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Communication Barriers Perceived by Nurses and Patients
Communication Barriers Perceived by Nurses and Patients
6; 2016
ISSN 1916-9736 E-ISSN 1916-9744
Published by Canadian Center of Science and Education
Received: August 10, 2015 Accepted: September 14, 2015 Online Published: September 28, 2015
doi:10.5539/gjhs.v8n6p65 URL: http://dx.doi.org/10.5539/gjhs.v8n6p65
Abstract
Communication, as a key element in providing high-quality health care services, leads to patient satisfaction and
health. The present Cross sectional, descriptive analytic study was conducted on 70 nurses and 50 patients in two
hospitals affiliated to Alborz University of Medical Sciences, in 2012. Two separate questionnaires were used for
nurses and patients, and the reliability and validity of the questionnaires were assessed. In both groups of nurses
and patients, nurse-related factors (mean scores of 2.45 and 2.15, respectively) and common factors between
nurses and patients (mean scores of 1.85 and 1.96, respectively) were considered the most and least significant
factors, respectively. Also, a significant difference was observed between the mean scores of nurses and patients
regarding patient-related (p=0.001), nurse-related (p=0.012), and environmental factors (p=0.019). Despite the
attention of nurses and patients to communication, there are some barriers, which can be removed through
raising the awareness of nurses and patients along with creating a desirable environment. We recommend that
nurses be effectively trained in communication skills and be encouraged by constant monitoring of the obtained
skills.
Keywords: communication, barrier, nurse, patient
1. Introduction
Communication is a multi-dimensional, multi-factorial phenomenon and a dynamic, complex process, closely
related to the environment in which an individual’s experiences are shared. Since the time of Florence
Nightingale in 19th century until today, specialists and nurses have paid a great deal of attention to
communication and interaction in nursing (Fleischer, Berg, Zimmermann, Wüste, & Behrens, 2009). Effective
communication is an important aspect of patient care, which improves nurse-patient relationship and has a
profound effect on the patient’s perceptions of health care quality and treatment outcomes (Li, Ang, & Hegney,
2012). Effective communication is the key element in providing high-quality nursing care, and leads to patient
satisfaction and health (Cossette, Cara, Ricard, & Pepin, 2005). Effective communication skills of health
professionals are vital to effective health care provision, and can have positive outcomes including decreased
anxiety, guilt, pain, and disease symptoms. Moreover, they can increase patient satisfaction, acceptance,
compliance, and cooperation with the medical team, and improve physiological and functional status of the
patient; it also has a great impact on the training provided for the patient (Aghabarari, Mohammadi, & Varvani,
2009).
However, most studies have reported poor nurse-patient relationships (McCabe, 2004; Jangland, Gunningberg, &
Carlsson, 2009; Gilmartin, & Wright 2008). Therefore, overall, nurse-patient communication has not led to
personal satisfaction (Jangland, Gunningberg, & Carlsson, 2009). This is due to the fact that health care quality
is strongly affected by nurse-patient relationship, and lack of communication skills (or not using them) has a
negative impact on services provided for the patients. The results of previous studies have shown that nurses
have been trained to establish an effective communication; however, they do not use these skills to interact with
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their patients in clinical environments (Heaven, Clegg, & Maguire, 2006). Similarly, the results of other studies
show that nurses and nursing professionals in general, have not made a lot of effort for establishing positive
interactions with the patients. Many reported problems are related to the decreased sense of altruism among
hospital staff including nurses (Bridges et al., 2013).
Communication pitfalls are 5-10% in general population and more than 15% in hospital admissions (Bartlett,
Blais, Tamblyn, Clermont, & MacGibbon, 2008). Hospitalized patients in all ages often experience complex
communication needs including mobility, sensory, and cognitive needs as well as language barriers during their
stay (Downey & Happ, 2013). Hospitalization is potentially stressful and involves unpleasant experiences for
patients and their families. All aspects of care and nursing are of high importance in communication with
patients, as the patients consider interaction with the nurses as a key to their treatment. Also, through
communication, nurses become familiar with the needs of their patients, and therefore, they can deliver
high-quality health care services (Cossette et al., 2005; Sheldon, Barrett, & Ellington, 2006; Thorsteinsson,
2002). Patients with communication disability were three times more likely to experience medical or clinical
complications compared to other patients (Bartlett et al., 2008).
Iran is a multicultural country with recognized cultural pluralism. In Iranian religious context, nurses are not
allowed to gaze or touch patients of the opposite-sex, except in emergency cases. In addition, although Iranian
formal language is Farsi, there are many dialects such as Lurish, Kurdish, and Baluchi, which might act as
communication barriers between nurses and patients (Anoosheh, Zarkhah, Faghihzadeh, & Vaismoradi, 2009). In
Iran, some communication facilitators and barriers have been reported including low educational preparation,
governmental policies, and inappropriate environment as barriers, and religious and cultural norms, role
modeling, and previous exposure of patients as facilitators (Rejeh, Heravi-Karimooi, & Vaismoradi, 2011).
The first step in eradicating the problems related to nurse-patient communication is two-sided (nurse and patient)
awareness of communication barriers. It is of no doubt that building an effective relationship is dependent on the
understanding of both sides of the interaction (Park & Song, 2005). In this study, we aimed to determine the
barriers to nurse-patient relationship from the perspective of nurses and patients. Through this evaluation, we can
improve the quality of nursing services and increase the satisfaction of patients and their families. We also
assessed the barriers to using communication skills by the nurses in nurse-patient interactions.
2. Method
2.1 Study Design
Cross sectional, descriptive analytic study.
2.2 Participants
This study was conducted on nurses and patients of two public hospitals affiliated to Alborz University of
Medical Sciences, Karaj, Iran. Simple random sampling method was applied.
2.3 Questionnaires
Data were collected via two separate questionnaires for nurses and patients. The reliability and validity of the
questionnaires were assessed. Content validity was approved by eight professors of Tehran University of
Medical Sciences and Tarbiat Modares University, and reliability was assessed using the split-half method.
Pearson’s correlation coefficient between the two halves was calculated, and reliability of patient (correlation
coefficient of 0.76) and nurse (correlation coefficient of 0.82) questionnaires were approved.
The questionnaires consisted of two sections. The first part included demographic questions and the second part
was concerned with the present barriers to nurses’ use of communication skills. The nurse questionnaire
contained 44 items and patient questionnaire consisted of 29 items; each item included 5 options: none, little,
average, high, and not included. The participants chose one of the options with regard to the importance of each
barrier; “not included” was selected if the subjects had not dealt with such a barrier before.
The barriers were divided to four categories: common barriers between patient and nurse, nurse-related barriers,
patient-related barriers, and environmental barriers. To determine the importance of each barrier, the qualitative
data were converted to quantitative data and the options were scored as follows: none: 1 score, low: 2 scores,
average: 3 scores, and high: 4 scores. The difference in the number of items between patient and nurse
questionnaires was related to the number of nurse-related factors. Some items were designed with regard to
nurses' working conditions, and there was a possibility that patients were unaware of these conditions; therefore,
these cases were removed from the patient questionnaire, and the remainders were included in both
questionnaires.
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Emergency 11 (15.7)
Overtime work Yes 54 (77.1)
No 16 (22.9)
Knowledge of communication skills Yes 56 (80.0)
No 14 (20.0)
Training of communication skills Trained 29 (41.4)
Untrained 41 (58.6)
Table 3. Comparison of four groups of barriers in two groups of nurses and patients
Barriers Nurse group Patient group P-value
(Mann-Whitney Test)
Factors common between nurses and patients 1.85±0.54 1.96±0.62 0.19
Nurse-related factors 2.45±0.42 2.15±0.61 0.012
Patient-related factors 2.30±0.48 1.97±0.53 0.001
Environmental factors 2.41±0.43 2.08±0.64 0.019
*P≤0.05 was considered statistically significant.
**P≤0.01 was considered statistically significant.
The most frequent communication barriers from the nurses’ viewpoint were as follows: differences in colloquial
languages of nurses and patients, nurses’ being overworked, family interference, and presence of emergency
patients in the ward. According to the patients, gender differences between nurse and patient, nurse’s reluctance
for communication, hectic environment of the ward, and patient’s anxiety, pain, and physical discomfort were the
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Table 4. The most important barriers from the viewpoint of nurses and, based on the type of barrier
Barriers from the Importance Barriers from the Importance
viewpoint of nurses degree viewpoint of patients degree
Factors common between nurses and patients Factors common between nurses and
patients
-Gender differences between nurse and patient -Cultural differences between nurse and
2 patient 2
-Patient’s unawareness of the status and duties of the 2 -Patient's lack of attention and focus 2
nurse - Patient’s attendees interference
-Anxiety, pain, and physical discomfort of the 3 3
patient
According to the data obtained from Man Whitney Test, comparison of patients’ and nurses’ mean scores of
barriers (to using communication skills by nurses) indicated that of 29 items common between nurse and patient
questionnaires, the mean scores of 13 items were significantly different (Table 5).
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Table 5. Comparison of the mean scores of barriers to communication skills by nurses in interacting with patients
from the viewpoint of nurses and patients
Barrier categories Barriers M±SD P-value
(Man
Nurses Patients
Whitney)
Factors common between Age differences between nurse and patient 1.30±0.84 1.92±0.89 0.001**
nurses and patients
Gender differences between nurse and 1.90±1.0 2.2±1.1 0.045*
patient
Cultural differences between nurse and 2.19±0.80 2.0±0.97 0.638
patient
Religious differences between nurse and 1.47±0.89 1.58±1.14 0.601
patient
Colloquial language differences between 2.35±0.68 2.00±0.97 0.060
nurse and patient
Nurse-related factors Despondency and apathy of the nurse 2.6±0.65 2.34±1.01 0.394
towards his/her profession
Patient-related factors Patient's unawareness of the status and 2.30±0.75 1.90±0.93 0.025*
duties of the nurse
Negative attitude of the patient toward the 2.27±0.79 1.90±0.90 0.023*
nurse
Resistance and reluctance of the patient to 2.28±0.64 1.60±1.11 0.044
communicate
Patient's lack of focus 2.28±0.68 2.02±0.91 0.154
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Environmental factors Unfamiliar environment of the hospital for 2.06±0.76 1.79±1.09 0.284
the patient
Busy environment of the ward 2.59±0.60 2.23±0.96 0.070
(noise and traffic)
Unsuitable environmental conditions 2.48±0.72 1.98±1.10 0.020*
(improper ventilation, heating, cooling, and
lighting)
Critically ill patients in the ward 2.78±0.48 2.17±0.99 0.000**
4. Discussion
The results of this study showed that in both groups of nurses and patients, the most and the least important
barriers were nurse-related factors and common factors between nurses and patients, respectively. These results
were consistent with the findings of Aghabarari et al., who performed a study to determine the barriers to
applying communication skills by nurses, from the viewpoint of nurses and patients (Aghabarari et al., 2009).
Also, in the study of Aghamolaei et al., nurse- and patient-related barriers were more important than
environmental barriers (Aghamolaei & Hasani, 2011). In terms of common factors between nurses and patients,
colloquial language, and cultural and gender differences were of high importance; however, priorities were not
quite similar between nurses and patients. Through establishing an appropriate verbal communication, the nurse
could thoroughly understand the patient's problems; hence, in many studies, the nurse's unfamiliarity with the
patient's colloquial language has been mentioned as a communication barrier (Anoosheh et al., 2009; Baraz,
Shariati, Alijani, & Moein, 2010; del Pino, Soriano, & Higginbottom, 2013; Li et al., 2012). If there is a
difference in spoken language, effective communication cannot be established; even non-verbal communication
in different cultures may have different interpretations. Patients are also less acceptant of nurses with different
languages and cultures (culture has an impact on individuals' attitudes and behaviors). Based on previous studies,
communicative needs and ways of expressing emotions vary in different cultures and religions. Sufficient
knowledge of nurses regarding patients' culture, language, customs, and beliefs can help them communicate with
the patients without having any pre-judgments or prejudice. Indeed, culture can act as both a facilitator and a
barrier to communication (Okougha & Tilki, 2010).
Alborz province is also called "little Iran", meaning that all ethnicities and cultures are present in this region;
therefore, the variety of cultures should not be neglected. Considering the population concentration of specific
ethnic groups in particular regions of this province, it is recommended that the patient’s language and ethnicity
be considered for the allocation of medical staff.
In this study, another factor affecting communication, particularly from the viewpoint of patients, was gender
differences; the results were consistent with those of previous studies (Anoosheh et al., 2009; Baraz et al., 2010).
The impact of gender differences on communication is mostly emphasized by the patients; in fact, nurses are less
affected by patients’ gender while performing their professional duties. According to cultural and religious
beliefs in Iran, touching and gazing are inconsistent with the principles of the society (Anoosheh et al., 2009).
Similar to many Asian cultures, speaking about sexual problems is also considered impolite (Im et al., 2008).
Given the aforementioned principles, the number of male nursing students should increase considering the
shortage of male nurses in hospital wards.
As to the patients’ viewpoint, another influential factor was age differences. Similarly, Sung and Park considered
generation gap as a communication barrier (Park & Song, 2005). In another study, differences in age and social
class were included as communication barriers (Anoosheh et al., 2009). However, according to a study by Baraz,
age differences had no negative impact on nurse-patient relationship (Baraz et al., 2010). Generally,
communicating with different age groups has its own challenges and complexities. Nurses can have good
interactions with patients through developing awareness of each age group's attitudes to health, disease, and
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Acknowledgments
This study is financially supported by Research Affairs, Alborz University of Medical Sciences, Karaj, Iran. The
authors wish to express their sincere gratitude to the study participants without whom this study could not have
been conducted.
Conflict of Interest
The authors declare that there is no conflict of interests regarding the publication of this paper.
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