Submitted: 11 June 2020 | Approved: 25 June 2020 | Published: 26 June 2020
How to cite this article: Wubneh M, Emishaw S. Animaw W. Level of Nurses to Patients Communication and Perceived Barriers in Government Hospitals of Bahir Dar City, Ethiopia, 2020. Clin J Nurs Care Pract. 2020; 4: 012-026.
Copyright License: © 2020 Wubneh M, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Keywords: Communication; Barrier; Nurse-patient; Bahir Dar; Ethiopia; 2020
Background: Communication is the process of exchanging information or messages from one group to the other through mutually understood verbal or non-verbal ways. Communication barrier is anything that prevents receiving and understanding the messages. poor communication between patients and the nurses’ result in an increased length of stay, wastage of the resource, patient dissatisfaction, absence of confidence, and frustration for both the nurses and the patients. This study will provide basic information on the level of nurses to patients’ communication and perceived barriers in government hospitals of Bahir Dar city.
Objective: The objective of this study was to assess the level of the nurse to patient communication and perceived barriers in government hospital of Bahir Dar city, Ethiopia, 2020.
Methods: Institution based cross-sectional mixed-methods study was conducted from February 24 – March 9/2020 in government hospitals of Bahir Dar city. A total of 380 nurses were included in the quantitative study by using simple random sampling. For both the quantitative and qualitative study, at the initial stage of data collection and interview; informed consent was obtained from respondents. Data were entered into Epi Data 4.6 and analyzed with a statistical package of social science version 25. Data were mainly analyzed using descriptive statistics and binary logistic regression. For the qualitative study, purposive sampling technique was employed, and 7 participants were interviewed. Thematic analysis was used.
Results: From the total participants 36.5% of nurses were found to have poor communication. Variables which have statistically significant associations with the level of communication were educational level, work experience, the unwillingness of nurses, and lack of communication skill. The highest perceived communication barriers were lack of continuous training with 82.7% followed by workload with 80.7% and lack of medical facilities with 79.2% as reported by nurses. All environmental-related barriers were the perceived barriers of the nurse to patient communication.
Conclusion: In this study, the communication of nurses to patients is found to low. To enhance communication with the patients; nurses and other stakeholders like the ministry of health, the health bureau, and hospital authorities need to recognize the communication barriers. Giving awareness on the communication barrier for the nurses helps to minimize the barriers and improve the nurses to patients’ communication.
Communication is the transfer of information by exchanging verbal and non-verbal messages. It is a core skill for all healthcare professionals and nursing staff in particular since nurses spend more time with patients and relatives than any other healthcare professional. When nurses communicate effectively with interest, listen actively, and demonstrate compassion, patients may be more likely to report their experiences as positive, even at times of distress and ill health .
Good communication between nurses and patients is essential for better care. They should also devote time to the patient to communicate with the necessary confidentiality, and must not forget that this communication includes persons who surround the sick person, which is why the language of communication should be understood by all those involved in it . It can facilitate recovery, sense of safety and protection, improved patient satisfaction, and greater adherence to treatment options. Besides these, good communication through a patient-centered approach also serves to reassure relatives that their loved ones are receiving the necessary treatment . Good communication has become increasingly reported as a key component in better nursing care outcomes . Communication is a multi-dimensional, dynamic, and complex process that takes place in the hospital or related places. Nurses in hospitals need to enhance their skills in communication to improve patient satisfaction .
A communication barrier is anything that prevents from receiving and understanding the messages others use to share their information, ideas, and thoughts. Language barriers occur when people do not speak the same language, or do not have the same level of ability in a language. Such a language difference is causing an inability to exchange information and therefore a potential for misdiagnosis and mistreatment. Even with in the same language, there are vocabulary differences based on regions and professions. The nursing professions have their nomenclature that non-medical persons may not be able to understand. It also affected by time constraints, cultural differences, lack of knowledge and communication skills, nurse discomfort, and environmental factors which causes poor patient outcomes [4,6-9].
The studies in Manchester, England, and Canada indicated that poor communication between patients and the nurses’ result in an increased length of stay, wastage of the resource, patient dissatisfaction, absence of confidence and frustration for both the nurses and the patients [1,10]. Failure to recognize the two-way communication capability quite often leads to negative conclusions and attitudes. Moreover, the message sent is not the same as the message received. The decoding of the messages is based on individual factors and subjective perceptions. The receiver interprets the message they heard is not according to what the sender said but according to their code . According to the research center for quality care, 10.8% of patients believed that nurses sometimes or never listened to them carefully, do not explain things clearly, and do not spend enough time with them .
In recent years the nurse to patient interaction is observed as an important element in nursing practice. Research findings from the United States, Australia, Norway, and Brazil have confirmed that there were problems on the patients’ side as a result of inadequate time given for them during nurse-patient engagement which in turn limits patients’ access to communicate their informational needs. Nurses do not understand communication as a key element to nursing care that should be used, especially at the time of the patient admission represented by feelings of fear, insecurity, and anxiety [8,12-14]. Evidence in Iran, Saudi Arabia, and Ghana showed that the patient, nurse, and environmental related issues affect the communication between nurses and patients which have the ultimate result in reducing good communication [4,9,15]. In Ethiopia, a study conducted in Jimma university hospital that assessed predictors of communication by patients’ point of view showed that therapeutic communication was poorly implemented . But this does not show that the level of the nurse to patient communication and perceived barriers among nurses as the study participants. This is because the communication of patients can be determined by the communication capacity of nurses. So, if the nurses have good communication skills, the patients’ communication will be smoothed with their nurses. Even if, the Ethiopian ministry of health has implemented a compassionate respectful caring training program for health care workers including nurses to bring satisfaction to the patients; it might, unfortunately, helps to improve nurses’ communication with the patient. However the nurse to patient communication in the health institution not solved which observed as the obstacles of better care and patients suffered for long periods in the health institution without a listener and better care. Poor communication between nurses and patients increase mortality, morbidity, long hospital stay, increasing health care costs, and minimize clients’ attraction towards health institutions. Study findings will be used as input for decision-makers and responsible bodies like the federal ministry of health (FMOH), regional health bureaus, academic institutions, and health care professionals which helps to decide what needs to be done to improve nurses to patients’ communications. It will be used as baseline data for the researcher who needs to conduct on the area of the nurse to patient communication. Therefore the purpose of this study was to assess the’ level of the nurse to patient communication and perceived barriers in government hospitals of Bahir Dar city. In addition to these nurses’ experience on the nurse to patient communication barriers was explored.
The study was conducted in Bahir dar city which is the capital city of the Amhara region located in 565 kilometers away from Addis Ababa in the NorthWest direction. There are three governmental hospitals in Bahir Dar city administration. These are Tibebe Gihon specialized- teaching hospital (TGSTH), Felege Hiwot comprehensive specialized hospitals (FHCSH), and Addis Alem primary hospital (AAPH). The total numbers of nurses in these three hospitals were 744 from February to March 2020.
Study design, population, sample size, and sampling procedure
An institutional-based cross-sectional mixed-method was used. The source populations were all nurses who work in government hospitals of Bahir Dar city, and nurses on sick leave or annual leave, and some other social problems were excluded. The total samples were 380 nurses for quantitative. First, the three governmental hospitals in Bahir Dar city were selected based on convenience because there are only three governmental hospitals, and private hospitals were not included because of the nurses in the governmental hospital also work at the private. Proportional allocation of samples based on the number of nurses was given for each hospital (Figure 1). Finally, nurses from each hospital were selected by simple random sampling using the lottery method. The sample size for qualitative was considered until data saturation, and 7 nurses were interviewed with data saturation was gained at the fourth participant. Data saturation is a matter of identifying redundancy in the data or relates to the degree to which new data repeat what was expressed in previous data during data collection . The study was conducted from February – March 2020.
Good communication: Those nurses’ who answered mean and above mean communication questions. That is there are 14 questions prepared to assess communication level with a Likert frequency scale (never, rarely, sometimes, often and always) with the value of 1 to 5. So the summation of the five Likert responses is 15 then divided by five which equals 3. Therefore the mean of one question is 3 and 42 is the mean of the 14 questions.
Poor communication: Those nurses who answered below mean communication questions.
Level of the nurse to patient communication Independent Variables.
Age, sex, religion, marital status, educational level, position, work experience, working units, age difference, gender difference, language difference, religion difference, culture difference, Workload, shortage of nurses, low salary, lack of communication skill, unwillingness to communicate, nervous experience, dialect unfamiliarity, lack of time, problem out of work area, Family interference, pain, distrust of nurse competency, contagious disease, contact different nurses, presence of family on the bedside, Inappropriate room, busy environment, unfamiliar environment, lack of training, lack of facilities.
Data collection tool
A questionnaire assessing the level of nurses’ to patients’ communication and perceived barriers was adapted after a review of different works of literature [4,18,19]. The data collection instrument was prepared in English and translated to Amharic, and again re-translated to English by nurse academician. The pre-test was done in 5% of the calculated sample at Debre Tabor hospital to check whether the questions are simple, clear, and easily understandable. The questionnaire contained three sections. The first part included demographic part contains 8 questions, the second part was concerned with the perceived barriers of nurses to patients’ communication which contains 27 questions which were assessed by five-point Likert using agreement (strongly disagree=1, disagree=2, neutral=3, agree=4 and strongly agree=5) then which latter recorded or categorized as strongly disagree, and disagree=1, neutral=2, agree and strongly agree=3 for analysis; and the third part is about the level of communication which contains 14 questions with a minimum score of 14 and maximum of 70 scores. The validity of questionnaires’ was checked by expert opinion (face validity) . Therefore the questionnaire’s validity was checked through face validity by four nurse academicians, one of them is an assistant professor, two lecturers, one assistant professor with a Ph.D. holder, and three clinical Bsc nurses who working at the hospitals. Internal consistency or reliability of the questionnaire was checked by using Cronbach’s alpha which was 0.919 for perceived barriers and 0.942 for the level of communication questions. An in-depth interview guide semi-structured questionnaire was used to elicit information concerned perceived communication barriers from the nurses’ point of view. Detailed information about nurses’ thoughts was explored in-depth which was offered a more complete picture of perceived barriers of the nurse to patient communication.
Data collection procedure
The data collection for a quantitative questionnaire was facilitated by BSc nurses, who had a better experience of data collection skills on clinical, and also training on data collection procedures and instruments were given. The data collectors distributed the self-administered questionnaire to the respondents to fill it. The qualitative data were collected by the principal investigator.
Data quality assurance
Adequate training and supervision were provided for the data collectors and supervisor. Codes were given to the questionnaires. The filled questionnaire was checked for completeness by data collectors and supervisors every day. Problems encountered during the study period were discussed in the study team and were solved. Computer frequencies and data sorting were used to check for missed variables, outliers, or other errors during data entry.
Data processing and analysis
Data were first checked for completeness and then each completed questionnaire assigned unique code. Subsequently, the data were entered using Epi Data 4.6. The generated data was exported to a statistical package for social sciences (SPSS) version 25. The data was cleaned by visualizing, calculating frequencies, and sorting. The analysis was done with descriptive statistics by using frequency, percentage, mean, median, and mode. Bivariate analysis between dependent and independent variables was performed using binary logistic regression by the enter method. Multicollinearity between independent variables was checked using the correlation coefficient. The correlation coefficients between predictor variables greater than 0.7 is an appropriate indicator for when collinearity begins to severely distort model estimation and subsequent prediction . All explanatory variables which had an association in bivariate analysis with a p- value less than or equal to 0.25 were entered into a multivariable logistic regression model. Hosmer and Lemeshow test were checked for model goodness of fit (0.363). During the analyses, 0.05 P-value, and 95% confidence interval (CI) was used. A P-value of less than 0.05 was taken as a significant association. Results were presented in text, tables, charts, and graphs. Convergent parallel design (the quantitative and qualitative strands of the research are performed independently, and their results are brought together in the overall interpretation). In both quantitative and qualitative, the data collection and data analysis occur concurrently (QUAN + qual) and independently . For the qualitative study field note and audio recorded was taken. Each interview was transcribed by cross-checked both the audio record and the field note. The accuracy of the transcripts was checked by repetitive listen to the audiotape and by reading the transcripts. The analysis was carried out by using deductive approach thematic analysis which involves coming to the data with some preconceived themes that expect to find reflected there, based on theory or existing knowledge . Based on this data were thematized in four major themes. The themes included; common communication barriers with sub-themes of language difference; nurse related barriers with sub-themes of lack of communication skill, shortage of nurses and workload; patient-related barriers with sub-themes pain, and family interferences; environmental/health setting related barriers with sub-themes of lack of medical facilities and lack of continuous training, inappropriate and busy environment.
The integration was taking place in the results point of integration; in which writing down the results of the first component, the results of the second component are added and integrated . The final result was triangulated to support the quantitative result.
Ethical issues within the study were taken into consideration when carried out the study. Ethical clearance was obtained from the institutional review board of Bahir Dar University, college of medicine, and health sciences with protocol number 0044/2020. A formal letter was submitted to Addis Alem primary hospital, Felege Hiwot hospital, and Tibebe Gihon hospital. For both the quantitative and qualitative study, at the initial stage of data collection and interview, informed consent was obtained from respondents and assured that their participation will be recorded anonymously, and confidentiality of response was maintained throughout the study.
Socio-demographic characteristics of the participants
A total of 380 samples were included in the study, and 370 participated with a response rate of 97.4%. The participants’ age ranged from 23 to 58 years, with a median age of 29 years. Among a total of participants, 189 (51.1%) were female (Table 1).
Level of communication
Nurse to patient communication is the exchange of information or message between nurses and patients.
About 135(36.5%) of the participants were found to have poor communication with 95%CI (31.9% - 41.9%) (Figure 1).
The communication level of nurses was assessed using 14 items of communication. The respondents’ score lies between a minimum of 14 to a maximum of 70. The mean used for dichotomous the data as poor and good communication was pre-determined (Table 2).
Distribution of socio-demographic and perceived barrier variables and the level of communication
Those nurses qualified as degree and above 107 (79.2%) were had poor communication. Nurses less than 2 years of experience 48(35.5%) were had poor communication (Table 3a,b).
From the total respondents, diploma nurses 28 (8%), and qualified as a degree and above 107 (29%) were had poor communication (Figure 2).
Perceived nurse to patient communication barriers
Perceived communication barriers include socio-demographic characteristics nurses, common- related or perceived barriers on both sides, nurse-related, patient-related, and environment- related communication barriers.
Common-related perceived communication barriers reported by nurses
Barriers that are common between nurses and patients inhibited the communication of nurses with the patients.
Language difference was the highest perceived common-related communication barrier with a- mean score of 2.27, and 60.5% of nurses at 95% CI (49.7%, 70.4%) were agreed as a perceived common-related communication barrier with (median=3, mode=3), whereas religion difference was the least perceived barrier with a mean score of 1.795. But nurses disagreed with gender, culture, religion, and age differences (median=1, mode=1) (Table 4).