Perceived barriers to effective therapeutic communication among nurses and patients at Kumasi South Hospital

Abstract Effective and skillful communication is a crucial and an important element when it comes to the quality of care. The aim of the study was to examine the perceived barriers to effective therapeutic communication among nurses and patients at Kumasi South Hospital. The study employed a descriptive study design using a quantitative approach to collect data. The study population was made up of registered general nurses and patients at the emergency, medical, surgical and recovery units of Kumasi South Hospital who were conveniently sampled. A sample of 72 registered general nurses and 40 patients were used for the study and data was collected by administering structured closed-ended questionnaires. The findings revealed that workload on the part of nurses and anxiety, pain and physical discomfort of the patient were the main perceived barriers to therapeutic communication. No significant difference was found in perceived barriers between the male and female groups (t = −1.382, p = .149) and perceived barriers among different age groups of respondents (F = 1.132, df = 3, p = .171). The hospital authorities should ensure that nursing workload is reduced in order to facilitate effective therapeutic communication.


PUBLIC INTEREST STATEMENT
The interaction between a nurse and a patient goes a long way to influence treatment outcomes. This study was conducted to clarify some of the obstacles that may prevent a nurse from interacting with a patient or vice versa at a health care setting. The results revealed that workload, anxiety, pain and physical discomfort are some of the obstacles that may prevent a nurse from interacting with a patient or vice versa at a health care setting. Therefore, authorities should put measures in place to reduce workload for nurses.

Introduction
Communication is a multidimensional, complex and dynamic process (Sheldon, Barrett, & Ellington, 2006). Failure to communicate effectively is a major potential obstacle in the provision of standard services in caring settings. This can result in anxiety, misunderstanding, misdiagnosis, possible maltreatment, exposure to complications, increased length of hospital stay, waste of resources as well as dissatisfaction and therefore possible misplacements as a result (Pronovost et al., 2003).
Therapeutic communication refers to the face-to-face process of interacting that focuses on advancing the physical and emotional well-being of a patient (Fleischer, Berg, Zimmermann, Wüste, & Behrens, 2009). Effective and skillful communication is a crucial and an important element in the quality of care (Fleischer et al., 2009). Employing effective therapeutic communication skills is a valuable tool to assess patients' needs and provide them with the appropriate physical care, emotional support, knowledge transfer and exchange of information (Caris-Verhallen, Kerkstra, & Bensing, 1999).
High standards caring behaviors may be as a result of appropriate nurse-patient communication that will lead to effective health promotion and therefore patient satisfaction (Caris-Verhallen et al., 1999).
Despite strong emphasis on training and improving the caregiver's communication skills, there are still obvious shortages and therefore good communication is restricted by a number of structured factors (Fleischer et al., 2009).
Therapeutic communication strengthens the nurse-patient relationship and creates a good atmosphere for healthcare delivery (Fleischer et al., 2009). Therefore, ineffective nurse-patient communication may lead to dissatisfaction with care, misdiagnosis, misunderstanding, uncertainty and frustration for both parties. Information on communication barriers is therefore necessary to identify possible causes of nurse-patient communication pit falls. Some studies have reported positive outcomes when communication was effective, consequently leading to adherence to treatment and patient involvement in their own care (Kullberg, Sharp, Johansson, & Bergenmar, 2015).
Although the quality of therapeutic communication is thought to predict patients general satisfaction, the barriers to effective therapeutic communication has not been examined using valid and reliable instrument in several public health care facilities in Ghana.
Furthermore, there have been serious problems with nurse-patient communication which has been expressed by the Ghanaian public, media and stakeholders in the country (Osei-Ntansah, 2014).
Moreover, patients now prefer to visit private hospitals instead of public hospitals and this is having a ripple effect on the revenue and image of public hospitals in Ghana generally. Therefore, the study sought to investigate the nurse-related barriers, patient factors and the Health system-related barriers to effective therapeutic communication at Kumasi South Hospital.

Study site
The study was conducted at the Kumasi South Hospital (KSH) which is a regional hospital located within Chirapatre Agogo under Asokwa Sub-metro. Outpatient attendance for the hospital in 2016 was 131,442. It serves various communities especially Atonsu and has a total bed number of 105. The hospital serves as a clinical Centre for medical students, herbal medicine students and nursing students from various Universities such as Kwame Nkrumah University of Science and Technology as well as nursing training colleges.

Study design and population
The study employed a descriptive study design which described the data and characteristics of the population used for the study. A quantitative approach was used because it enabled the researchers to collect numerical data and perform quantitative analysis using statistical procedures. The study population was made up of registered general nurses and patients at the emergency, medical, surgical and recovery units of Kumasi South Hospital.

Inclusion criteria
• Registered nurses who were willing to take part in the study at KSH.
• Registered nurses who have worked for six months and above.
• Patients who communicated comfortably in English and local Akan language.
• Registered nurses who were aged 18 and above.

Exclusion criteria
Registered nurses who have worked for less than six months at the emergency, medical, surgical and recovery unit of KSH and respondents who were not willing to take part in the study were excluded as well as; • Registered midwives.
• Community health nurses.
• Public health nurses.
• Patients less than 18 years.

Sampling and Sample
Convenience sampling technique was used to select 72 nurses and 40 patients at Kumasi South Hospital for the study. Respondents that were available at the various departments and willing to respond at the time of study were used.

Instruments and data analysis
Data was collected by administering questionnaires. Closed ended questions were used, as this method was less costly, do not consume much time and could be analyzed easily. The structured questionnaires were self-administered and collected after respondents completed them. This helped in getting honest responses.
The questionnaire was divided into five subsections that included the demographic characteristics of nurses and patients; patient-related barriers; health system -related barriers and Nurse-related barriers. Respondents were asked to identify and specify their level of agreement or disagreement in a list of possible patient-related barriers, health system -related barriers and Nurse-related barriers to effective therapeutic communication on a Likert scale of 1 to 5 where 1 = strongly disagree 2 = Disagree 3 = Don't know 4 = Agree and 5 = strongly agree. The responses were analyzed using descriptive statistics such as frequency, percentage and mean.
The entire questionnaires were checked to ensure that they have been answered completely. Data was first sorted into the various categories where the questions were asked and was analyzed using SPSS version 21. The findings were presented in tables and figures.

Ethical consideration
The study was a non-invasive and did not cause any physical harm. Also, respondents who decided to opt out of the study during the course of the study were allowed to do so. The participation of each patient selected was voluntary and under no cohesion, a verbal consent was obtained from each participant.
The ethical standards in the selected institution were adhered to and an introductory letter was sent to the institutions to ask for permission to conduct the study in the institution before using the facility. The Committee on Research at the University approved the study. Ethical clearance was sought from the authorities of Kumasi South Hospital before administration of questionnaires. Sufficient information on the study was made available to respondents to enable them decide to participate without coercion. The research was ethical as much as possible by giving maximum respect to the rights of the respondents. Information obtained from the study subjects was handled as strictly confidential. By anonymity, the names of the respondents were not indicated.

Validity and reliability
To ensure validity and reliability of the questionnaire, samples were given to the research supervisor and administrators of K.S.H for their input. Some additions and omissions were effected after suggestions for necessary corrections. The designed questionnaire was further pre-tested at Manhyia District Hospital which has similar facilities as the study site. The questionnaires were given to 10 selected respondents to answer and after the responses were analyzed, the reliability was calculated to be .827 using Cronbach's alpha correlation coefficient. This suggests that the items had relatively high internal consistency and that the instrument was highly reliable.

Limitations of the study
The study made use of a convenience sampling technique and therefore only the respondents who were available and at the convenience of the investigators were used. Some of the nurses were suspicious of the purpose of the study and therefore were unwilling to co-operate and disclose certain information.
Also one of the researchers works at the facility where the study was conducted and her presence could influence the responses given by some of the respondents However, the outcome of the study was not affected negatively by the limitations.

Delimitations
The study did not include nurses working in other hospitals in the region and only focused on nurses at Kumasi South Hospital due to time. Simple random sampling technique and other probability sampling techniques were not employed for this study and also qualitative data were not used for this study.

Demographic characteristics of respondents
A total of 72 registered nurses and 40 patients at the Kumasi South Hospital took part in the study. The demographic characteristics of study respondents as shown in Tables 1 and 2 had majority of nurses being females (86.1%) whiles a little more than half of patients were females (55%).
More than half (69.4%) of the nurses were within the age group of 26-35 years and the predominant nursing grade was Senior Nurse (41.7%). Most of the respondents worked at the emergency unit (40.3%) and had obtained Diploma in nursing (69%). Half (50%) of the patients were married and majority (65%) had tertiary education. Christians were also dominant (72.5%) among the selected patients (Table 2).

Nurse-related barriers
On the Nurse-related barriers to therapeutic communication, overwork during shifts had the highest mean score of 4.09 as shown in Table 3 and was therefore the major barrier to therapeutic communication whiles some of the least perceived barriers were nurses lack of knowledge regarding therapeutic communication (33.4%), age difference between the patient and the nurse (31.9%) and lack of interest (22.3%).

Health system-related barriers
Workload was identified as the major Health system-related barrier to therapeutic communication by nurses and had a mean score of 4.21 and an average percentage of 87.5% whilst Lack of respect (56.9%) and unfamiliar environment of the hospital to the patients (55.5%) were identified as some of the least perceived health system-related barriers to therapeutic communication as shown in Table 4.
The patients also identified Nurses workload as the major Health system-related barrier to therapeutic communication with a mean of 3.80 and identified busy environment of the ward (noise and traffic) with a mean score of 3.40 as one of the least perceived health system-related barriers to therapeutic communication which is shown in Table 5. Table 6 shows that Anxiety, Pain, and Physical discomfort of the patient was the major patient-related barriers to therapeutic communication with a mean score of 3.85. Some of the least perceived barriers were lack of assurance of confidentiality with an average percentage of 42.5% as well as age and gender difference between nurse and patient.  Table 7 shows the distribution on differences in perceived barriers based on gender.From the table, no significant difference was found in Perceived Barriers between the male and female groups (t = −1.382, p = .149).

Discussions
This research sought to determine barriers to effective therapeutic communication among nurses and patients. The results indicated that shortage of nurses was perceived as barrier to effective therapeutic communication. This support a study conducted by Park and Song (2005), which revealed that shortage of nurses increases work load, and therefore, there is not enough time to establish a good therapeutic relationship. Again negative attitude of the patient towards the nurse, working multiple jobs and fatigue, lack of enough time, being overworked during the shift were also perceived as barriers to Therapeutic Communication. Similarly, Nayeri, Nazari, Salsali, and Ahmadi (2005) agreed that stress, being overworked, and lack of welfare facilities could decrease nurses' satisfaction and quality of health care provision. Other factors included negative attitude of the patient towards the nurse, lack of empathy from nurses and cultural preferences and beliefs. In a recent study conducted by Vida, Eesa, and Fazlollah (2014), to explore the experiences of nurses and patients on communication barriers in hospital cardiac surgical wards using qualitative analysis method, one of the findings that emerged was distrust in competency of nurses (with the subthemes of cultural contrast, less responsible nurses, and their apathy towards the patients).This implies that both nurses and patients can play a role in ensuring that effective Therapeutic Communication is achieved at the hospital setting.
The findings also revealed that anxiety, pain, and physical discomfort of the patient as well as reluctance of the nurse to communicate were some of the patient related barriers to Therapeutic Communication. This corroborates with a study by Aghabarari, Mohammadi, and Varvani-Farahani (2009) who compared the viewpoints of nurses and patients regarding patient-related barriers and  revealed that patients' physical pain, discomfort, and anxiety, lack of attention were among the factors that can serve as barriers. It can therefore be deduced from the research that, patients do not feel comfortable to communicate when in pain.
Use of jargons/technical terms by the nurse as indicated by respondents as a barrier to effective Therapeutic Communication is in line with Desmond and Copeland (2000), who also found that healthcare professionals often distance themselves from clients by using jargon, technical language that may be perfectly appropriate when communicating with other providers, but it is confusing and potentially frightening to the client. They commended that nurses should use language that is easily understood by the average layperson, explaining medical terminology in "plain English" at every opportunity.
Some of the less perceived barriers were lack of trust (40%), lack of privacy (37.5%), loss of confidence in the competence of nurses (45%) and lack of assurance of confidentiality of information (57.5%). This may imply that patients had few issues when it comes to trust and confidence in the nurses. Antipuesto (2015), also added that if patients cannot trust the people delivering their care they may not make the most informed decisions in the care they receive, including refusing certain procedures, or treatment altogether.
Majority of the nurses and patients held different opinions about a list of items presented in the questionnaire that each group perceived as health system-related barriers to effective therapeutic communication. This implies that though such barriers may exist, not all the respondents were privy to such barriers.
A good number of the respondents (62.5%) agreed to the statement that nursing is becoming task-oriented instead of patient-centered. Similarly McCabe (2004) also found that health care organizations do not appear to value or recognize the importance of nurses using a patient-centered approach when communicating with patients to ensure the delivery of quality patient care and thus nurses continue to use the task-oriented approach that is approved by their managers.
It was discovered from the study that busy environment and unsuitable conditions in the hospital environment were among the health system related barriers to effective Therapeutic Communication. Similarly, Bartlett, Blais, Tamblyn, Clermont, and MacGibbon (2008), also identified that the presence of critically ill patients in the ward, the hectic environment of the hospital, and unsuitable environmental conditions are the main barriers to Therapeutic Communication. Mendes, Trevizan, Nogueira, and Sawada (2009), also added that actors 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.

Conclusion
The study concludes that predominantly perceived barriers to effective Therapeutic Communication was work overload on the part of the nurses. On the part of the patients, the commonly perceived barriers to effective therapeutic communication was anxiety, pain, and physical discomfort. Other perceived barriers were resistance and reluctance of the nurse to communicate, misinterpretation of communication by nurse, language barrier and use of jargons/technical terms by the nurse.
Commonly perceived barriers as indicated by both nurses and patients included work overload, busy environment of the ward (noise and traffic) and unsuitable environmental conditions (improper ventilation, heating, cooling, and lighting).
No significant difference was found in Perceived Barriers between the male and female groups of respondents as well as in Perceived Barriers among different age groups of respondents.

Recommendations
The hospital authorities should ensure that nursing workload is reduced in order to facilitate effective therapeutic communication.
The hospital authorities should also ensure that there is a safe and comfortable atmosphere for both nurses and patients that could facilitate effective communication.
Again, more nurses should be employed to meet the nurse-patient ratio and Hospital authorities and unit managers should ensure that nurses use a patient-centered approach when communicating with patients to ensure the delivery of quality patient centered care.
Furthermore, the hospital should have a section where complains could be channeled. This would enable patients to air their dissatisfaction and also comment on some issues at the hospital. This section should be known to the patients and the general public and the process for airing grievances should not be cumbersome.
Also, Nurses should be encouraged by hospital authorities to spend time with patients and speak in simple language they could understand as well as provide frequent in-service training on effective therapeutic communication strategies for all health professionals.