The Experiences and Meanings of Nurses’ Smiles to Patients in the Emergency Department

Corresponding Author: Vera Fitriana Akademi Keperawatan Krida Husada, Kudus, Indonesia Email: vera.fitriana88@gmail.com Background: Psycho-emotional aspects play an important role in both health services and health workers in the emergency department. Smiles are forms of interactions between nurses and patients that are given in providing health services to patients in terms of nonverbal communication. However, high workloads in the emergency unit may hinder nurses from smiling. Purpose: This study aimed to explore the experiences and meanings of nurses’ smiles to patients in the emergency department. Methods: This study employed a qualitative design with a descriptive phenomenological approach. Thirteen participants were recruited through purposive sampling using the inclusion criteria, such as emergency nurses with more than three years of work experience and nurses who had attended training on effective communication. Data were collected through in-depth interviews with semi-structured questions and analyzed using the Colaizzi’s phenomenological approach. Results: The study generated four themes, namely, the importance of smiles in emergency services, the miracle of smiles, the hindrances for emergency nurses to smile, and that smiles and humor in an emergency situation are important for children. Conclusion: The study concluded that nurses’ smiles had a significant benefit on emergency department services as a form of interpersonal relationship, although the practice still needs to be improved. Nurses are expected to be able to apply smiles in communicating with patients and their families in the emergency departments.


Research design
This study was a descriptive qualitative study with a phenomenological approach. This approach explores, interprets, and analyzes data in a structured and comprehensive manner to obtain the essence of individual experiences in the form of narratives, stories, and sayings (Polit & Beck, 2012).

Setting and participants
This study was carried out in a hospital in Kudus, Central Java, Indonesia in 2019. The population in this study was emergency nurses within the hospital. Purposive sampling was used to recruit 13 participants who met the inclusion criteria. The criteria included nurses with more than three years of work experience and nurses who had attended training on effective communication. The number of participants was determined by reaching the level of redundancy, in which the data were saturated, and adding more participants would not provide any new information.

Data collection
The data were collected through in-depth interviews using semi-structured interview guidelines for 40-60 minutes. The interview guidelines were made based on a relevant theory, starting with open-ended questions that were flexible and could be developed during the interview process without leaving the predetermined topic. The interview asked fourteen questions to get deep information about nurse experiences, for example, "How is your experience in giving a smile while treating patients with emergency conditions?". Then, the researchers explored deeper to disclose information on each question. The interviews were recorded using a voice recorder, and the results of observations were written as field notes. The researchers interviewed the participants face-to-face at the agreed time. The time and place of the interview were arranged in a calm environment within the hospitals, which were according to the participants' preferences. Data collection was continued to the point of data saturation, in which no new information was obtained, and redundancy was achieved. The researchers concluded the results of the interview by clarifying the answers that had been given by participants to the researchers.

Data analysis
The data analysis used in this research was the Colaizzi's model. This model consisted of several stages. The initial stage of data analysis was done by carefully listening to the recordings repeatedly. The next stage was transcribing process, which was done by conducting verbatim transcriptions to all recordings. The data then were categorized into categories, sub-themes, and themes (Morrow et al., 2015).

Trustworthiness
The trustworthiness in this study was achieved through the principles of credibility, dependability, confirmability, and transferability. To obtain high data credibility for the results of this study, triangulation and member check were employed. Triangulation techniques included triangulation of data sources and theory triangulation. In theory triangulation, the researchers compared the data obtained from the research with the existing theories from both books and journal articles. Data source triangulation was done by comparing the interview results with the head nurse and patients' families' interview results, direct observations, and field notes. Memberchecking was done by giving the interview results to all participants in the form of transcripts to determine the suitability data obtained from participants. The dependability in this study was maintained by involving a supervisor to audit and analyze a series of research processes such as entering the field to recruit the participants, data collection mechanisms, checking the data validity, data analysis, and how to draw the conclusions. Confirmability was done by debriefing the results of the study with the research team. Lastly, the researchers carried out transferability by describing in detail the findings obtained in the study, then making an explanation of the interview results in a narrative form. It was done so that the readers could clearly understand the results of the research and could use and apply the results of the study elsewhere.

Ethical considerations
Prior to the data collection, participants were informed and provided their consent for voluntary participation. Their identities were kept confidential using the nurse code (P) given to the participants based on the order of interview. The ethical approval in this study was received from the Ethics Committee of the Faculty of Medicine, Universitas Sebelas Maret, Surakarta, Indonesia, with a reference number of 449/III/HREC/2019.
The result generated four themes: (1) the importance of smiles in emergency services, (2) the miracle of smiles, (3) the hindrances for emergency nurses to smile, and (4) smiles and humor in emergency cases are important for children.

The importance of smiles in emergency services
The participants in this study mentioned that smiles had become one of the most important parts of emergency department services. Smiles were given to patients and their families when they first entered the room to create a good relationship. The intended relationship was aimed to establish trust between the nurses and patients.

The miracle of smiles
The second theme revealed that smiles could yield some miracles to the patients. These miracles were speeding up the healing process, providing comfort, making happiness, fostering a mutual trust relationship, and opening patients' attitudes. The participants stated that a smile could speed up the healing process of the patients. A smile also could provide positive energy for the patients so that it could be a good influence on the patients' healing process. The participants also said that a smile could give comfort. Even though it was difficult because of the patients' emergency condition, a nurse still had to smile so that the patients were calm and comfortable by showing concern and providing motivation.
"... Smiles bring them closer to nurses, can make the patient comfortable... for example, when we smile, the family becomes happy..." (P11) "... Smile has become our basis before entering the patients' rooms, before we start any conversation with them... the patients will be more comfortable; they won't cover anything, insyaallah (God willing), they will have trust in us... If I assume, before going to the verbal communication, we should begin with the non-verbal communication first..." (P12) Participants expressed that a smile could make patients happy. As a nurse who served patients, giving smiles could be considered as a part of the duty to bring happiness, especially a sincere smile.

Smiles and humor in an emergency situation are important for children
This theme illustrated the importance of smiles and humor for children in emergency situations. The participants showed a caring attitude towards pediatric patients who came to the EDs by comforting them, making lots of jokes and smiles. These were done so that the children were not afraid. Participants occasionally teased the children with funny jokes.
"... I get close to the children by smiling; then we make a joke, we assure them. For example, when measuring the temperature, we ask "Does it feel sick or not?", even until the patients willingly move into the room. I ask them to make a "toss (high five)" first." (P4) "For pediatric patients, we try to go straight to the children, we make jokes and entertain them…keep looking at the patients…we try to keep calm because a nurse must be calm and gentle in explaining to the family about the further treatment, so the family's trust on us will be maintained …" (P7) "... We always smile when we meet the kid. We try to be cheerful with them ..." (P9) "... I joke to the kid … and say, "Come on, what do you like ...?" "Your illness is treated so you can go home quickly ...". We try to cheer up the kid ... We find difficulties when we meet kids who keep silent and cry..." (P12) "... Children tend to trust their parents ... we can still have their trust. Sometimes we tease them, sometimes we challenge them to lay down on the bed." (P13)

Discussion
The study resulted in four major themes. They were the importance of smiles in emergency services, the miracle of smiles, the hindrances for emergency nurses to smile, and that smiles and humor in emergency cases were important for children.

The importance of smiles in emergency services
The result of the research showed that it was important to give a smile to patients in emergency departments due to unpredictable and overcrowding situations in emergency services. Participants revealed that they had to provide the best services, although the EDs were very crowded. One of which was through non-verbal communication like smiles. This is important since EDs are the main gate for urgent and emergent patients whose impressions will affect their satisfaction. This is in line with the opinion that smiling is very important in the EDs, considering that EDs are units with many challenges, various diseases, and unpredictable emergency situations. The crowded environment of EDs and various emotional responses of family members, like grief, anger, anxiety, and fear, make a smile very meaningful (Arshad, 2017;Australian College for Emergency Medicine, 2014;Finlayson, 2010). It means that emergency services are demanded to be promptly precise and responsive to high patient stressors. It has become the standard quality of service for hospitals that provide special services to emergency patients continuously for 24 hours every day. Health services especially nursing services, should be improved as emergency patients require fast, precise, and accurate services, so patients can be treated without experiencing disabilities (Ministry of Health Republic of Indonesia, 2009).
Mechanisms are needed to handle various emergency cases. The most effective coping mechanism in the emergency room is smiling. Naturally, there is an inappropriate time to smile in an emergency department with complex conditions. However, it should be considered that a smile stimulates the release of endorphins and dopamine, which helps to feel more relaxed to reduce patient stressors and nurse stressors (Arshad, 2017). Smiling during nurse-patient interactions in the emergency services may become a key success to enhance the communication process. A smile can reduce anxiety, stress, and obstacles resulting from the crowded environment. It also has a positive effect on health (Dias et al., 2015). A smile is contagious. It is the facial expression that breaks most barriers and brings people together, and can have a positive effect on people who feel sad, anxious, and depressed (Pontifice-Sousa, 2012).
A smile is a facial expression that is very important and essential in expressing one's feelings. An attractive or pleasant smile will create a good interpersonal relationship (Kishorekumar et al., addition to the decreasing motivation of nurses and distrust of nurses' competencies related to cultural differences and less responsive nurses. The participants had also explained that they experienced conflicts of roles related to psychological and physical issues resulting in their appearance when conveying information to the patients' families. This was caused by fatigue and personal problems that affected their appearance, such as, rarely smiling when passing information to the patients' families. This statement is in line with Loghmani et al. (2014)'s research which concludes that personal problems may interfere with interactions between nurses and the patients' families, in addition to lack of staff and high workload issues that cause the nurses not to have adequate time for the patients' families. Consequently, negative interactions between nurses and families occur. Efforts are made to encourage nurses to smile to bring a positive mood that causes positive reactions (Barger & Grandey, 2008).

The smiles and humor in emergency cases are important for children
The results of this study found that giving smiles to pediatric patients in the emergency department through humor was important to reduce children's fear and anxiety during emergency situations. According to Brock (2010), humor in communication is crucial as expressions of feedbacks to patients. When patients laugh, meaning that a mutual trust relationship with the patients was created. Interaction between nurses and patients related to smiles and the use of humor is considered as an important instrument in the communication process that can eliminate anxiety, stress, and obstacles resulted from the hospitals (Haydon & Riet, 2014). Humor has a positive effect on the patients' health (Pontifice-Sousa, 2012). A study by Eldridge and Kennedy (2010) explained that warm smiles and slow approaches to patients are important to eliminate the perception of scared in a child towards the medical services. Even to some extent, people consider medical services as a threat.
A fun and friendly atmosphere during medical treatment such as smiling, keeping eye contact with patients, stay sitting while explaining, and providing time to take questions will establish trust and eliminate anxiety. Talking to the patients and their families directly and giving explanations in simple and clear ways are classified as non-pharmacological medication, especially for children in emergency cases, because most children have issues with hospitalization processes (Eldridge & Kennedy, 2010). Furthermore, the use of humor is said to be a form of positive expression in inviting communication, as people who communicate with a smile and the use of humor will entertain the counterparts and may forget their problems (Ruch, 2008).

Implication and limitation
This study is one of the limited studies that depicted smile as an important non-verbal communication form for emergency nurses in the emergency departments. However, this study had some limitations. First, the choice of interview time, which was within working time, may affect how the participants answered the questions as they also had their responsibilities as the duty nurses. However, to minimize the interruption and concentration loss, the interviews were held in a private room at the agreed time between researchers and participants. Second, the principal researcher, who is novice, may impact how deep the interview was conducted and how to analyze the data forming the themes. However, member checking had been carried out to all participants, and peer debriefings with more expert researchers during data analysis were also done to maintain the data quality.

Conclusion
The findings showed that smiles are important in emergency services. Smiles may create a miracle. Also, smile and humor in emergency cases are very important for children. A smile is very important in emergency department services as a form of interpersonal relationships. However, there are several reasons why emergency nurses do not smile. Therefore, nurses are expected to be able to smile in communicating with patients and their families regardless of any internal and external problems. The results of this study are expected to be the basic consideration for hospitals to improve their medical services, especially in the emergency departments. For future research, this study can be used as a benchmark for conducting further research that focuses on the importance of a smile in the emergency department in addition to fast, careful, precise, and responsive actions.