Shortage of nursing staff, high workload, burnout, and limited-time constituted one complex institutional and healthcare system-level barrier to effective care delivery [ 18, 19]. For instance, Loghmani et al. [ 20] found that staffing shortages prevented nurses from having adequate time with patients and their caregivers in an Iranian intensive care unit. Limitations in nursing staff, coupled with a high workload, led to fewer interactions between nurses, patients, and caregivers. Similarly, Anoosheh et al. [ 16] found that heavy nursing workload was ranked highest as a limiting factor to therapeutic communication in nurse-patient interactions in Iran. We express our gratitude to the first author’s doctoral committee members for their valuable comments, suggestions, and critique of an earlier version of this paper. We are also grateful to the anonymous reviewers for the insightful comments and suggestions that have helped us improve the study’s quality. Authors' information In addition to the availability of formal training programmes, peer learning, availability of care guidelines and protocols, self-directed learning, including the use of the internet and videos, such as a video developed by NIID, are the main learning strategies used by nurses. Promoting peer learning and ensuring timely care guidelines and protocols are essential. Self-directive knowledge has a promising role in health profession education [ 34], especially in emerging pandemic like COVID-19. Ensuring the availability of self-directive learning materials and providing facilities, for example, the internet and computers can promote nurses’ motivation for learning during health crises. Murira N, Lützen K, Lindmark G, Christensson K. Communication patterns between healthcare providers and their clients at an antenatal clinic in Zimbabwe. Health Care Women Int. 2003 Feb 1;24(2):83 – 2. https://doi.org/10.1080/07399330390170060. In addition to forming connections with patients, nurses are in charge of ensuring patients understand, and therefore are engaged in, their care plans. In 2018, the American Academy of Nursing reaffirmed patient education as a core part of nursing work.

Amoah KMV, Anokye R, Boakye SD, Acheampong E, Budu-Ainooson A, Okyere E, Kumi-Boateng G, Yeboah C, Afriyie OJ. A qualitative assessment of perceived barriers to effective therapeutic communication among nurses and patients. BMC Nurs. 2019 Dec;18(4)1–8. https://doi.org/10.1186/s12912-019-0328-0. Parents are first and foremost the children's representatives, but if the parents are unable to do this, the nurses will take the responsibility for supporting children during NRMP. This study explored the experiences of nurses who cared for patients with COVID-419 in Sri Lanka, especially in the initial period of the crisis. To the authors’ knowledge, this study is one of the first studies to examine the overall experiences of nurses as the recent studies related to caring for patients with COVID-19 have focused mainly on physical and psychological distress [ 5, 6, 14, 22].

Materials and methods

Henly SJ. Health communication research for nursing science and practice. Nurs Res [Editorial] 2016:257–8. doi: https://doi.org/10.1097/NNR.0000000000000171. McCabe C. Nurse-patient communication: An exploration of patients’ experiences. J Clin Nurs. 2004 Jan;13(1):41–9. Clinicians really do leverage their communication skills and they have to focus on that and be more intentional because they are going to lose any of the subtle body language cues that they would get in an in-person setting,” she explained.

Dahlberg K, Dahlberg H, Nyström M. Reflective lifeworld research. 2nd ed. Lund: Studentlitteratur; 2008. [ Google Scholar] Furthermore, when nurses fail to listen to patients’ and caregivers’ concerns, coerce patients to obey their rules and instructions [ 16, 17, 20], or fail to provide patients with the needed information, nurse-patient communication and patient-centered care practices suffer. To illustrate, in Ddumba-Nyanzia et al.‘s study on communication between HIV care providers and patients, a patient remarked that: “I realized no matter how much I talked to the counselor, she was not listening. She was only hearing her point of view and nothing else, [and] I was very upset” [ 17]. This quote indicates how care provider attitudes can constrain care outcomes. Due to high workload, limited time, poor remunerations, and shortage of personnel, some nurses can develop feelings of despair, emotional detachment, and apathy towards their job, which can lead to low self-esteem or poor self-image, with negative consequences on nurse-patient interactions [ 13, 18]. Hedström M, Haglund K, Skolin I, Von Essen L. Distressing events for children and adolescents with cancer: Child, parent, an nurse perceptions. Journal of Pediatric Oncology Nursing. 2003; 20(3):120–132. [ PubMed] [ Google Scholar] B]ecause there are few nurses at the ward, sometimes you would want a nurse to attend to you, but he or she might be working on another patient, so in such case, the nurse cannot divide him or herself into two to attend to you both [ 16]. Using nurse communication strategies that emphasize those points can help healthcare professionals both meet the clinical and emotional needs of their patients while fulfilling their other job demands. MAKING PERSONAL CONNECTIONS

Cohen L, Manimala R, Blount R. Easier said than done: What parents say they do and what they do during children's immunizations. Children's Health Care. 2000; 29(2):79–87. [ Google Scholar] Research has shown that effective communication between patients and healthcare providers is essential for the provision of patient care and recovery [ 5, 6, 7, 8]. Madula et al. [ 6], in a study on maternal care in Malawi, noted that patients reported being happy when the nurses and midwives communicated well and treated them with warmth, empathy, and respect. However, other patients said poor communication by nurses and midwives, including verbal abuse, disrespect, or denial from asking questions, affected their perceptions of the services offered [ 6]. Similarly, Joolaee et al. [ 9] explored patients’ experiences of caring relationships in an Iranian hospital where they found that good communication between nurses and patients was regarded as “more significant than physical care” among patients. This is the highest point of the PC4 Model, where patient-centered care is actualized. At this stage of the communication continuum, patients and caregivers are treated as unique persons with specific care needs and are seen as collaborators in the care process. As McLean [ 14] observed, caregiving becomes a transactional relationship between the care provider and receiver at the person-centered stage of the continuum. The care itself becomes intersubjective, a mutual relational practice, and an ongoing negotiation for care providers and receivers [ 14]. The findings indicate that nurses use different types of conversation in their attempt to be supportive when talking to children and their parents. Metaphors can be used to facilitate an understanding between the child and the nurses, helping the child to become involved in the procedures. Most importantly, the nurses are able to talk in a language that the child understands. This finding is consistent with previous research from Kortesluoma and Nikkonen ( 2006) who maintain that children from the age of five are able to construct metaphorical expressions. Fleitas ( 2003) also discusses the benefits of using metaphors when talking with children in pediatric settings. We believe that nurses can be supportive by using metaphors although nurses have to be vigilant as there is a risk that children do not always understand, especially the younger children. Anderzén-Carlsson A, Kihlgren M, Skeppner G, Sørlie V. How physicians and nurses handle fear in children with cancer. Journal of Pediatric Nursing. 2007; 22(1):71–80. [ PubMed] [ Google Scholar]

This study was undertaken to describe the lived experience of supporting children during NRMP, from the perspective of nurses. The analysis resulted in the following constituents: developing relationships through conversation, being sensitive to embodied responses, balancing between tact and use of restraint, being the child's advocate, adjusting time, and maintaining belief; and the discussion will focus on some of these findings. But being a nurse isn’t easy, as nurses face full patient loads and crowded workflows. It may be challenging for nurses to find time to build interpersonal patient relationships between their clinical duties and other job demands.Dempsey has boiled her own communication strategy down to about 56 seconds, a timeline all nurses should be able to follow, she said. Wong EL, Wong SY, Lee N, Cheung A, Griffiths S. Healthcare workers’ duty concerns of working in the isolation ward during the novel H1N1 pandemic. Journal of clinical nursing. 2012;21(9‐10):1466–75. pmid:21777312 Technology is likely to continue challenging the interpersonal nurse-patient relationship, but the nature of those challenges is likely to evolve. As telehealth continues to become an integral part of patient care access, patients and nurses may become accustomed to building relationships across a computer screen, just as they became accustomed to the EHR in the exam room. Yoo HJ, Lim OB, Shim JL. Critical care nurses’ communication experiences with patients and families in an intensive care unit: A qualitative study. PLoS One. 2020 Jul 9;15(7):e0235694. https://doi.org/10.1371/journal.pone.0235694. However, some research has indicated that small changes to existing workflows can help circumvent those time constraints.