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ISPUB.COM The Internet Journal of Advanced Nursing Practice
Volume 10 Number 1
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Bedside Manner: Concept Analysis and Impact on
Advanced Nursing Practice
A Person, L Finch
Citation
A Person, L Finch. Bedside Manner: Concept Analysis and Impact on Advanced Nursing Practice. The Internet Journal of
Advanced Nursing Practice. 2008 Volume 10 Number 1.
Abstract
Bedside manner has received little in-depth evaluation in the literature, especially from an advanced nursing practice
perspective. Concept analysis revealed specific provider behaviors that are consistently deemed positive or negative by
patients. Positive behaviors include displays of respect, courtesy, and listening ([12]). Negative behaviors include arrogance,
indifference, and disrespect ([34]). The patient’s perception of provider bedside manner impacts health status, satisfaction, and
compliance ([5678]). Effective bedside manner by Advanced Practice Nurses (APN) is essential for effective patient care as
APNs increase as primary care providers ([9]). Further research in the area of bedside manner is needed to provide additional
clarification of patient expectations and desires from their relationship with the clinician.
INTRODUCTION
Bedside manner is a term with which most medical
professionals and lay persons are familiar. A provider’s
bedside manner can impact professional reputation in the
community, affect the loyalty of patients, and even impact
effectiveness ([7]). Once thought to be a “personality trait” or
an inherent ability, many medical schools are now
attempting to teach bedside manner to prospective
physicians ([10]). This trend to provide education on bedside
manner may be attributable to patient demands for more
personal healthcare ([11]). While the term “bedside manner”
may be readily recognizable to both medical personnel and
to the public, this concept has received little attention in the
literature. In addition to being a poorly described concept,
the significance and relationship of bedside manner to the
Advanced Practice Nurse ([APN]) is lacking insight. This
paper will analyze the concept of bedside manner, determine
how bedside manner impacts advanced nursing practice and
education, and identify areas for further research.
CONCEPT ANALYSIS
PURPOSE
The purpose of concept analysis is to recognize, define, and
clarify phenomena to improve understanding and promote
further research. A concept is a phenomenon that occurs in
nature or in thought and is derived from certain attributes.
Through the process of concept analysis, ideas area broken
down and analyzed through identification of key features of
the concept. These features include: attributes, which are the
characteristics that define a concept and are consistently seen
when the concept exists; antecedents, which is what must
occur for the concept to exist; consequences, or the results of
concept existence; and, empirical referents, which are
phenomena that, by their existence, demonstrate the
occurrence of the concept ([12]).
The concept of bedside manner warrants analysis and
scrutiny because good bedside manner is highly valued by
patients, yet bedside manner has received minimal literary
attention ([[[[13; 14]]]]). One study showed that patients
value good bedside manner and listening skills more than
clinical competence ([13]). In addition to patient satisfaction
with care, good bedside manner has also been implicated in
improving overall health status ([[[[5; 15; 16]]]]). The
relevance of practitioner behavior in medical care has been
said to be of greater importance to customers than in other
service professions. This increased significance has been
related to the fact that the customers must bare themselves
both physically and emotionally ([1]). While the value of
good bedside manner has been established, specific
behaviors and actions that dictate and guide this experience
have received little attention ([14]).
DEFINITION
The term bedside manner dates back as far as 1869. The
Merriam-Webster dictionary definition of “bedside manner”
is “the manner that a physician assumes towards a patient”
Bedside Manner: Concept Analysis and Impact on Advanced Nursing Practice
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([17]). For further clarification, the term “manner” is defined
as “a way of acting”. The term “bedside” literally means
“the side of a bed” ([17]). In healthcare, references to
“bedside” may have the literal meaning of being by a patient
in their bed, or simply imply a personal encounter with a
patient.
From these definitions, the assumption can be made that
bedside manner is a behavior or group of behaviors. All
human behaviors have been theorized to result in a multitude
of consequences; intentional and unintentional, positive and
negative ([18]). Considering the consequences of human
behavior, it can thus be assumed that health provider
behaviors, communicated through an encounter designated
as bedside manner, result in an experience for patients, one
that may be perceived as positive or negative.
REVIEW OF LITERATURE
Various provider behaviors have been identified by patients
as consistently positive or negative. Verbal communication
skills are reported as very valuable when patients assess the
performance of their provider ([[[[15; 16; 19]]]]). One study
that assessed the value of communication skills found that
physicians who where deemed as being good listeners had
the best relationships with patients and the least amount of
complaints ([15]). A similar study reported that patients
related bedside manner and listening skills with the feeling
that their clinician really cared about them ([16]). Specific to
advanced nursing practice, research has identified
communication skills and longer visits as a favorite aspect of
APN care ([19]). Non-verbal communication, such as neat
appearance and body language, have been said to relay a
positive impact on patient’s perceptions of provider bedside
manner as well as effectiveness ([1]). Other non-verbal cues
associated with a positive experience for patients include eye
contact, body position, and tone of voice ([20]).
Humanistic behaviors such as care and concern are also
frequently reported by patients as positive and desirable.
One study of patients cared for by APNs found a statistically
significant correlation between patient satisfaction and the
feeling that the nurse practitioner was caring ([21]).
Additionally, Finch ([22]) questioned patients as to what
behaviors and actions were expected from nurses, with
“caring” as the most common response. “Caring” was
described as concerned, compassionate, genuine, and kind
([22]). In the United Kingdom, a national summit sought
feedback from the public of their expectations and desires
from primary care services. The findings revealed that the
public’s priority was care that was interpersonal, including
sympathy and attention ([11]). Findings from a study ([23])
that asked patients what made a medical provider “good”
reported sensitivity as the most common response. Similarly,
Bendapudi and colleagues ([1]) asked patients to describe
their ideal doctor. The top responses were a provider who
was confident, empathetic, humane, personal, forthright,
respectful, and thorough ([1]).
The literature also revealed information about provider
behaviors deemed negative and related to undesirable and
negative patient experiences. Luthy and colleagues ([23])
identified good clinicians as being sensitive and bad
clinicians as “self-serving”. An article discussing patient
satisfaction with medical care cited “bad” providers as being
arrogant, rude, dismissive, and indifferent ([3]). Behaviors
such as insensitivity, lack of respect, arrogance, disinterest,
and impatience were reported when a group of patients were
asked to describe their worst experience with a clinician
([1]). Disrespect, distrust, and unavailability where also
reported as negative provider behaviors ([4]).
The review of literature revealed that patients typically
described clinicians based on interpersonal behaviors with
little mention of clinical skills or competence. Bendapudi
and colleagues ([1]) theorized that patients lack the
knowledge to judge their provider’s technical quality. These
authors also proposed that most patients view clinical
proficiency as an expectation, perhaps limiting focus on
clinical competence or expertise. Therefore, providers
appear to be judged by what the lay person can readily
assess, most often being overt behavior.
ATTRIBUTES
From the review of literature, concrete critical attributes of
bedside manner do not appear to exist, and further, clear
identification of bedside manner attributes has received little
study ([14]). The literature did reveal, however, common
themes of patient-perceived encounters with positive or
negative connotations. Positive provider behaviors were
described as empathetic, friendly, listener, effective
communicator, courteous, caring, and respectful ([[[[1; 2;
21; 22; 23]]]]). Terms describing bad or negative provider
behaviors included rude, arrogant, dismissive, uncaring, and
indifferent ([[[[1; 3; 23]]]]). Along with behavior,
appearance was found to impact the patient’s impression of
their clinician, including neatness and body language ([[[[1;
20]]]]).
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ANTECEDENTS
In the case of bedside manner, the primary and basic
antecedent is an interaction between provider and patient.
Bedside manner, or provider behavior, will always exist
when there is an encounter with a patient, yielding a positive
or negative experience ([2]). These interactions may occur in
various settings, including medical offices, community
clinics, hospitals, or by telephone. Since provider behaviors
may be unspoken, such as body language, a verbal
interaction does not have to occur for bedside manner to
exist ([1]). Current research also reports that good bedside
manner is a skill, inferring that if one does not exhibit it,
development and mastery may occur ([2]). While good
bedside manner is proposed as a learnable skill, specialized
training in bedside manner is not included as an antecedent.
According to Merton’s theory of human behavior, which
states that all human interactions reveal behaviors with
subsequent consequences, providers will exhibit intentional
and unintentional behaviors when engaging with patients
whether training on this interaction has been received or not
([18]).
CONSEQUENCES
Consequences of bedside manner are dependant on each
patient’s perception of the encounter and whether the
provider’s behavior and the patient’s overall experience are
deemed as positive or negative. A multitude of positive
consequences of bedside manner have been demonstrated in
the literature and are directly related to the patient’s
perceptions. Research has shown that patients who feel that
their provider has good bedside manner are more compliant
with treatment regimens, have more positive health
outcomes, and are satisfied with the care that they receive
([[[[5; 6; 7; 8; 24]]]]).
Negative consequences of bedside manner can be as equally
dramatic as the positive ones. Patients whom feel their
provider has poor bedside manner have been shown to be
less compliant with treatment regimens, have poorer
outcomes, and are generally less satisfied with the
relationship with their provider ([[[[5; 7]]]]). Patients whom
report that their provider does not listen to them hold the
highest correlation with reports of poor bedside manner and
less desirable health outcomes ([7]).
EMPIRICAL REFERENTS
Identification of concrete empirical referents for bedside
manner is difficult due to limited research of the
phenomenon as well as the subjectivity of the experience. In
the presence of the phenomenon of bedside manner, other
consequential phenomena will likely occur. Just as providers
will always exhibit some sort of behavior toward each
patient, the patient will have impressions and perceptions
based on the experience. The challenge in universal
description of empirical referents, similar to that of the
attributes, is that each patient interprets bedside manner and
the behavior of others differently ([[[[1; 18]]]]). Further
research is indicated in this area to clearly identify those
phenomena which coexist with good and bad bedside
manner.
IMPLICATIONS FOR PRACTICE
Literature to date has typically discussed bedside manner
related to physicians; however, the number of APNs
delivering primary and tertiary care is increasing and
expected to continue to rise ([9]). Bedside manner has been
shown to occur in every provider-patient contact, and APNs
need to be privy to the impact of this interaction. Research
has shown that patients are more likely to judge their
provider’s ability to communicate as well as interpersonal
behaviors, such as expressions of care and empathy, more so
than clinical abilities ([113]). Furthermore, concept analysis of
bedside manner revealed outcomes-related consequences
that may prove vital to the development and maintenance of
effective, holistic advanced nursing practice.
The impact of bedside manner on patient compliance is of
utmost importance ([8]). Patients who perceive their
provider’s behavior as positive have been shown to be more
compliant with treatment regimens ([57816]). Good bedside
manner also improves communication and the professional
relationship, and effective relationships have revealed the
greatest impact on adherence to education strategies and
therapeutic regimens ([616]). Patient compliance is vital to
health and wellness, and effective bedside manner is a
strategy without cost in which APNs may improve patient
adherence. In addition to compliance with regimens,
research supports the influence of bedside manner on actual
and perceived health status ([58]). Care that is patient-
centered and includes the positive attributes of bedside
manner has been shown to improve recovery from illness,
revealing a link between provider behavior and effective
disease management ([8]). As well as increased efficacy of
care delivery, bedside manner impacts cost effectiveness
([8]). Decreasing expenditures is relevant since healthcare
responsibilities of practicing APNs are expanding, including
delivery of cost effective care ([21]). A study by Stewart and
colleagues ([8]) revealed that patients who felt their provider
Bedside Manner: Concept Analysis and Impact on Advanced Nursing Practice
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displayed care, empathy, and effective communication had
significant reductions in health care costs. Spared resources
were in the form of a 50% decrease in specialist referrals and
a 75% decrease in diagnostic tests ([8]). While clinically
competent care is of utmost importance, these discoveries
support the need for APNs to focus on behaviors as heavily
as diagnosis and treatment ([5]).
IMPLICATIONS FOR EDUCATION
An understanding of bedside manner will enhance nurse-
patient relationships, lead to more accurate assessments, and
thus, promote improvement in patient outcomes. APNs must
develop and maintain holistic and caring characteristics
inherent to nursing to continue delivery of quality and
satisfying nurse practitioner care ([21]). Knowing about
bedside manner, both the concept and related behaviors, can
be used to develop teaching strategies to be integrated into
basic baccalaureate as well as advanced practice nursing
programs.
Historically, literature has deemed bedside manner as a
“personality trait” or an inherent gift ([10]). Current research,
however, regards provider behavior in patient interactions as
a skill that may be learned and taught ([2]). Physician
education has already begun to embrace both the importance
of bedside manner and the need to include this concept in
medical training ([1025]). Concept analysis has revealed
numerous benefits of effective bedside manner, and
inclusion of this concept in nursing curriculum warrants
consideration. Two increasingly accepted methods of
bedside manner education are simulation scenarios and
direct supervision of patient encounters ([10252627]).
Simulation of encounters with “patients”, whom may be
faculty, other students, or lay persons, is one strategy for
bedside manner education ([2627]). One method for utilizing
simulation scenarios is through faculty observation of
simulated patient encounters. Students receive feedback
from faculty regarding responses to simulated patient
questions, the manner in which concerns or challenges are
handled, and nonverbal communication cues such as body
language and eye contact ([27]). Another method of
instruction utilizing simulation scenarios includes formal
lecture on patient interactions and evaluates learning through
student self-report ([26]). Rosenzweig and colleagues ([26])
evaluated APN students who received classroom instruction
on communication, provider behaviors, and how to deal with
various challenging situations. In addition, the students
participated in a simulation lab composed of nursing faculty
posed as patients. Students reported improved confidence
and communication abilities both immediately after the
simulation experience as well as 4 months after training
([26]).
Bedside manners may also be evaluated and improved upon
by direct evaluation of student interactions with actual
patients. In 2006, Boehm ([25]) incorporated this method into
the clinical experience of 106 medical students. Instruction
and evaluation addressed nonverbal communication
including proper professional attire, sitting at eye level when
speaking to patients, and limitation of distractions such as
television or telephones. When speaking with patients,
students were encouraged to display care and emotion, using
phrases such as “I am so very sorry”. At the conclusion of
the rotation, students reported the experience as helpful and
recommended that the exercises be incorporated into
medical education ([25]).
INDICATIONS FOR RESEARCH
Knowledge and study of bedside manner attributes with
further clarification of desirable behaviors will help guide
APN practice and education. Understanding the patient
experience has many potential benefits, such as allowing
APNs to shape practice in a way that is more therapeutic,
trusting, and satisfying. An appropriate research approach
into the bedside manner concept is qualitative research;
specifically, phenomenological research. A
phenomenological method aims to describe phenomena as
they are experienced and lived ([28]). Concept analysis has
revealed a high level of subjectivity in perceptions of
provider behavior, and subsequently, bedside manner. Thus,
a phenomenological approach to study seems most
appropriate and likely to further identify themes and shape
the gestalt of bedside manner.
A research focus for APN practice should include
identification of behaviors and attributes that reflect good
bedside manner and the level of impact on patient health
outcomes. Furthermore, insight as to which attributes of
good bedside manner are seen most in care delivered by
APNs versus physicians is warranted. Identification of
disparities between the disciplines would be beneficial to
both nursing and medical practice and education. Another
research area is identification of the most effective method
to educate APNs on bedside manner, patient relationships,
and communication skills.
Bedside Manner: Concept Analysis and Impact on Advanced Nursing Practice
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CONCLUSION
The concept of APN bedside manner has received minimal
attention in nursing research and literature. While most
publications related to provider behaviors discuss
physicians, APNs need to be equally as diligent and
conscious of behavior when interacting with patients. The
impact of patient-provider encounters is evident in the
consequences, as bedside manner and provider behaviors
have been shown to effect patient satisfaction, compliance,
and overall health status ([[[[7; 8]]]]). Further research
assessing bedside manner that is specific to advanced
nursing is warranted to guide and shape APN practice and
curriculum.
CORRESPONDENCE TO
Amanda Person, MSN, RN
60 Winding Creek Drive
Oakland, TN 38060
amandap414@comcast.net
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Author Information
Amanda Person, MSN, RN
Loewenberg School of Nursing, University of Memphis
Linda Finch, PhD, APN, RN
Loewenberg School of Nursing, University of Memphis
