Global Journal of Health Science; Vol. 8, No.

6; 2016
ISSN 1916-9736 E-ISSN 1916-9744
Published by Canadian Center of Science and Education

Communication Barriers Perceived by Nurses and Patients

Roohangiz Norouzinia1, Maryam Aghabarari2,3, Maryam Shiri3, Mehrdad Karimi4 & Elham Samami3
1
School of Paramedical, Alborz University of Medical Sciences, Karaj, Iran
2
Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Tehran University of
Medical Sciences, Tehran, Iran
3
School of Nursing and Midwifery, Alborz University of Medical Sciences, Karaj, Iran
4
School of Public Health, Department of Epidemiology and Biostatistics, Tehran University of Medical Sciences,
Tehran, Iran
Correspondence: Maryam Aghabarari, Nursing and Midwifery Care Research Center, School of Nursing and
Midwifery, Tehran University of Medical Sciences, Nosrat St., Tohid Sq., Tehran, Iran. Tel: 98-912-610-4684.
E-mail: [email protected]

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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2.4 Data Collection

After obtaining the required approval, nurses and patients in the two hospitals were asked to participate in the
study. In order to collect the data, the researchers visited the wards on a daily basis during different shifts. After
explaining the study objectives to the nurses and taking informed consents, the questionnaires were given to the
participants; after completion, the questionnaires were collected by the researchers.
The nurse sample included nurses of medical, surgical, intensive care unit, and emergency wards. They were
working in morning, evening, night, evening and night, and circulating shifts. The sample size was calculated
according to the number of nurses in the ward.
The inclusion criteria for the nurse group were as follows: 1) bachelor's degree (minimum education level), 2)
minimum of 6-month working experience, and 3) willingness to participate in the study.
The participants in the patient group were selected based on the inclusion criteria of the patient sample: 1)
willingness to participate in the study, 2) ability to establish communication, 3) literacy, and 4) older than 15
years of age. The exclusion criteria for the patients were poor speech ability, hearing difficulty, language
impairment following a stroke, and intubation.
The subjects were selected from hospitalized patients. After explaining the objectives of the study, an informed
consent was obtained and the patient was given a questionnaire, which was collected after 1 hour. The patient
sample was randomly selected from medical, surgical, and emergency wards.
2.5 Statistical Analysis
For data analysis, descriptive and inferential statistics (Binomial, Mann-Whitney, and Friedman tests) were used
and SPSS version 14 was utilized. P-value less than or equal to 0.05 was considered statistically significant.
3. Results
3.1 Demographic Characteristics
According to the results, the mean age of the nurses was 30.95 yrs, and the mean working experience was 7.02
yrs. The mean age of the patients was 29.30 yrs and the mean of hospitalization days was 2.3 days. Tables 1 and
2 show the demographic characteristics of the subjects.

Table 1. Demographic characteristics of nurses

Variables N (%)
Gender Female 67 (95.7)
Male 3 (4.3)
Marital status Single 21 (30)
Married 46 (65.7)
Divorced 3 (4.3)
Education level Bachelor 65 (92.7)
MSc 4 (5.7)
PhD 1 (1.4)
Work shift Morning 11 (15.7)
Evening 2 (2.9)
Night 4 (5.7)
Evening and night 3 (3.4)
Circulating 50 (71.4)
ward Medical 20 (28.6)
Surgical 25 (35.7)
Intensive Care Unit 14 (20)
CCU, ICU, Dialysis

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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 2. Demographic characteristics of patients

Variables N (%)
Gender Female 35
Male 15
Marital status Single 3 (6.0)
Married 47(94.0)
Education Primary 10 (20.0)
Secondary 14 (18.0)
Diploma 16 (32.0)
University 10 (20.0)
Hospitalization ward Medical 26 (52.0)
Surgery 20 (40.0)
Emergency 4 (8.0)

3.2 The Most and Least Important Barriers

The findings suggest that among four categories of communication barriers in nurse and patient groups,
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 the most and least important factors, respectively.
3.3 Compare the Nurses and Patients’ Viewpoint
Regarding patient-related factors (P=0.001), nurse-related factors (P=0.012) and environmental factors
(P=0.019), there was a significant difference between the mean scores of nurses and patients (Table 3).

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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most important barriers to communication (Table 4).

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

-Colloquial language differences between nurse and

patient 1 -Gender differences between nurse and 1
-Cultural differences between nurse and patient patient

-Gender differences between nurse and patient -Cultural differences between nurse and
2 patient 2

-Colloquial language differences

3 between nurse and patient 2
-Age differences between nurse and
patient 3
Nurse-related factors Nurse-related factors

-Being overworked 1 -Reluctance to communicate with the 1

patient

-Shortage of nurses 2 -Lack of understanding of the needs 2

and status of the patient
-Being overworked
-Lack of time 3 3
Patient-related factors Patient-related factors

- Family interference 1 -Anxiety, pain, and physical discomfort 1

of the patient

-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

Environmental factors Environmental factors

-Critically ill patients in the ward 1 -Hectic environment of the ward 1

-Hectic environment of the ward 2 -Critically ill patients in the ward 2
-Unsuitable environmental conditions 3 -Unsuitable environmental conditions 3

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

Nurse's lack of knowledge regarding 2.25±0.72 2.28±0.89 0.508

communication skills
Nurse's low self-esteem 2.38±0.85 1.96±1.05 0.024*

Negative attitude of the nurse towards the 2.28±0.90 2.15±1.13 0.834

patient
Nurse's reluctance to communicate with the 2.40±0.84 2.48±0.86 0.451
patient
Nurse's insufficient knowledge about the 2.27±0.92 2.44±0.93 0.170
needs and status of the patient
Nurse's unpleasant experiences of previous 2.24±0.74 1.69±1.01 0.003**
encounters with patients
Relationship between other health care 2.16±0.77 2.00±0.87 0.306
team members and the nurse
Shortage of nurses 2.67±0.68 2.30±0.90 0.019*

Being overworked during the shift 2.70±0.53 2.35±0.91 0.056

Lack of enough time 2.62±0.64 2.04±1.03 0.001**

Working multiple jobs and fatigue 2.44±0.75 2.06±1.14 0.105

Poor economic status of the nurse 2.36±0.76 1.50±1.24 0.000**

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

Anxiety, pain, and physical discomfort of 2.30±0.71 2.32±0.87 0.578

the patient

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family’ interference 2.39±0.69 1.90±1.11 0.026*

Patient’s companions 2.06±0.76 2.02±1.02 0.209

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**

*P≤0.05 was considered statistically significant.

**P≤0.01 was considered statistically significant.

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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body function (Bridges et al., 2013).

Evaluation of the viewpoints of nurses and patients showed that among nurse-related barriers, being overworked,
shortage of nurses, and lack of time were the most important barriers for the nurse group. Also, the nurses’
unwillingness to communicate, and lack of understanding of patients' needs were the most important barriers
from the patients' perspective. Shortage of nurses increases the work load, and therefore, there is not enough time
to establish a good therapeutic relationship (Park & Song, 2005); also, nurses' low income has been mentioned as
a barrier to nurse-patient interaction (Aghamolaei & Hasani, 2011; Baraz et al., 2010; Mendes, Trevizan,
Nogueira, & Sawada, 1999). Stress, being overworked, and lack of welfare facilities could decrease nurses'
satisfaction and quality of health care provision (Nayeri, Nazari, Salsali, & Ahmadi, 2005). Based on the results
of the study by Park and Song, being overworked is a nurse-related communication barrier, which affects the
quality and quantity of the relationship between nurses and patients (Park & Song, 2005).
In the present study, comparison of the viewpoints of nurses and patients regarding patient-related barriers
showed that interference by family, patients’ unawareness of the status and duties of the nurses, patients’ physical
pain, discomfort, and anxiety, lack of attention, and the presence of patients’ companions were the most
important factors; these results were considerably consistent with previous studies (Aghabarari et al., 2009).
Definitely, the patient’s disease and dependence after hospitalization result in anxiety, tension, and fear in the
patient; moreover, the patient's family also experiences a difficult time and has different needs and demands.
Negligence of the patient and the family of the status and duties of nurses leads to misconceptions about the
nurses’ role in the improvement or deterioration of the patient’s health and may even result in the patient’s death.
If nurses are not successful in establishing an effective communication with the patients, they can apply
communication facilitators; if they still do not succeed, they can explain the problems to the patients so that they
can obtain positive treatment results without having a good communication (Ammentorp, Sabroe, Kofoed, &
Mainz, 2007).
Nurse is considered the direct care provider and the smallest delay in care provision will be considered as
medical negligence. However, it is quite obvious that a medical team consisting of physicians, nurses, clinical
departments, and even medical center crew are all responsible for the patient's health care. Thus, given the direct
relationship between nurses and patients, the image created by nurses affects their being accepted as professional
staff, and their role will be highlighted in establishing an effective communication (Aghabarari et al., 2009).
In terms of environmental barriers, the presence of critically ill patients in the ward, the hectic environment of
the hospital, and unsuitable environmental conditions are considered the main barriers in both groups. The
findings of previous studies confirm the aforementioned results. The shortage of nurses and the presence of
critically ill patients in the ward cause a lot of stress for the patient and lead to decreased ability and motivation
to communicate with other patients; on the other hand, medical environment conditions have great effects on the
quantity and quality of communication (Bartlett et al., 2008). Factors disturbing the communication process can
be improper temperature, excessive noise, poor ventilation, and lack of respect for the privacy of the two sides of
the relationship (Mendes et al., 1999). Thus, providing a safe and comfortable environment leads to
psychological and physical comfort of the nurse and patient, and facilitates using communication skills and
establishing an effective communication.
One of the limitations of this study was the low number of male nurses. Another limitation was lack of
evaluation of cultural forces operating between patients and nurses, regardless of the country of origin or
background in the hospitals (active, passive, or power relationships). It is recommended that future studies pay
more attention to communication facilitators and divide the participants to male and female groups. It is also
suggested that religious and cultural beliefs as well as language barriers be more thoroughly evaluated in patients
and nurses.
5. Conclusion
The purpose of any system is to provide services with optimal quality and quantity, and health care systems are
no exception. One of the best ways to gain the patients’ satisfaction, as major clients of health care systems, is
through establishing effective and appropriate communication. Thus, according to the results of this study and
previous studies, the following measures will be considerably helpful in establishing an effective nurse-patient
communication: allocation of medical staff with regard to the language and culture of the region, motivating
nurses to provide high-quality health care services, upgrading medical clinics and facilities, holding periodic
workshops of communication skills, holding nursing quality assurance committees, and most importantly,
changing attitudes of nursing managers and administrators from offering task-based services toward following a
holistic approach.

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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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