BMC Nursing volume 18, Article number: 4 (2019) Cite this article Show
AbstractBackgroundTherapeutic communication is essential in the provision of quality healthcare to patients. The purpose of this study was to explore the perceived barriers to effective therapeutic communication among patients and nurses at Komfo Anokye Teaching Hospital,Kumasi. MethodsAn exploratory study design was employed using a qualitative approach. A purposive sampling technique was used to select 13 nurses and patients who were interviewed using an unstructured interview guide. Interviews were audio-taped, transcribed verbatim and analyzed using thematic content analysis. ResultsPatient-related characteristics that were identified as barriers to effective therapeutic communication included socio-demographic characteristics, patient-nurse relationship, language, misconception, as well as pain. Nurse-related characteristics such as lack of knowledge, all-knowing attitude, work overload and dissatisfaction were also identified as barriers to effective therapeutic and environmental-related issues such as noisy environment, new to the hospital environment as well as unconducive environment were identified as barriers to effective therapeutic communication among patients and nurses at Komfo Anokye Teaching Hospital,Kumasi. ConclusionNurse-patient communication is an inseparable part of the patients’ care in every health setting; it is one of the factors that determine the quality of care. Several patient-related characteristics, nurse- related characteristics and environmental-related issues pose as barriers to effective therapeutic communication at Komfo Anokye Teaching Hospital,Kumasi and have ultimately; resulted in reducing effective communication at the wards. Therefore, all the barriers must be eradicated to promote effective therapeutic communication. Peer Review reports BackgroundTherapeutic communication is essential in the provision of quality healthcare to patients. According to the American Nurses Association [1], nurses serve the role as patient advocates and must, therefore, preserve a therapeutic and professional nurse-patient relationship in their professional role with specific boundaries to their role. This makes it necessary that nurses adopt techniques in interacting with patients within the clinical setting which is an important part of their work in the provision of healthcare to patients. Therapeutic communication involves a direct face to face contact with patients that focus on enhancing the physical and emotional well-being of patients [2]. A variety of techniques are used by nurses in communicating with patients. In therapeutic communication, there is a verbal and non-verbal flow of information between nurses and patients [3]. The verbal aspect of communication employs the use of words whilst non-verbal communication makes use of non-verbal cues such as eye contact, body language, and facial expression [3]. Bournes and Mitchell [4] state, “Health is the way people go on and live what is important to them, moment to moment and day to day”. The recognition of effective therapeutic communication as a critical part of healthcare provision has been highlighted in several studies [5]. Therapeutic communication has the potency of increasing patients’ knowledge and understanding, enhancing trust and self-health skills, increase adherence, providing comfort and facilitating the management of emotions key to patients’ health and well-being [2]. Again, it has been well documented in several studies that medical practice is affected with the quality of communication between patients and clinicians as more medical errors occur with less effective communication within the clinical setting [6, 7]. Nevertheless, several factors such as the environment/surroundings, circumstances and timing affect the restorative and soothing facets of patients that give significance to therapeutic communication [8]. For instance, in emergency cases where there will be little time for verbal interaction, the use of non-verbal cues such as the holding of hand could carry much more words to patients [8]. Even in cases where nurses are much experienced in therapeutic communication, there can still be a gap in communication as sometimes it becomes difficult to understand patients from their own viewpoints [8]. Therefore, this study sought to investigate the barriers to effective therapeutic communication among patients and nurses at the Komfo Anokye Teaching Hospital in Kumasi. MethodsStudy siteKomfo Anokye Teaching Hospital (KATH) is a tertiary health facility premise in the environs of Kumasi within the Ashanti Region and ranked as the second largest hospital in Ghana. Komfo Anokye Teaching Hospital (KATH) has a bed capacity of about 1000 with twelve (12) clinical directorates providing healthcare services to the people within the region as well as handling referrals from other closer regions. Study designThe study employed an exploratory based design which followed a qualitative approach to investigate Nurses’ and Patients’ experiences and views on the barriers to effective therapeutic communication to serve as a springboard for further studies. Study populationThe study population included patients and nurses at Komfo Anokye Teaching Hospital. Inclusion criteriaParticipants included in the study were individuals who had been admitted for a minimum of 3 to 4 days. This meant that participants would have communicated regularly with the nurses during their stay. Registered nurses employed full-time and having worked for four months or more at KATH were also included. Exclusion criteriaUnconscious and patients who had not been on admission for up to a minimum of 3 days were excluded from the study. Nurses who were not full time and had not worked for more than 4 months were also excluded. Techniques, instruments for data collection and analysisAn in-depth interview guide was used as the data collection instrument to gather in-depth information from participants. The interview guide allowed the researcher to probe further in order to understand and explore participant contributions in as much depth as possible. An unstructured interview guide which followed an open-ended approach permitted the in-depth investigation of experiences and views regarding nurse-patient communication. The interview guide contained interview questions on the demographic profile of nurses and patients as well as interview questions on Nurse-related barriers; Patient-related barriers and Environmental-related barriers to Therapeutic Communication. The interview days and time were discussed with participants and each interview was scheduled at their convenience. Interviews were then audio-taped so that participants’ responses could later be transcribed verbatim. The researcher used two weeks for data collection (3rd March to 17th March 2016) with each interview lasting approximately 45 to 60 min. The collection of data was done by two of the authors (sixth and seventh authors) and assisted by two (2) research assistants. Participants were informed about the time before commencement. The data collected was then transcribed verbatim and analyzed through thematic content analysis. This was done by listening to tape recordings and transcribing the content. The transcript was coded by going through the transcript line by line and paragraph by paragraph, to find significant statements and codes according to the topics addressed. The similarities and contrast within the data were compared by the investigators and data that seemed to cluster together were sorted into categories. Sampling and sampling techniquesThe participants were purposively selected to participate in the study based on the characteristics they exhibited which were of interest to the researchers and were able to provide the needed information. According to Patton [9], the logic and power of purposeful sampling lie in selecting information-rich cases for in-depth study. A sample of 13 participants was used for the study which was made up of 6 nurses and 7 patients. The interviews were conducted till a saturation point was reached after interviewing the 13th participant. Saturation refers to the point at which new data collected and analyzed does not provide further meaning to the research question [10]. Validity and reliabilityTo ensure rigour, or the integrity in which the study was conducted, and ensure the credibility of findings in relation to qualitative research, several steps were taken to enhance the validity and reliability of the study [11]. Firstly, comparisons were done to find out similarities and differences across accounts to ensure that all different perspectives were represented. Also, active and continuous reflection was done by the researcher during the interpretation of data to ensure the quality of the data and to mirror participants’ experiences to add credibility to the study. The context of the research and assumptions central to the study were thoroughly described to achieve transferability. The criteria applied were made explicit, according to the purpose and orientation of the study [12]. Furthermore, other researchers were engaged to reduce research bias and the researchers and supervisor again ensured that the findings, conclusions, and recommendations were braced by the data collected and that the interpretation of the data was meaningful and relevant to the study. Limitations of the studyThe study was conducted at Komfo Anokye Teaching Hospital which is a single facility and therefore the findings cannot be generalized. Some of the participants were not willing to respond to some of the interview questions due to its sensitive nature. However, these limitations did not influence the findings of this study in any negative way. ResultsThematic content analysis was used to analyze data collected based on the aims of the study. The results included background characteristics of study participants as well as the main and sub-themes of the study. Three main themes were derived from the data collected. The themes included; patient-related barriers with sub-themes personal/ social characteristics; patient-nurse relationship; language barriers as well as misconception and pain. The nurse related barriers came with sub-themes such as availability of nurses; inadequate knowledge; all-knowing attitude; dissatisfaction as well as the disease state and family interference. The environmental barriers included sub-themes such as noisy environment; new to the hospital environment and unconducive environment. Background characteristics of study participantsTable 1 shows the background characteristics of the study participants.From the table,five (5) of the study participants were females whiles eight (8) were males. The participants were between the ages of 20 and 50 years and most of them were between the ages of 20 and 30 years. Moreover, six of the participants were married and seven were single. Most of the patient participants have attained their tertiary education while most of the nurses have attained their degree in nursing. Table 1 Background characteristics of both patients and nurses Full size table Main findingsPatient-related barriersPatient-related barriers are those obstacles directly from patients that inhibit effective therapeutic communication. Sub-themes that emerged are personal/social characteristics, patient-nurse relationship, language barriers, misconception, and pain. Personal / social characteristicsThese included characteristics such as age, religion, ethnicity among others that have the tendency of influencing communication. One Participant revealed that;
One nurse also reported that religious beliefs and culture play a key role;
A greater number of the nurses admitted that the cultural background of patients affected their communications. One echoed;
Patient-nurse relationshipPatient-Nurse Relationship is essential for effective healthcare delivery. In this study, patients complained about their relationship with the nurses and the way the nurses attend to them when they are in need. The nurses also admitted that the kind of relationship between the client and them also influences the level of effective communication. One patient admitted that;
MisconceptionMisconceptions can distort effective communication. One individual may perceive another to be of a certain trait, character or of a certain attitude. Patient revealed that;
PainPain is one thing that can change one’s mood and influence his/her behaviour. Participants verbalized how pain act as a barrier to effective therapeutic communication;
Another participant had this to say:
LanguageLanguage can act as a barrier to any form of communication and effective therapeutic communication is not an exception. Some of the patients complained that nurses mostly resorted to the Twi language when most of the patients have difficulties in understanding Twi.
Ghana is an Anglophone speaking country and most residents don’t speak French. Therefore, if a patient cannot speak English, it will be difficult communicating. Occasionally, foreigners who speak French and other languages and are living in Ghana visit the Hospital. Majority of the nurses commented on how language was a problem to effective therapeutic communication. Nurses complained of having patients from different tribes and countries which makes it difficult for them to communicate effectively.
Nurse-related barriersThis category includes barriers related to attributes of the nurse. These attributes can be barriers in establishing a therapeutic nurse-patient relationship in the hospital. Six sub-themes emerged from it and they are inadequate knowledge, disease state, availability of nurses, all-knowing attitude, family interference, and dissatisfaction. Availability of nursesThe Nurses complained that due to the small number of nurses and the workload it becomes difficult attending to all patients as and when they call. One Nurse revealed;
A patient stressed that;
Another Nurse commented;
Inadequate knowledgeMost nurses admitted and verbalized that, some nurses had little knowledge on how to communicate with others. Lack of knowledge on therapeutic communication on the part of some nurses also contributed to ineffective therapeutic communication. If there is a close relationship between the patient and the nurse, a patient can speak out all their problems to the nurse. One of the Nurses echoed;
All-knowing attitudeAttitude refers to the predisposition to behave in a certain manner. Majority of the nurses verbalized that because some of the patients have stayed at the ward for a long time and in an era where most patients are educated, they think they know more about the nursing procedures and thus, do not adhere to whatever their health care provider says. The nurses revealed;
DissatisfactionWhen one is not pleased with a service provider or a process, it may distort effective communication between the individual and another person. Most of the nurses identified dissatisfaction with services provided by nurses as the predominant barrier to effective communication. One Nurse revealed;
Another echoed;
Disease stateAll nurses verbalized that, the disease state and mental status of patients also affect the level of communication between nurses and patients. One of the Nurses’ commented;
Another Nurse also added;
Family interferenceA family may interfere in a service process in order to influence outcomes. Another problem that the nurses admitted to facing is family interference in most of the procedures at the ward. Also, the kind of behaviour exhibited by clients’ families also affects how they communicate with them. A Nurse said;
Another added:
Environmental barriersEnvironmental barriers are obstacles within the environment that inhibit effective therapeutic communication. Almost all nurses and some of the patients asserted that environmental barriers influence therapeutic communication at the ward. Most of the patients expressed how they felt when things they didn’t expect emerged. Sub-themes that emerged were a noisy environment, new to the hospital environment smell, work overload, mosquitoes, and unconducive environment. New to the hospital environmentAdapting to a new environment can be problematic for some people at times, therefore, influencing their ability to communicate effectively. One Nurse stated;
Noisy environmentNoise can affect any form of communication and in this case therapeutic communication. The issue of noise is reflected in the following;
Unconducive environmentCommunication can be effective only in an environment that is conducive enough for everyone. Participants shared their views on how unconducive the hospital environment is for effective communication. One participant had this to say;
DiscussionsThe study explored the barriers to effective therapeutic communication among patients and nurses in Kumasi. The barriers that were explored include nurses related, patient-related, and environment-related barriers. A key demographic characteristic of patients that were identified as a barrier was age. Similarly, Payne et al., [13], reported that age can serve as a barrier to effective communication. This implies that conditions such as dementia that may set in once you age and causes the level of interpretation and understanding to go down makes it difficult to communicate effectively. Religion was also identified as a barrier as patients who were Muslims would not want females to attend to them but preferred males. People from different parts of Ghana have different cultures and thus patient status, culture, and religion are key barriers to effective therapeutic communication. This implies that religion, age as well as culture has a tendency to influence therapeutic communication. There may be cases where both may belong to the same ethnic group, however, different social orientations and circumstances may affect their communication. Payne et al., [13], also found generational gaps between the elderly and young nurses as key barriers to effective communication. However, culture and ethnic group were not mentioned by Payne et al., [13], but reported by Anderson et al., [14] who emphasized that nurses in interacting with patients from different backgrounds should be sensitive, effective and attach professional attitude. Language was also identified as a barrier to effective therapeutic communication in this study. Similarly, Quesada [15] reported that in general, the majority of the nurses and patients report that language barrier is an impediment to quality care. The findings corroborate with this study results where patients complained that nurses mostly resort to the Twi language when some of the patients had difficulties in communicating in Twi. Nurses also complained of having patients from different tribes and countries which also makes it difficult for them to communicate effectively. This study reports that patients complained that they feel like they have been neglected by nurses because they do not promptly attend to them while nurses also complained that, due to the small number of nurses and the workload it becomes difficult attending to all patients as and at when they call. This gives credence to the findings that heavy work schedules of nurses, tough and intensive nursing tasks and the absence of welfare facilities for nurses obstruct communication as reported by Anoosheh et al., [16]. This study reported that several patients complain about their relationship with the nurses and lack of attention. Teutsch [17], reported that nurses undivided attention for patients as they listen to them and observe them gives patients a high level of satisfaction. Interactions with patients therefore eliminate scary thoughts, doubts, and misinterpretations. The researchers do believe that if there is a close relationship between the patient and the nurse, the patient can voice out all their problems to the nurse. Loghmani, Borhani, and Abbaszadeh [18] in their studies came to the conclusion that nurse-patient communication is declining due to family interference. This gives credence to this current study reporting that family interference is a barrier to effective therapeutic communication. Most of the patients were dissatisfied due to inattention on the part of the nurses and this was a predominant barrier to effective communication in this study. In a similar study, the majority of patients that recounted their experiences on nursing care felt dissatisfied due to neglect [19]. According to McQueen [20], patients in a healthcare facility require information,education, encouragement and support, and nurses are in an ideal position to meet this need. ConclusionsNurse-patient communication is an inseparable part of the patients’ care in every health setting; it is one of the factors that determine the quality of care. However, the results of this study have shown that several factors, which are patient-related, nurse- related and environmental-related pose as barriers to effective therapeutic communication and has ultimately, resulted in reducing effective communication which could affect the quality and comprehensive care delivery at the hospital wards. Authorities at the hospital must ensure that all barriers are eradicated to promote effective therapeutic communication. AbbreviationsKATH: Komfo Anokye Teaching Hospital References
Download references AcknowledgementsOur gratitude goes out to the management and staff of Komfo Anokye Teaching Hospital, Kumasi as well as all patients and nurses who took part in this study. Further thanks to all whose works on therapeutic communication helped in putting this work together. FundingThere were no external grants received for the conduction of this study. Researchers of this study bear all expenses related to the study. Availability of data and materialsThe whole document, data, materials, and results of this work are available at the Library of the Garden City University College, Kumasi. If someone wants to request the data the corresponding author should be contacted. Author informationAuthors and Affiliations
Authors
ContributionsThe collection of data was done by sixth and seventh authors (EO and GKB). The secondary data compilation, data analysis, and interpretation were done by the second author (RA). The first and third authors (VMKA and EA) in their individual capacities reviewed the manuscript thoroughly. Authors DSB, ABA, CY and JOA played a significant role during data collection, data analysis, and interpretation. All authors contributed to the designing, preparation of manuscripts, the analysis of the data, proofreading and the final approval process of the manuscript. The authors all approved the submission of this manuscript for publication. Corresponding authorCorrespondence to Reindolf Anokye. Ethics declarationsEthics approval and consent to participateThe study was approved by the Committee on Human Research, Publication and Ethics (CHRPE) at Komfo Anokye Teaching Hospital (KATH) and Kwame Nkrumah University of Science and Technology (KNUST). The participants were reassured that information taking will be confidential. Participation was voluntary and participants were informed of their right to pull out of the study at any point of the research which was not going to affect the care they were receiving. Written consent was obtained from participants before they participated in the study. The study was well explained to the participants and also the recording tape was locked to prevent other people from getting access to it. All the participants were given pseudonyms to protect their anonymity. All authors have agreed to the submission of this manuscript for publication. Consent for publicationNot Applicable. Competing interestsThe authors declare that they have no competing interests. Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Rights and permissionsOpen Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Reprints and Permissions About this articleCite this articleAmoah, V.M.K., Anokye, R., Boakye, D.S. et al. A qualitative assessment of perceived barriers to effective therapeutic communication among nurses and patients. BMC Nurs 18, 4 (2019). https://doi.org/10.1186/s12912-019-0328-0 Download citation
Keywords
Which interaction by the nurse could be considered inappropriate in some cultures?In nursing practice, touch is therapeutic and helps to build a trusting relationship between nurse and client. According to the Western tradition, moderate touch conveys caring. In other cultures, however, touch may be considered taboo.
In which nurse patient interaction would it be appropriate for the nurse to consider using touch?Touch is a powerful way to professionally communicate caring and empathy if done respectfully while being aware of the patient's cultural beliefs. Nurses commonly use professional touch when assessing, expressing concern, or comforting patients.
What are some challenges nurses face in communicating effectively?Sometimes, the sheer volume of information a patient needs to hear can be one of the main communication challenges in nursing. Trying to absorb lots of information in one sitting may make it difficult for your patients to take everything in. Especially when they are upset, distressed or in shock.
What are the 7 nonverbal communication?These nonverbal communication types are facial expressions, gestures, paralinguistics (such as loudness or tone of voice), body language, proxemics or personal space, eye gaze, haptics (touch), appearance, and artifacts.
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