Accessible Requires Authentication Published by De Gruyter October 25, 2019

Determinants of effective nurse-patient communication based on the health action process approach in Yazd hospitals

Mohammad Ali Morowati Sharifabad, Mohammad Rafati Fard, Mojtaba Fattahi Ardakani, Ali Dehghani Ahmadabad and Ahmad Sotudeh



Nurse-patient communication is one of the most important care relationships that affects the treatment process. The health action process approach (HAPA) has been used to explain a number of behaviors. However, this approach has not been used to explain nurse-patient communication. Therefore, this study was conducted to investigate effective nurse-patient communication using this approach.

Materials and methods

In this cross-sectional study, 300 nurses from public hospitals in the center of Iran were enrolled in the study. A researcher-developed questionnaire was used to measure the HAPA constructs. The data were analyzed using Pearson’s correlation coefficient and one-way analysis of variance with least significant difference (LSD) post hoc tests in SPSS as well as structural equation modeling using AMOUS software.


In the motivation phase, risk perception, outcome expectancies and task self-efficacy predicted 19% of variance in intention to communicate effectively. In the volitional phase, planning and action self-efficacy predicted 22% of variance in effective communication. The scores of HAPA constructs were different depending on the levels of effective communication.


The model can serve as a reference framework to promote effective nurse-patient communication.


We really appreciate of all those who collaborated with the researchers in this study, including the directors and nurses of Shahid Sadoughi Hospital in Yazd, Seyed al-Shohada, Imam Jafar Sadegh in Meybod and Ziaei in the city of Ardakan, I would like to express my sincere appreciation. This article is part of a PhD thesis on health education and promotion at Shahid Sadoughi University of Medical Sciences in Yazd, Iran.

Author Statement

  1. Author contributions: MAMS, MFA and ADA designed this study. ADA, MRF, AS and MFA collected the information. MFA analyzed the information. All authors read and approved the final manuscript.

  2. Research funding: No funding for this manuscript.

  3. Conflict of interest: The authors declare that they have no competing interests.

  4. Informed consent: Participants provided written informed consent.

  5. Ethical approval: The study protocol was approved by the Ethics Committee of the Shahid Sadoughi University of Medical Sciences, Yazd, Iran (code: IRSSU.SPH.REC.1395.76).


[1] Bowles N, Mackintosh C, Torn A. Nurses’ communication skills: an evaluation of the impact of solution-focused communication training. J Adv Nurs. 2001;36:347–54.10.1046/j.1365-2648.2001.01979.x11686749 Search in Google Scholar

[2] Liu Y, Wang G. Inpatient satisfaction with nursing care and factors influencing satisfaction in a teaching hospital in China. J Nurs Care Qual. 2007;22:266–71.10.1097/01.NCQ.0000277785.52428.a5 Search in Google Scholar

[3] Moulton C-A, Tabak D, Kneebone R, Nestel D, MacRae H, LeBlanc VR. Teaching communication skills using the integrated procedural performance instrument (IPPI): a randomized controlled trial. Am J Surg. 2009;197:113–8.10.1016/j.amjsurg.2008.09.00619101253 Search in Google Scholar

[4] Johansson P, Oléni M, Fridlund B. Patient satisfaction with nursing care in the context of health care: a literature study. Scand J Caring Sci. 2002;16:337–44.10.1046/j.1471-6712.2002.00094.x12445102 Search in Google Scholar

[5] Hemsley B, Balandin S, Worrall L. Nursing the patient with complex communication needs: time as a barrier and a facilitator to successful communication in hospital. J Adv Nurs. 2012;68:116–26.10.1111/j.1365-2648.2011.05722.x Search in Google Scholar

[6] Sheldon LK, Barrett R, Ellington L. Difficult communication in nursing. J Nurs Scholarsh. 2006;38:141–7.10.1111/j.1547-5069.2006.00091.x16773917 Search in Google Scholar

[7] Anoosheh M, Zarkhah S, Faghihzadeh S, Vaismoradi M. Nurse-patient communication barriers in Iranian nursing. Int Nurs Rev. 2009;56:243–9.10.1111/j.1466-7657.2008.00697.x19646175 Search in Google Scholar

[8] Park E-K, Song M. Communication barriers perceived by older patients and nurses. Int J Nurs Stud. 2005;42:159–66.10.1016/j.ijnurstu.2004.06.00615680614 Search in Google Scholar

[9] Fleischer S, Berg A, Zimmermann M, Wüste K, Behrens J. Nurse-patient interaction and communication: a systematic literature review. J Public Health. 2009;17:339–53.10.1007/s10389-008-0238-1 Search in Google Scholar

[10] Parle M, Maguire P, Heaven C. The development of a training model to improve health professionals’ skills, self-efficacy and outcome expectancies when communicating with cancer patients. Soc Sci Med. 1997;44:231–40.10.1016/S0277-9536(96)00148-79015875 Search in Google Scholar

[11] Oates J, Weston WW, Jordan J. The impact of patient-centered care on outcomes. Fam Pract. 2000;49:796–804. Search in Google Scholar

[12] Stajkovic AD, Luthans F. Self-efficacy and work-related performance: a meta-analysis. Psychol Bull. 1998;124:240.10.1037/0033-2909.124.2.240 Search in Google Scholar

[13] Artinian NT, Fletcher GF, Mozaffarian D, Kris-Etherton P, Van Horn L, Lichtenstein AH, et al. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults. A scientific statement from the American Heart Association. Circulation. 2010;122:406–412062511510.1161/CIR.0b013e3181e8edf1 Search in Google Scholar

[14] Glanz K, Bishop DB. The role of behavioral science theory in development and implementation of public health interventions. Annu Rev Public Health. 2010;31:399–418.10.1146/annurev.publhealth.012809.10360420070207 Search in Google Scholar

[15] Schwarzer R. Modeling health behavior change: how to predict and modify the adoption and maintenance of health behaviors. J Appl Psychol. 2008;57:1–29.10.1111/j.1464-0597.2007.00325.x Search in Google Scholar

[16] Schwarzer R, Sniehotta FF, Lippke S, Luszczynska A, Scholz U, Schüz B, et al. On the assessment and analysis of variables in the health action process approach: conducting an investigation. Berlin: Freie Universeitat Berlin; 2003. Search in Google Scholar

[17] Bodys-Cupak I, Majda A, Zalewska-Puchala J, Kaminska A. The impact of a sense of self-efficacy on the level of stress and the ways of coping with difficult situations in Polish nursing students. Nurse Educ Today. 2016;45:102–7.2742941410.1016/j.nedt.2016.07.004 Search in Google Scholar

[18] Faul F, Erdfelder E, Lang A-G, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39:175–91.10.3758/BF0319314617695343 Search in Google Scholar

[19] Kline R. Principles and practice of structural equation modeling. 3rd ed. New York, NY: Guilford Press; 2011. Search in Google Scholar

[20] MacCallum RC, Browne MW, Sugawara HM. Power analysis and determination of sample size for covariance structure modelling. Psychol Methods. 1996;1:130–49.10.1037/1082-989X.1.2.130 Search in Google Scholar

[21] Glock S, Kneer J. Are deterrent pictures effective? The impact of warning labels on cognitive dissonance in smokers. Appl Psychol Health Well Being. 2009;1:356–73.10.1111/j.1758-0854.2009.01019.x Search in Google Scholar

[22] Williams RJ, Herzog TA, Simmons VN. Risk perception and motivation to quit smoking: a partial test of the Health Action Process Approach. Addict Behav. 2011;36:789–91.2146392010.1016/j.addbeh.2011.03.003 Search in Google Scholar

[23] Fischhoff B. Risk perception and communication. Oxford: Oxford University Press; 2009:940–53. Search in Google Scholar

[24] Heaven CM, Maguire P. Training hospice nurses to elicit patient concerns. J Adv Nurs. 1996;23:280–6.10.1111/j.1365-2648.1996.tb02668.x8708240 Search in Google Scholar

[25] Renner B, Schwarzer R. The motivation to eat a healthy diet: how intenders and nonintenders differ in terms of risk perception, outcome expectancies, self-efficacy, and nutrition behavior. POL Psychol Bull. 2005;36:7–15. Search in Google Scholar

[26] Fishbein M, Ajzen I. Belief, attitude, intention, and behavior: an introduction to theory and research. Philosophy Rhetoric. 1977;10:130–2. Search in Google Scholar

[27] Orbell S, Sheeran P. Inclined abstainers: a problem for predicting health-related behaviour. Brit J Educ Psychol. 1998;37:151–65. Search in Google Scholar

[28] Abraham C, Sheeran P, Johnston M. From health beliefs to self-regulation: theoretical advances in the psychology of action control. Psychol Health 1998;13:569–91.10.1080/08870449808407420 Search in Google Scholar

[29] Lippke S, Ziegelmann JP, Schwarzer R. Behavioral intentions and action plans promote physical exercise: a longitudinal study with orthopedic rehabilitation patients. J Sport Exerc Psychol. 2004;26:470–83.10.1123/jsep.26.3.470 Search in Google Scholar

[30] Scholz U, Sniehotta FF, Schwarzer R. Predicting physical exercise in cardiac rehabilitation: the role of phase-specific self-efficacy beliefs. J Sport Exerc Psychol. 2005;27:135–51.10.1123/jsep.27.2.135 Search in Google Scholar

[31] Bagozzi RP, Dholakia UM, Basuroy S. How effortful decisions get enacted: the motivating role of decision processes, desires, and anticipated emotions. J Behav Decis Mak. 2003;16:273–95.10.1002/bdm.446 Search in Google Scholar

[32] Martinez-Brockman JL, Shebl FM, Harari N, Pérez-Escamilla R. An assessment of the social cognitive predictors of exclusive breastfeeding behavior using the Health Action Process Approach. Soc Sci Med. 2017;182:106–16.10.1016/j.socscimed.2017.04.01428437693 Search in Google Scholar

[33] Wiedemann AU, Lippke S, Reuter T, Schüz B, Ziegelmann JP, Schwarzer R. Prediction of stage transitions in fruit and vegetable intake. Health Educ Res. 2009;24:596–607.1904306510.1093/her/cyn061 Search in Google Scholar

[34] Lippke S, Ziegelmann JP, Schwarzer R. Stage-specific adoption and maintenance of physical activity: testing a three-stage model. Psychol Sport Exerc. 2005;6:585–603.10.1016/j.psychsport.2004.11.002 Search in Google Scholar

[35] Arbour-Nicitopoulos KP, Ginis KA, Latimer A. Planning, leisure-time physical activity, and coping self-efficacy in persons with spinal cord injury: a randomized controlled trial. Arch Phys Med Rehabil. 2009;90:2003–11.1996916110.1016/j.apmr.2009.06.019 Search in Google Scholar

[36] Liu J-E, Mok E, Wong T, Xue L, Xu B. Evaluation of an integrated communication skills training program for nurses in cancer care in Beijing, China. Nurs Res. 2007;56:202–9.1749557610.1097/01.NNR.0000270030.82736.8c Search in Google Scholar

[37] Tudoran AA, Scholderer J, Brunsø K. Regulatory focus, self-efficacy and outcome expectations as drivers of motivation to consume healthy food products. Appetite 2012;59:243–51.2259528710.1016/j.appet.2012.05.002 Search in Google Scholar

[38] Renner B, Kwon S, Yang B-H, Paik K-C, Kim SH, Roh S, et al. Social-cognitive predictors of dietary behaviors in South Korean men and women. Int J Behav Med. 2008;15:4–13.10.1007/BF0300306818444015 Search in Google Scholar

[39] Norouzi S, Moghaddam MH, Morowatisharifabad MA, Norouzi A, Jafari AR, Fallahzadeh H. Examining social-cognitive predictors of parenting skills among mothers with preschool and early elementary school-aged children. J Health Educ Health Promot. 2015;4:96. Search in Google Scholar

[40] Pollak KI, Arnold RM, Jeffreys AS, Alexander SC, Olsen MK, Abernethy AP, et al. Oncologist communication about emotion during visits with patients with advanced cancer. J Clin Oncol. 2007;25:5748–52.10.1200/JCO.2007.12.418018089870 Search in Google Scholar

Received: 2019-06-01
Accepted: 2019-09-05
Published Online: 2019-10-25

© 2019 Walter de Gruyter GmbH, Berlin/Boston