found between clinicians, where nurses significantly more often provided responses that produced space for further disclosure of patients' cues/concerns compared with physicians.NAs' and RNs' responses to older persons' emotional concerns, coded with the VR-CoDES.A total of 121 responses by RNs were found.Most of the RN responses were non-explicit (n = 92.2%)and provided space (78.5%) for further disclosure.Responses less frequently reduced space (21.5%).Examples of such responses are given in the text.RN responses were mainly non-explicit responses providing space for older persons to talk more about their emotional concerns Joint convergence of nurse-patient behaviours and non-verbal communication was found.The most common was laughing, smiling and eye contact.The findings point to nurses supporting patients through non-verbal communication.Symmetrical and asymmetrical communication was present in the consultations 13652648, 2023, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15548by University Of Boras, Wiley Online Library on [31/01/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Author/year/by acknowledgement.Nurses gave appropriate information in response to most informational cues.Patients' expressions of emotional or informational cues did not influence recall; neither did nurses' responses to informational cues.Responses to emotional cues did affect recall.The more nurses responded by giving 'minimal' encouragements (e.g.'Hmmm'), the more patients recalled, while distancing responses (e.g.switching focus) were associated with lower recall scores.A common response to emotional cues was distancing (35.8%) followed by acknowledgement (29.5%).How the nurses responded to emotional cues influenced patient recall (remembering information) whereas distancing responses negatively influenced the recall (remembering less) TA B L E 1 (Continued) (Continues) 13652648, 2023, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15548by University Of Boras, Wiley Online Library on [31/01/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License The complete communication loop could be noted in 11% of the talks.Most common were to clarifying health information (58%) and repeating health information (33%).81% never used to check understanding and 42% never asked for understanding.17% used medical jargon and mismatched language and 25% used respectively.Patients' HL did not affect patterns of communication regarding the use of communication loops.Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15548by University Of Boras, Wiley Online Library on [31/01/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Less than 5% of the nurses and physicians used utterances that focused on lifestyle information or psychosocial topics.All participants used closed questions more often than open questions.Nurses asked 1 open question concerning lifestyle and they did not use questions regarding psychosocial content or patients' feelings (Berry, 2009;Pettersson et al., 2018;Sundler et al., 2020), with RNs Abbreviations: MIARS, the Medical Interview Aural Rating Scale; NS, not state; RIAS, Roter Interaction Analysis System; VR-CoDES, the Verona Coding Definitions of Emotional Sequences.TA B L E 1 (Continued) 13652648, 2023, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15548by University Of Boras, Wiley Online Library on [31/01/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License