Communication Barriers Perceived by Nurses and Patients

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.

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.

Study Design
Cross sectional, descriptive analytic study.

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.

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.

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.

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.

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 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.

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). 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 most important barriers to communication (Table 4).

Factors common between nurses and patients
-Colloquial language differences between nurse and patient -Cultural differences between nurse and patient -Gender differences between nurse and patient 1 2 3

Factors common between nurses and patients
-Gender differences between nurse and patient -Cultural differences between nurse and patient -Colloquial language differences between nurse and patient -Age differences between nurse and 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).

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 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.

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.