Are Patient’s Satisfied With Nurses’ Communication? A Cross Sectional Survey

Background: Patients visiting a hospital specially cancer patients are vulnerable and in pain. Communication during this stage is different as they are dependent on health care professionals for their physical and communication needs. Nurse’s communication plays a key role in patient’s satisfaction. Therefore, this study aimed to assess patient satisfaction regarding communication received from nurses. Methodology: A descriptive survey method was used. Likert scale was developed to elicit information. The tool was translated in two local languages. Patients were selected using non-probability convenience sampling technique. Data was collected using selfreport method and face to face interview for patients who were illiterate. Results: Seventy-seven patients participated in the study. Maximum (50%) patients were between 46-65 years of age and around 64% were male. With regard to their education, there were 17 percent patients who were illiterate. There was overall satisfaction with regard to nurse’s communication. Fifty two percent and 47 percent of patients responded that they are extremely satisfied and satisfied with nurse’s communication respectively. Forty three percent of patients felt that they always felt nurses should spend more time communicating with them and few of them mentioned that they always (15%) and sometimes (18%) feel frustrated due to lack of communication. Among the patients who felt frustrated due to lack of communication, 91 percent (n=10) also felt that nurses should spend more time with them and this result is significant (p<0.05). There was no association between level of satisfaction and demographic variable. (p>0.05) Conclusion: Awareness and understanding of each patient’s communicative preferences will allow healthcare professionals to adapt to the patient’s state of mind and thus greatly facilitating the communicative process. Therefore, training in communication skills as a part of their induction and in-service program is essential; this training can be imparted through self-instructional module, lectures or interactive video applications. Nursing Implications: The activity of nurses for e.g. Talking or listening to the patients, usually exceeds other activities such as care related procedures. Thus, communication can be viewed as a core clinical skill that requires considerable investment in terms of time and resources to train them in communication skills. Nursing administrators need to remember that persistence in training is necessary to improve nurse’s communication skill and patient satisfaction.

in 2004 Harris Poll where key factors that contribute to patient satisfaction in rank order were that a) they are treated with dignity and respect, b) care providers listen carefully to their health concerns, c) the care provider is easy to talk to, d) the care provider takes their concerns seriously, e) the care provider is willing to spend enough time with them, and f) the care provider truly cares about them. It is clear that nursing care and communication go hand in hand. Risser first proposed a definition of patient satisfaction with nursing care, which was described as "the degree of congruency between a patient's expectations of ideal nursing care and his perception of the real nursing care he receives" [3] Patient satisfaction or patient experience implies patient's perception or judgement of the care received during the stay in the hospital [4] Communication during this stage is different as they are dependent on health care professionals for their physical and communication needs. It is noted that nurses often missed cues that patient needed someone to listen to their concern [5]. Patients often sensed an atmosphere of indifference on the part of the nursing and medical staff and frequently remained uninformed about the results of care. Lack of space and peace and quiet were also fairly common complaints [6]. Although the dangers of "poor communication," are evident: "poor communication" is a primary reason for filing a law suit in >80% of cases [7]. People relate to nurses. Patient should feel that nurses genuinely care for them. In most of the cases being genuine and caring comes natural to the nurses. Yet nurses need to showcase their talents, abilities and knowledge while dealing with patients, thus leaving a lasting impression on patient.
Satisfaction is based on how patient was treated while in hospitals. Nurses are on frontline of patient interaction and can make a patient feel respected or can provide a negative experience for patients. Patient's expectations are influenced by various forms of suffering and can change during the course of hospitalisation and can vary from culture to culture, state to state or region to region. A good night sleep, caring nurses who attend to their needs without causing undue delays or causing patient to suffer in agony, a nurse who has a pleasant expression, is helpful and empathetic is what most patients expect. Patient expectation of care and attitude greatly contribute to satisfaction. Therefore, nurse's communication plays a key role in patient's satisfaction. Communication may occur verbally or non-verbally with a patient. Communicative behaviours of nurse like empathy, touch and comforting are essential in cancer patients, but few studies reveal that communication in oncology care setting is complicated by emotional laden issues due to life threatening character of the disease and side effects of medical treatment. This results in barriers to effective communication between patient and the nurse [8]. Research has identified good communication skills to be a key factor in ensuring better patient outcomes, and nurturing patient satisfaction [9]. Poor communication can leave patients lacking the confidence required to be a competent collaborator in their own care and affect their perceptions of the service [10]. Therefore, this study aimed to assess the patient satisfaction regarding communication received from nurses.

Methods
A cross sectional survey method was used for this study. The survey was a part of a major study approved by Institutional Review Board (IRB) at ACTREC. The major study was "Facilitating Clinical Communication Skills: Development of a training module and testing its efficacy on knowledge and practices in selected aspects of clinical communication skills of nurses in their interaction with patients and healthcare professionals, in an oncology unit in Navi Mumbai". This study was undertaken to identify if patients were satisfied with nurse's communication after the intervention in the major study. The study was conducted at The Advanced Centre for Treatment, Research and Education in Cancer (ACTREC) Navi Mumbai, which is the stateof-the-art Research and Development satellite of the Tata Memorial Centre (TMC). For patient satisfaction feedback questionnaire, nonprobability convenience sampling technique was used.
A brain storming session with nurses, talking to patients about their expectations from nurses and literature review helped to identify few key areas which were considered important to elicit patient satisfaction with nurse's communication. This was further developed into a Likert scale. The Data Collection tool (Likert scale) consisted of a structured format and had three sections. Section I had four items related to demographic variables of the patients i.e. age, gender, education of patient, and the department they were admitted. Section II included a structured questionnaire with 10 statements using threepoint Likert scale (Always, Sometimes, Never) to elicit response from patients about nurse's communication with them. The statements focused on the communication behaviour of the nurses during their interaction with the patients. Section III had one statement using a five-point Likert scale to elicit information about their overall level of satisfaction with nurse's communication. Content validity of the patient feedback was established by giving it to eight nursing experts, one clinician, one language expert and one communication expert. Suggestions were incorporated wherever required. Thus, the content validity of the tool (instrument) was established. After establishing content validity, patient feedback and satisfaction questionnaire was translated from English to Hindi and Marathi and from Marathi and Hindi to English by two experts. Same tool was administered to patients and parents of the children being treated in Out Patient and In-Patient Department at our institution. Patients, who were registered with our institution, were willing to participate, and could read and write English, Hindi or Marathi was included in the study. Purpose of the study was explained to them. Data was collected by using self report method was used for patients/parents of children who were able to read and write English, Hindi or Marathi, and by face to face interview for patients/parents of children who were illiterate. Their responses were recorded by the researcher.
Statistical analysis was carried out using SPSS software, version 21. To assess the patient satisfaction regarding communication received from nurses, descriptive statistics (frequency and valid percentage) was used and inferential statistics (chi-square and Fischer exact test) was used to identify association between the responses and demographic variables.

Demographic variables
Half of the patients were in the age group of 46 -65 years, while 14% of respondents were parents of children below the age of 15 years. Majority (64%) of patients were male. Nearly 33% of patients were graduates/post graduates, while 17% were illiterate. Length of stay of inpatients varied from 1 day to 67 days with a median of 7 days. Around 50% of patients were from surgical unit while 25% and 26% were from DayCare and medical unit respectively (

Patient's feedback related to nurse's communication:
Majority (86%) of patients responded that the nurses always greet them. Around (96%) mentioned that nurses' spoke in a language they understood, maintained eye contact (92%), asked about their condition (97%) and were polite while conversing (98%). Most (96%) patients mentioned that they were explained prior to procedure/investigation/ medicines. With regard to nurses spending time with them, around forty three percent of patients expressed that they always felt nurses should spend more time communicating with them and around 1/3 rd patients were frustrated due to lack of communication ( Figure 1).
Among the patients who felt frustrated (n=23) due to lack of communication, 96 percent (n=22) also felt that nurses should spend more time with them (p<0.05) ( Table 2).

Overall satisfaction
There was overall satisfaction with regard to the nurse's communication. Fifty two percent and 47 percent of patients responded that they are extremely satisfied and satisfied with nurse's communication respectively (Figure 2).

Association among variables
The association between level of satisfaction and demographic data is presented in table 3. Overall satisfaction was observed in more than 90% of patients in all age groups. Similar trend was seen with respect to gender, education and departments. There was no association between level of satisfaction and demographic variable (p>0.05). Association of overall satisfaction with nurse's communication, frustrated due to lack of communication and nurses should spend more time with respect to variables were assessed using Fischer's Exact test. There was no association with respect to any of the variables like Length of stay (LOS), Inpatient/outpatient, Private/ general category or Disease Management Group (DMG). None of the factors showed any statistically significant association.

Discussion
Nurses may have good intentions in caring for their patients. However, not communicating the plan of care, or not attending to their      needs and ineffective patient nurses' interaction can be a potential hindrance to patient-nurse communication.
Patients will feel comfortable and accepted when the nurse greets them, thus acknowledging their presence. It also denotes that the nurse is approachable. Another important aspect of communication is speaking in a language the patient understands. India being a diverse country, people speak different languages. Effort should be taken by a nurse to identify the language the patient understands as this is vital for following instructions related to care and also expressing their thoughts and concerns. In this study around 96% patients mentioned that they were explained prior to procedure/investigation/medicines. Moghaddasian in his study found that "Being informed of the treatments provided" was the most important perceived needs [11]. While Leino, reported that 28% of patients had not received enough information during their stay in the hospital, whereas Messina's analysis indicated that "receiving continuous information" and "explaining about delay" significantly influenced overall satisfaction [12]. Patients are more satisfied when nurses have time for them. Around forty three percent of patients expressed that they always felt nurses should spend more time communicating with them and around 1/3 rd patients were frustrated due to lack of communication. This finding is also consistent with a study conducted by Ben-Ami et al. In their study, interviews with discharged patients revealed that as many as a quarter of those who could remember their hospitalization reported feelings of anxiety, anger, distrust in the staff and difficulty in communication [13]. Thi et al also noted that the nurses did not allow enough time for communication. This may be due to work overload or they are too busy to respond to patient's needs. Nursepatient communication barriers can also be due to age, sex and language difference between patient and nurse [14,15]. These findings suggest that the nursing staffs need to improve their communication skills. Judicious use of communication techniques may improve patient satisfaction, reduce anxiety and reduce duration of treatment. Effective communication between nurses and patients is one of the most important elements for improving patient satisfaction, treatment compliance and health outcomes [16]. The patient, who is the crux of all interaction, should be updated with information relevant to them and involved in decision-making, which may help in reducing errors and create a sense of well-being and satisfaction [17]. Since patient satisfaction is patient centric, positive experience a patient encounters, will leave the patient with a positive note and thus a lasting impression about the nurses and hospital. Satisfaction affects clinical outcomes. A satisfied patient will heed to follow up instructions and treatment plan.
A factor common to many patient satisfaction surveys is that very few patients express dissatisfaction or are critical of their care [18]. Patients expectations from nurses is varied and therefore it is difficult to define patient satisfaction, as satisfaction for some patients may be providing timely care, whereas for some patients it may be related to courtesy, spending time with them or speaking in a language they understand. Therefore, nurses should take efforts to make patients feel unique, involve them in decision making and keeping them abreast with information about treatment/care which in turn may help to improve patient satisfaction.
Audits on nurses' communication, will help in obtaining feedback from patients and correct shortcoming if any. Patient satisfaction should be at the heart of patient care, with a strong focus on effective communication skills, which in turn will help to identify ways to improve nursing practice and these translate into better care and happier patients. More research is needed to continue to define and improve patient satisfaction. Nurses should learn to manage time effectively so as to complete the various and varied tasks that fall into their responsibility. Finding time to avoid showing rush, to collect vital diagnostic facts, to coach patient, and to ascertain therapeutic relationships remains a major challenge for each nurse [19]. Nurses need to strive to provide better care and soar above each and every patients expectation. When needs are unmet, if it's often reflected through angry letters, feedbacks, mails and poor patient satisfaction scores. By communicating better with their patients, nurses will not only improve patient satisfaction, they will improve their own job satisfaction as well. Awareness of each patient's communicative preferences and understanding their preferences will allow nurses to adapt to the patient's state of mind greatly facilitating the communicative process.

Nursing Implication
Nurse's focus on care related procedures as part of their nursing activity and less attention is given to talking or listening to patients. Availability and visibility, use of jargon free language, providing opportunity to clear their doubts and queries and nurses ability to respond are also important activities of a nurse which will contribute to patient satisfaction [20]. Implementing regular nursing rounds and use of SBAR technique during transition of care(17) will help nurses to have a focused, easy communication and can have a positive impact on patient satisfaction, since it may improve patient-nurse interactions and promote the quality of nursing care and patient satisfaction [21]. Thus, communication can be viewed as a core clinical skill that requires considerable investment in terms of time and resources to train them in communication skills. Communication within the health service can be improved with a robust leadership, focusing on implementation of policies and procedures and by improving welfare facilities for nurses [22]. Nursing administrators need to remember that persistence in training is necessary to improve nurses' communication skill and patient satisfaction. Nurses have the opportunity to demonstrate that what they do definitely makes difference. Good communication can have a positive effect especially for a patient with cancer, while poor communication can have an opposite effect both with the patient and the healthcare personnel. Patients believe caring is demonstrated when nurses respond to specific requests. Thus, patient satisfaction will be improved if nurses can adapt their work to accommodate patients require or communication why these requests cannot be met. Awareness of each patient's communicative preferences and understanding their preferences will allow healthcare professionals to adapt to the patient's state of mind greatly facilitating the communicative process. Therefore, training in communication skills as a part of their induction and in-service program is essential; this training can be imparted through selfinstructional module, lectures or interactive video applications.

Study Limitation
The limitation of the study is the lack of generalization of the findings. A structured questionnaire using self-report techniques was used to elicit information. In-depth information could have been on quality of nursing care which is an important component of patient satisfaction. Also, other factors that may influence patient satisfaction, such as nursing competence, clinical experience, nurse patient ratio and period after admission has not been considered.

Financial Support And Sponsorship
Nil