COMMUNICATION SATISFACTION OF PROFESSIONAL NURSES WORKING IN SELECTED PUBLIC HEALTH CARE SERVICES IN THE CITY OF JOHANNESBURG

The purpose of this study was to explore and describe communication effectiveness and communication satisfaction experienced by professional nurses in selected public health care services. Quantitative, explorative and descriptive research was conducted to determine the communication effectiveness and levels of communication satisfaction. The Downs and Adrian (2004) structured questionnaire was adapted and used to collect the data. The study population consisted of three groups of professional nurses, namely nurse managers (n=18), operational managers (n=22) and professional nurses (n=90). The study highlighted areas of effective and ineffective communication, as well as areas of communication satisfaction and dissatisfaction, among professional nurses. The findings revealed that although professional nurses are satisfied with their supervisorsubordinate communication, they are dissatisfied with personal feedback between all categories of professional nurses. Recommendations for the improvement of the communication effectiveness and communication satisfaction of professional nurses are aimed at creating an organisational atmosphere conducive to two-way communication.

ii     (Landman, Mouton & Nevhutalu 2001). This audit included communication as one of its major ethical pillars. Results from this survey underlined the need for this study.
According to Landman et al (2001:xvi), three-quarters (76%) of the staff indicated that there was too little transparency in the hospital, evidenced by rumour (the grapevine) being an important source of information, too little communication between management and staff, and too much secrecy. A substantial proportion of staff (45%) did not believe that employees were allowed to say what they really thought.
Communication between employees and their supervisors was less than optimal and 50% of staff said their complaints had not been acted upon, while nearly two-thirds (65%) said they had not received regular feedback from their supervisors. Fifty-four percent of staff also did not believe that there was a system in place for reporting instances of misconduct. According to 62% of staff, rumour was a common source of information in the hospital, which is another indicator that existing channels of and procedures for communication were regarded as inadequate. Landman et al (2001:xiv) are of the impression, after having analysed the data on management and communication in the audit, that an organisation will be unsuccessful if it does not value participation and consultation in decision making, if views of ordinary staff members do not matter, and if opportunities for constructive communication are limited or non-existent.
A follow-up study conducted by Von Holdt and Maseramule (2005) reported that this hospital still had no internal communications capacity, implying that it did not make provision for formal or informal communication channels. This was one of its many managerial problems, creating justifiable frustration and disempowerment among staff; no health care transformation was evident.

Administrative situations where communication silence is observed often include
situations where managers open new sections and accept additional beds without creating additional posts for adequate patient care; or when organograms are reviewed and the number of chief professional nurse (CPN) posts are reduced, to the extent that their responsibilities are filled by ward unit managers who are junior professional nurses (Zuma 2007:52). This scenario clearly constitutes a closed-door and communicationchannel approach in which the opinion of the junior professional nurse is not valued.
A study conducted by Kekana, Du Rand and Van Wyk (2007:32) on job satisfaction at a community hospital in Limpopo reflected a poor interpersonal relationship between supervisors and employees at the specific community hospital. The respondents in this study indicated their dissatisfaction with the guidance provided by their supervisors and expressed dissatisfaction with the lack of performance appraisals. However, they were satisfied with the opportunity to get to know other people at work and the chance to socialise and communicate with colleagues.
The NDOH admitted in 2007 that it was not blind to its own shortcomings. Due to persistence of poor service delivery and patient care, the NDOH performed introspection in 2007 on its internal affairs, identifying "poor quality information (among other challenges) as a problem in both public and private health care services in South Africa that require immediate addressing and redressing" (NDOH 2007:3).

RESEARCH PROBLEM
In the capacity of professional nurse, the researcher observed that some satisfaction dimensions (such as feedback and proper communication channels) are absent in some of the health care facilities of the NDOH, contributing to communication dissatisfaction amongst the professional nurses in public health care services. Such a situation can lead to miscommunication on important work-related issues, a lack of feedback about performance, poor team spirit and a general sense of non-cohesion.

RESEARCH QUESTIONS
A research question is a concise, interrogative statement that is worded in the present tense and includes one or more variables. The foci of the research questions are to describe a variable or variables, determine the differences between two or more groups regarding selected variables, examine relationships among variables (relational), and to use independent variables to predict a dependent variable (Burns & Grove 2009:167).
The research questions that stemmed from the research problem were: This study explored the question of what constitutes effective organisational communication and determined the level of communication satisfaction of professional nurses working in selected public hospitals in the City of Johannesburg.
The significance of this study was embedded in the fact that once the communication aspects with which professional nurses are dissatisfied have been clearly identified, recommendations can be developed to improve overall formal communication in public hospitals. Improved communication could have several advantages for operational functioning, productivity, interpersonal relations and managerial functioning.

DEFINITION OF TERMS
For the purposes of this study the following terms were defined:

Communication
Communication is a process whereby messages are transferred between senders and receivers via a number of formats (types), such as verbal and non-verbal formats (Concise Oxford Dictionary 2009:289). For the purposes of this study, communication will refer to all types of communication that travel vertically or horizontally in both directions between nurse managers, the NDOH and professional nurses.

Communication satisfaction
Communication satisfaction can be described as an affective feeling, dependent on the level of effectiveness of communication interaction between stakeholders in an organisation (Morele 2005:20-21).
Communication satisfaction in this study referred to the professional nurses' state of being satisfied and the meeting of their communication expectations, needs and desires in public health services during all types of formal communication interactions (vertically or horizontally in both directions).

Nurse Manager (NM)
The term nurse manager (NM) refers to a person who is registered under section 31 of the Nursing Act (Act No.33 of 2005) as a registered nurse. For the purposes of this study the term nurse manager will refer to nurses registered, functioning at middle and top managerial levels within public hospitals in the City of Johannesburg.

Operational Manager (OM)
The term operational manager (OM) refers to a person who is registered under section 31 of the Nursing Act (Act No. 33 of 2005) as a registered nurse. For the purposes of this study the term operational manager will refer to registered nurses functioning at operational (first-level) management levels in public hospitals in the City of Johannesburg.

Organisation
An organisation can be defined as an organised group of people with a particular purpose, such as a business or government department. It further implies the organising and systematic arrangement of elements (Concise Oxford Dictionary 2009:1008). Jooste (2009:52) states that the word "organisation" can refer to several contexts, and suggests that any health care organisation should structure its functions and tasks in an orderly fashion. The tasks referred to in this statement are for all the levels, divisions, units and individuals in the organisation and therefore an organogram (clear description of the plan) is necessary to explain the lines of authority, span of control and assignment of responsibilities.
In this study, organisations refer to the public hospitals resorting under the Department of Health; the concept pertains to all levels, divisions and units therein, where professional nurses are working within the lines of authority, span of control and assigned responsibilities as stipulated by the micro organogram of the specific public hospital or the macro organogram of the NDOH.

1.7.9
Organisational communication Jones (2006:4) describes the study of organisational communication as "a study of how organisation in social collectives is produced and affected by communication; and a system identified by purpose, operational procedures and structure". Organisational communication in this study refers to all types of formal communication travelling horizontally or vertically through all structures, levels, divisions and units of public health services, for different purposes, through operational procedures and structures. This concept is discussed in context and in more detail in Chapter 2 of this study.

Professional Nurse (PN)
The term professional nurse (PN) refers to a person who is registered under section 31 of the Nursing Act (Act No. 33 of 2005), and pertains to "a person registered as such".
For the purposes of this study the term "professional nurse" will refer to nurses 1.9 RESEARCH DESIGN AND METHODOLOGY Polit and Beck (2008:21) define a research design as the researcher's overall plan for obtaining answers to the research question, including specifications for enhancing the study's integrity. It spells out, in advance, the strategies the researcher plans to adopt in order to develop information that is accurate and interpretable.
A quantitative approach utilising an explorative and descriptive design was used for this study. Research methodology refers to the process or plan for conducting the specific steps of the study (Polit & Beck 2008:719). The steps may include the population, sampling and sampling method, data collection, validity and reliability of the instrument, and the data analysis.
The research design and methodology of the study were discussed under the following headings:

Quantitative approach
According to Burns and Grove (2009:717), quantitative research is a formal, objective, systematic process to describe and examine cause and effect interactions amongst variables. A quantitative approach was selected for this study as this study aims to explore and describe interactions among the variables of communication satisfaction.

Exploratory design
An exploratory research design will conduct research into an area or phenomenon that has not been studied (Botma, Greeff, Mulaudzi & Wright 2010:50), and in which a researcher wants to develop initial ideas and a more focused research question (Neuman 2003:535). Furthermore, according to Adler and Clark (2003:12), studies with an "exploratory purpose is aimed at developing a plausible explanation of the variables in the study phenomenon". Thus an exploratory study is the first stage of research and gives the researcher new knowledge on the study phenomenon in order to design a more in depth study.The aims of this study were exploratory in nature and it attempted to explore to what extent the professional nurses in public hospitals are satisfied with the existing formal communication processes.

Descriptive design
A descriptive research design refers to an accurate portrayal or account of the characteristics of a person, situation or group in real life, and/or the frequency with which certain phenomena occur, and implies the categorising of information (Burns & Grove 2009:696). This research sought to describe what constitutes effective formal organisational communication.

POPULATION AND SAMPLE SELECTION
According to Burns and Grove (2009:714), the population of a study refers to all the elements, including individuals, objects or substances that meet the criteria for inclusion in a given universe. The sample refers to a subset of the population that is selected for a study (Polit & Beck 2008:721).

Population
The population for this study consisted of professional nurses (from professional nurse to nurse manager level) functioning in all departments within the three selected public hospitals in the City of Johannesburg.

Target population
According to Burns and Grove (2009:724), the target population consists of a group of individuals who meet the sampling criteria and to which the study findings will be generalised. In order for a respondent to be included in this study, the respondent had to be a professional nurse with at least one year's work experience (in the capacity of professional nurse) in one of the three selected public hospitals.

Sample
A sample of 265 professional nurses, working in selected public hospitals was included, and a disproportionate stratified sampling method was used (Polit & Beck 2008:345-346) for the purposes of this study. dependability with which an instrument measures the attribute it is designed to measure".
The reliability of the Downs and Adrian CSQ (2004) lies in the fact that this instrument has been tested several times in the past. According to Downs and Adrian (2004:139-140), "this CSQ has been the basis for more than 30 PhD dissertations and MA theses" to date, and has been used in a variety of organisations, "including banks, hotels, mental health centres, airlines, hospitals, and police departments".

Pre-test
De Vos, Strydom, Fouchė and Delport (2005:206) state that the pre-testing of a measuring instrument implies trying out the instrument on a small number of persons displaying characteristics similar to those of the target group. A pre-test was conducted on 10 professional nurses in a fourth public hospital, inclusive of the three target population strata and sampling criteria, to assess the time required to complete the questionnaire, as well as the clarity of the questions.

DATA ANALYSIS
Data analysis refers to the categorising, ordering and summarising of data to obtain answers to research questions (De Vos et al 2005:218). The statistical analysis of the data obtained in this survey was performed with the assistance of an independent statistician; the data were analysed by utilising the Statistical Analysis System (SAS JMP version 10.0) statistical software.
Descriptive analysis and frequency calculations were computed first, to report on the distribution of the respondent demographics (Jones 2006:26). Item analysis was then performed to explain variances observed in the eight communication satisfaction dimensions. Cronbach's alpha was computed to test internal reliability and to test whether the communication satisfaction dimensions had been measured in a useful way. Furthermore, a one-way analysis of variance (ANOVA) test was performed in case of statistically significant differences between the three different strata of the study population with regard to communication satisfaction dimensions.

ETHICAL CONSIDERATIONS
Ethical clearance was sought from the Higher Degree Committee of the Department of Health Studies, University of South Africa. Permission was requested from the Director of the Department of Health and Social Development of the Gauteng province, the Chief Executive Officers of the hospitals in which the research was conducted, and from the respondents participating in the study.
Ethical considerations were followed to enhance the protection of respondents in accordance with the DENOSA ethical research criteria (1998:1-4). Permission was also sought from the original creators of the CSQ to adapt and use their instrument for the purposes of this study (Annexure D).
To verify his integrity, the researcher hereby declares that he has acknowledged in full all sources and reference material utilised for the compilation of this research, to avoid the possibility of plagiarism.

Right to self-determination or autonomy
The researcher addressed issues including the freedom of respondents to withdraw from the research at any time. Informed consent was acquired from the respondents after they had been clearly and fully informed about what the research entailed.

Anonymity and confidentiality
According to Bell (2007:48), a promise of anonymity is a promise that even the researcher will not be able to tell which responses came from which respondent.
Informed consent was acquired by means of a separate document from the questionnaire, and was handled separately throughout the study to ensure the anonymity of the respondents.
Confidentiality, according to Polit and Beck (2008:750), refers to the protection of participants in a study, that their individual identities will not be linked to the information they provide and will not be publicly divulged. This information should not be divulged or made available to any other person. This responsibility was adhered to only as far as positive identification of the subjects was concerned.

Right to privacy
Privacy is the freedom of an individual to determine the time, extent and general circumstances under which personal information will be shared or withheld from others (Burns & Grove 2009:715). The respondents in this study were informed that the information they provided would not be shared with their operational managers on the basis of discussing who had said what; such information would only be used when highlighting recommendations, without disclosing respondents' personal information.

Beneficence
Beneficence requires the researcher to actively promote good and do no harm (Burns & Grove 2009:689). It was anticipated that this study would result in positive outcomes for public hospitals and professional nurses in their service, by means of recommendations to improve effective communication and promote communication satisfaction.

SCOPE AND LIMITATIONS OF THE STUDY
The scope of the study was focused on selected public hospitals in the City of Johannesburg and the professional nurses working there. A constraint that could limit the study was:  The questionnaire was available only in English, as the official language medium; while the majority of the respondents do not speak English as their home language.

ORGANISATION OF THE REPORT
The report stemming from the research study was organised in the following way: Chapter 1 contains the introduction to the study, the background to the research, problem statement, the purpose and objectives of the study, the terms used, the research design and methodology and the ethical considerations.
Chapter 2 discusses the literature reviewed for the study on communication and the theory underlying communication satisfaction and effective communication.
Chapter 3 describes the research design and methodology.
Chapter 4 discusses the data analysis and findings.
Chapter 5 concludes the study with a summary of the main findings, conclusions, limitations and recommendations developed for clinical practice. This is despite the fact that a number of the job satisfaction studies reviewed have even been South African based, for example those of Kekana et al (2007) and Morele (2005).

CONCLUSION
Communication satisfaction studies conducted in the past have focused on professions and organisations such as manufacturing industries (Tsai, Chuang & Hsieh 2009), legal departments (Jones 2006) and media centres (Coffman 2004in Jones 2006, but are still not widely conducted in the nursing field. Studies conducted on communication satisfaction among nurses are based abroad; examples are the studies by Tzeng (2002) and Shader, Broome, Broome, West and Nash (2001). Only one study could be found on communication satisfaction conducted within South Africa, that by Meintjes and Steyn (2006), which focused on the higher education domain. That study attempted to measure the communication satisfaction of the personnel at the Johannesburg University during its transformational phase in 2005.

Contexts and dimensions of communication satisfaction
The Downs and Hazen model (1977) contains three conceptual contexts: were identified by Downs and Adrian (2004)

Interpersonal Communication Context
The Interpersonal Communication Context defines the communicative relationship between the manager and the employee in an organisation (Downs & Hazen 1977:72).
There are three dimensions listed under this context (see Figure 2.2). Mueller and Lee (2002:222)  It is essential for employees to receive timely information on how to do their jobs, but equally important is the acknowledgement of work well done. Kekana et al (2007:31) state that nurses in general value the opportunity and freedom to express their doubts about delegated duties should they not agree with them.
Nurse managers should concentrate on acknowledging their employees' achievements.
To promote self-esteem and job satisfaction among employees, managers can give due  Trust Trust refers to the extent to which the supervisor trusts the employee and vice versa.
Honesty, according to Robbins et al (2003:258), is absolutely essential in leadership and underlies the key dimensions of trust: integrity, competence, loyalty and openness (Robbins et al 2003:75). Leaders must be worthy of the trust of their followers; once the followers are assured of this trustworthiness, they will willingly follow the leader.
"Knowledge-based trust" is the most prominent type of trust that exists in organisations and is based upon a history of interaction with someone, and knowing someone well enough to make a prediction on their probable behaviour (Robbins et al 2003:259). James, Kotzé and Van Rooyen (2005:7) researched ineffective communication in general and found, in addition to a lack of self-confidence on the part of nurse managers and non-communication with professional nurses, "a problem of non-engagement between these two nursing categories that resulted in a lack of trust by the professional nurses". The need to "take the initiative and offer support and encouragement of effective relationships among colleagues" is ultimately the function of the nursing manager (James et al 2005:5). Kreitner and Kinicki (2007:352) highlight communication as one of the six guidelines for building and maintaining trust in relationships between managers and employees. This guideline (communication) embraces aspects such as telling the truth, keeping employees informed and providing accurate feedback. Jooste (2009:225) states that managers who supply their subordinates with appropriate information that will simplify work and is readily available reflect an open climate of trust in nurses to make their own decisions.

 Guidance
Guidance refers to the extent to which the supervisor offers guidance for solving jobrelated problems. Employees are faced with many job-related problems on a daily basis which require the insight of the manager. The employee needs regular guidance from management on how to handle challenges in the employee's job (Jones 2006:10).
However, according to James et al (2005:5), in the health sector the "disillusionment" The anticipation of the manager's need for information refers to the extent to which employees anticipate the needs of the manager for information, even if not trained to do so. Managers need information from lower organisational levels to make decisions, and this information should not always be on a demand-and-supply basis but on an automatic and forthcoming basis (Jooste 2009:103). This is, however, not a given, as it is sometimes difficult for employees to gauge the needs of the manager, especially if the manager is not a pro-team type of manager who encourages inputs from lower-level employees. Managers should simply inform subordinates what it is that they as managers require, when, how often and in what format.

Group Communication Context
The Group Communication Context defines the communicative relationship between same-level employees in an organisation (Downs & Hazen 1977:72) and is the second context in the conceptual framework. There are two dimensions listed under this context (see Figure 2.3). Mueller and Lee (2002:222) state that according to the Downs and Hazen (1977) model, the two dimensions of co-worker communication (horizontal communication) and organisational integration, resort under communications in group context. Each of these dimensions will be discussed in further detail.   Accuracy of co-worker communication Horizontal communication has four main functions in an organisation, namely task or project coordination, problem solving, sharing of information and conflict resolution.
Task or project coordination allows employees to share and discuss their thoughts and feelings on how respective members are contributing to the group's objectives. Problem solving allows employees to brainstorm ideas in different ways to solve challenges faced in the organisation. The sharing of information allows employees to gain knowledge that is often filtered out in downward communication. Conflicts in the organisation are resolved, as employees are allowed, due to the nature of horizontal communications, to have a free flow of communication (Jones 2006:18).
Often conflict is resolved directly at the lower level, without being brought to the attention of the supervisor (Jones 2006:18). It would be a waste of time and effort for information on issues that could be handled at a lower level to travel up through all the levels of the chain of command and back down again (Conrad & Poole 2002in Jones 2006. A suggestion from Van Staden et al (2002:23) is that it would be a good idea for managers to become involved in communications at peer-group level in order for them to know "what is said on the ground" and to become more sensitised to the feelings and needs of subordinates.
Nurses, especially professional nurses, need to feel that they are part of a team and experience effective two-way communication with their nurse managers. However, this seems not to be the case in most public health services of the Department of Health (NDOH). Zuma (2007:52) states that there is a deafening silence in the nursing profession in situations which require nurses to speak up against the ills evident in their working environment.
 Activeness of the grapevine The "grapevine" refers to the informal communication network that exists in all organisations. The grapevine helps employees to make sense of the world around them and provides relief from emotional stress (Muller et al 2006:147-148). It is important to know how comfortable employees are with utilising this communication network to discuss issues with co-workers. In the public sector, as in all other organisations, the grapevine is a lively one. How healthy it is is debatable, but what is a given is that in the public hospital setting information often follows the grapevine route; as a result important messages might end up being distorted and taken out of their originally intended context.
Rumours spread through the grapevine are in direct proportion to their importance to the employees and to the lack of information on the subject from official sources (Muller et al 2006:305). This informal communication network does not concentrate solely on gossip; in fact 80% of the information communicated via this network consists of business-related politics, and 70 to 90% of this information is usually correct as to detail.
It serves an important purpose, as it fulfils a basic human need for social-interaction in the workplace, but it needs to be managed to increase productivity and job satisfaction (Booyens 1998:269). Conrad and Poole (2002:74) state that informal communication networks might actually produce more accurate information than formal channels, because communication in informal networks is voluntary, uninhibited and not power-based. Mutual give and take occurs; communicators provide more detail in their messages and they are more willing to provide feedback as well (Conrad & Poole 2002:74).

Organisational Integration Dimension
Organisational integration refers to the satisfaction of employees with the amount of information they receive about their immediate work environment (Downs & Hazen 1977:70). This type of information could include information regarding departmental policies and goals, job requirements and personnel news (Jones 2006:40). An analysis of the amount of information that employees receive about their immediate environment indicates the issues that should be addressed. It should include information about the job progress of the employee, personnel news, departmental policies and goals, job requirements and the employee benefits and pay (Jones 2006:40).

 Departmental policies and goals
According to Meyer, Naudé, Shangase and Van Niekerk (2009:268), policies and procedures are guidelines enhancing the standard of nursing care in the nursing unit.
Departmental goals are broad statements used to formulate departmental objectives that need to be achieved by members of the health care team (Jooste 2010:94). regarding departmental policies and goals should be available to all employees in that specific department and should preferably be formulated in written, understandable form, following a specific, concise and complete format. It should be stored in a policy manual that is easily accessible to all personnel (Jooste 2010:95).
When an organisation states an intention, the intention is formulated into a goal or aim (Jooste 2010:105), and objectives are set which indicate how the organisation intends to reach the set goal. Policies and procedures are perceived as means to accomplish set organisational goals and objectives (Jooste 2010:94). Policies, for that matter, can be utilised by implication or by expression. Policies by implication are not directly voiced or written but are established by a pattern of decisions (Jooste 2010:94).
According to Booyens (2008:59), policies have to be communicated throughout an organisation to be effective. Although a policy manual is the most common way of informing non-supervisory employees about policies, it should be followed up by oral explanations and interpretations provided by first-level supervisors.
 Job requirements and job progress Every job has inherent job requirements (key performance areas) that the employee needs to adhere to. Job requirements should be communicated to the employee at the earliest convenient time to eliminate the possibility of mistakes (Jooste 2009:405).
Information about the progress of employees (measuring how well they are doing their jobs on a performance appraisal system) must be shared with them on a regular basis. Jooste (2009:405) views performance management as an assessment of the interest of subordinates in their jobs, good health, responsiveness and fairness of financial contributions. Nel, Van Dyk, Haasbroek, Schultz, Sono and Werner (2004:283) state that health care professionals expect the rewards received from the organisation to correlate with their performance. This compensation should be perceived by nurses as fair and equitable if they are to sustain a good employment relationship with their health services (Jooste 2009:288).

 Personnel news
Employees want to be informed regarding the well-being of co-workers. The way in which this information is conveyed to them will have a large impact on their level of psychological belonging. News regarding personnel in the nursing unit or larger organisational setting is viewed as important to the psychological well-being of the employees (Jones 2006:14).

Organisational Communication Context
The Organisational Communication Context defines the communicative relationships in an organisational context (Downs & Hazen 1977:72). According to Mueller and Lee (2002:222) there are three communication satisfaction dimensions, in the Downs and Hazen (1977)

Corporate Information
Corporate information refers to the broadest kind of information about the organisation as a whole (Downs & Hazen 1977:72 receive as a whole regarding changes in the organisation, profits and financial standing of the organisation and the achievements or failures of the organisation (Jones 2006:43).

 Organisational change
Change, according to Muller et al (2006:520), is a process resulting in differences of varying magnitude in the state of an organisation. It is unavoidable and occurs continuously, in some form or another, in all organisations; health care organisations are no exception. However, employees need to be aware of these changes as they might influence them personally or professionally, so the effective informing of employees becomes a challenge. Jooste (2009:372) states that effective communication is essential if effective change is to occur in the organisation. Employees must be informed about the reasons for the change, but circulating this information through e-mails only is not enough. It will require a lot of face-to-face communication to get employees involved in the change process.
 Profits/financial standing Unlike the private health care sector in South Africa, the public health care service is a non-profit, government-subsidised entity. Due to a constant lack of financial resources, the NDOH (one of the governmental departments included in the national budget annually) needs to perform proper financial planning (Zuma 2007:52 Communication within an organisation must be helpful and interesting to its employees. Dolamo (2008:42) states that in order for subordinates to provide a good service they need to be informed by the leader, on a consultation basis, about the service they are providing and the needs they are facing. Information should be clear and readily available for the subordinates to make informed decisions. Leaders have a wide range of choices in providing more and better information, such as utilising electronic and printed media for example (Dolamo 2008:43).
 Identification with the organisation The employee has to identify with the vision, mission, goals and objectives of the organisation in order to feel part of it. Organisational identification refers to the extent to which communication in an organisation makes the employee identify with it or feel a vital part of it. According to Downs and Adrian (2004:140), organisational information makes employees feel that they are "a vital part of the organisation".
 Attitudes towards organisational communication Muller et al (2006:518) state that attitude is an internal, emotional opinion a person has towards people, things, actions and behaviour. The attitudes of employees at an organisation must be basically healthy. If the attitudes of employees are not healthy it might imply that there are certain barriers hampering the free flow of information.
One such a barrier could be difference in status between members of a group when employees at different levels of the hierarchy need to communicate with one another.
Van Staden et al (2002:23) state that "with a positive and relaxed attitude" towards the communication process and one another, "this barrier can be overcome and valuable insights gained" from one another.

Media Quality Dimension
Media quality refers to the employees' reactions to several important communication methods, formats and channels (Downs & Hazen 1977:72). Assessment criteria pertaining to the media quality dimension on a communication audit will make reference to the degree to which meetings are organised, written directives and reports are clear and concise and the amount of communication received satisfactory (Downs & Adrian 2004:54;Jones 2006:42).

 Meetings
Meetings in an organisation occur when "two or more people gather to discuss and resolve issues of common interest" (Jooste 2010:100). An organisation is dependent on formal meetings for the smooth running of its day-to-day operations. These meetings should be well organised and it is the extent to which these meetings are organised that is going to determine how successful they are.
Meetings are "one of the most effective communication tools of the work environment" (Jooste 2010:100), where ideas can be stimulated, plans of action generated, teamwork encouraged, guidance provided, employees empowered and productivity improved.
"Effective meetings also ensure the continuous flow of information to all levels and between all health care professionals" in the organisation (Jooste 2009:402).

 Written directives
The medium in which organisations distribute their information to internal and external destinations could have a huge impact on the effectiveness of such information. It is the receiver that needs to make sense out of the intended message and interpret it as the correct intention of the sender. Thus the correctness of organisational media is essential. The correct medium should be used for the specific purpose intended; for example, a memorandum is used as a formal form of communication inside a nursing unit or for communication between the nursing unit and departments. The telephone or e-mail communication should be used in cases where information is required urgently (Meyer et al 2009:270).
Written communication in the form of directives and reports in an organisation must be clear and concise. Grammatical errors should be avoided. Messages should contain the gist of the matter but not be so brief as to create more questions than answers (Meyer et al 2009:267).

 Amount of communication
The amount of information the employee receives from the manager is closely aligned with communication overload, and must involve a precise process. Employees can easily feel overwhelmed by too much informationregardless of whether this information is applicable to their work situation or not. It is the responsibility of the manager to provide employees with correct and up-to-date information that is relevant and applicable to their work situation, but the manager should not restrict the flow of information that could stimulate growth and creativity.

Concluding remarks on the theoretical framework
This study is founded in a multi-dimensional communication context (public health care services). The Downs and Hazen model (1977), as discussed in the literature review thus far, formed the basis for this study. It was selected on the grounds that it was based on the theoretical assumption that communication satisfaction is multidimensional. It contains three contexts: the interpersonal communication, group communication and organisational communication contexts. Each of these contexts contains specific communication dimensions, which were individually discussed in detail. However as this study is founded within the broader communication domain, the communication process also have to be discussed.

COMMUNICATION
Communication is an integral part of our daily existence, but it needs to be purposeful and effective. However, before the concept of communication can be applied to any aspect of this study it is essential that the concept be viewed in more detail in terms of its definition, process, climate, types, methods, networks, flow, contexts, characteristics and barriers.

Definition of communication
Communication, according to Meyer et al (2009:265-266), is a two-way process whereby information (messages) are sent from one person (the sender) through a channel to another (the receiver), who responds after interpreting the message and taking into account the various communication barriers.

The communication process
A specific process is followed during communication that involves key elements including: a sender, a message, a specific message format, a receiver, an interpretation and a response (Muller et al 2006: 142). The communication process is displayed in   The message is the information which is conveyed during the process of communication.
 The communication channel represents the way in which the message is sent from sender to receiver, and feedback is sent from receiver to sender. Communication channels can include verbal channels (voice, telephone, fax, intercom, letter, memorandum, report, meeting and interview) or non-verbal channels (pictures, graphs and body language) (Trenholm 2011:204).
 The code may be any set of symbols such as language, figures, pictures and sign language that the receiver can understand.  According to Steinberg (2007:45-46), the message medium (plural media) is a kind of language that is divided into verbal and non-verbal media in which the message is sent. Van Staden et al (2002:14) refer to these media as methods of communication; the medium also represents the perceived form in which the message is transmitted.
 The receiver, also referred to as the addressee, respondent, destination or decoder, is the person to whom the sender directs the message.
 Interpretation is the responsibility of the receiver who needs to make sense out of (interpret and react to) the message which was received. The receiver interprets and decodes the code in order to understand it (Steinberg 2007:48-49).
 Feedback/Response is the message that the receiver sends in response to the sender's message. A response indicates the receiver's reaction and may take a verbal or non-verbal form. It also indicates that communication has occurred successfully.
 A communication barrier is any interference or "noise", but could also indicate anything which causes a communication breakdown or prevents the receiver from receiving the message (Van Staden 2002:14; Cleary 2008:11).

Communication climate
As individuals settle into an organisation, they start to communicate in ways they feel are appropriate to the organisation (Trenholm 1998:268). A communication climate refers to a psychological environment and can be defined as the general socioemotional feeling that is produced between the leader and the group; thus, according to Trenholm (2011:185-186), a psychological and emotional contract that arises within the work group. Trenholm (2011:185)  The communication climate of an organisation links into the social working climate.
According to Adam and Bond (2000:538), the social working climate refers to the interaction between persons at work, the group cohesiveness and the general team spirit. Nurses prefer to work in an environment with a good team spirit, where they can communicate freely with their nursing and medical colleagues. Adam and Bond (2000:541) point out that staff experience job dissatisfaction when they get the feeling that their supervisors undervalue their work and do not attend to their concerns appropriately.
Professional nurses, according to James et al (2005:9), "want to control their nursing practice", and therefore also the climate in which they have to perform their nursing functions. A conducive nursing climate with access to properly functioning formal and informal communication channels can give professional nurses the authority to take control when performing their nursing tasks because they are knowledgeable and skilful (James et al 2005:9). This type of empowerment can only exist when the professional nurse is satisfied with the level of communication within this climate.
Communication audit questions that could stem from the analysis of the communication climate in an organisation will centre on how employees view the overall effectiveness of the communication. It could include questions on satisfaction with organisational and personal communication, the extent to which organisational communication motivates the employee to meet the organisation's goals, and whether the employee has the communication abilities to do so. It also involves issues such as the extent to which the employee can identify with and feel a vital part of the communication in the organisation.
Other important issues are whether the employee receives the information to perform his or her job in a timely manner and the extent to which conflicts are handled appropriately through proper communication channels (Downs & Adrian 2004:59).  to Jooste (2010:208-209), is not confined within the unit itself; members of the health team also communicate within the health care institution.

External communication
The external communication extends to networks and organisations external to the institution. This type of communication (similar to internal communication) requires listening, verbal and non-verbal competencies, the ability to build supportive climates and to manage conflict (Jooste 2010:208-209).
When dealing with stakeholder links external to the organisation, it is important to draw attention to the fact that organisations have their own culture, and in linking to external networks the messages and specific vocabulary of the organisation must be clearly explained. It cannot be taken for granted that external networks linking with health care organisations will necessarily understand the health care language communicated by health care personnel in their internal organisational networks (Jooste 2010:209).

Methods/Media of communication
According to Muller (2009:203)   Face-to-face communication is, for instance, direct communication between a manager and staff.
 Communication by telephone is an impersonal medium of communication.
 Formal gatherings of individuals used to provide information and make specific decisions are another medium of oral verbal communication and are called meetings (Muller 2009:207).

Non-verbal communication
Non Non-verbal communication, according to Afifi (2007:48-50), includes structuring and regulating interaction, creating and managing identities, communicating emotions, defining and managing relationships and influencing others.

Written communication
Written communication is perceived as equally important as oral verbal and non-verbal communication but is performed in written form, for example in policy statements, procedures, minutes, circulars and letters (Meyer et al 2009:267;Van Staden et al 2002:27;Muller 2009:227). Jooste (2010:20) adds to these recording, report writing, staff evaluation reports, communication books, daily, monthly and annual reports, electronic documents, research reports, audit documents and memorandums.

Information systems and electronic media
Technology plays a major role in communication, and therefore information systems must be up to date (Meyer et al 2009:272). Information systems such as computers, PowerPoint presentations and overhead projectors can be utilised in many ways within an organisation for greater accessibility to information. Radio and television sometimes also help to inform employees on a large scale of happenings in an organisation.

Symbolic communications
Symbolic communications are performed by messages being conveyed consciously or subconsciously by symbols worn by people to reflect certain images, for example the insignia worn by the police or by nurses. The use of symbols such as hand-sign for the deaf and picture symbols for illiterate people resort under symbolic communication.

Communication networks/channels
Communication Communication networks can influence the speed with which tasks are performed, the accuracy of the task, the satisfaction attached to such a task and the flexibility of the task. The emphasis is on the type of communication network used in an organisation.

Formal communication
Formal communication networks or channels, according to Jooste (2010:209) and Muller et al (2006:304), can take many forms, such as reports of various kinds (including monthly reports and incident reports) meetings (between top management and between management and personnel), memorandums, newsletters and official notices (with regard to policies and procedures).

Informal communication in an organisation is unofficial internal communication through
informal networks or channels. The types and modes of such communications, according to Muller et al (2006:147), can differ from organisation to organisation, but three types are often present, namely, phatic communication (referring to the daily conveying of feelings and common courtesy greetings), informal social groupings (referring to the natural formation of groups due to common shared interests) and the grapevine (referring to casual communication and rumours conveyed by an informal and unofficial communication system).
The grapevine is an unofficial system of communication and the information is based on casual communication and rumours. It helps employees to make sense of the world around them and provides relief from emotional stress (Muller et al 2006:304-305).

Communication flow
Communication flow refers to the direction in which messages travel in an organisation and includes upward, downward and lateral (horizontal) communication flow (Steinberg 2007:295-296)

Upward communication
Upward communication, according to Muller et al (2006:303), "flows to a higher level in the organisation or group". It is aimed at informing managers about how things can be improved in the organisation and about the feelings employees have regarding general issues in the organisation (Steinberg 2007:295).

Downward communication
Downward communication refers to communication that "flows from one level of an organisation or group to a lower level" (Muller et al 2006:303). It is aimed at informing personnel about policies and procedures, the assigning of goals and objectives, providing job instructions to personnel, the highlighting of problem areas, disciplinary action and feedback on the performance of personnel (Steinberg 2007:295). Downs and Adrian (2004:54) state that although quality downward communication is the best indication of organisational communication effectiveness, "some of the most important information processing goes from employees at one level to their superiors, on another".

Lateral (Horizontal) communication
According to Jooste (2010:20), horizontal communication is the lateral exchange of messages between co-workers. This form of communication usually occurs between persons of equal hierarchical rank. It is also more informal than both downward and upward communication. There are no authority relationships and it assists employees to satisfy their needs for socialisation, to coordinate their activities with their departments, to improve their understanding of their individual and departmental responsibilities and to solve their own challenges before it becomes necessary for others to intervene (Steinberg 2007:295-296).

Communication contexts
Communication contexts, as defined in the terminology of this study (see section 1.7.3), refer to different types of communication situations; they are classified according to the number of people involved in the interaction as well as the degree to which they are able to interact. The three communication contexts applicable to this study include the interpersonal, group and organisational communication contexts.

Hierarchical structure/Lines of authority effecting communication
According to Steinberg (2007:295), information is distributed through an organisation within a hierarchical structure. This structure is often outlined in an organisational chart (a linear diagram indicating the status of different members of an organisation and the relationship between them). The hierarchical structure not only affects the interpersonal relationships between employees but also controls the channels of communication within the organisation (Steinberg 2007:295).
The lines of authority in this study refer to the rigid hierarchical structures found within  The chart furthermore indicates the relationships between staff in the organisation such as, firstly, line-directed relationships between managers and subordinates, secondly the lateral relationships between different units on the same hierarchical level, and finally staff relationships between an operational manager and other areas where the operational manager will offer assistance to the line manager (Jooste 2010:132). There are different types of organisational charts (structure) that can have an influence on the communications in an organisation.

Organisational structures effecting communication
Organisational  Centralised organisational structures refer to structures where, according to Conrad and Poole (2002:66), only the managers at the top would make decisions in the organisation because the authority is centralised in a small core of managers.
 Decentralised organisational structures refer to structures where a process of change occurs and decision making is distributed down through the hierarchical structure to lower-level employees to empower them (Jooste 2009:225).

Decentralisation creates opportunities for innovation in the work situation by
providing subordinates with more opportunities to develop their specific areas of expertise. In a decentralised system, two-way interaction and information ensure that subordinates have ready access to information.

Links to external environments
Organisations do not limit their communication to within their own borders; they communicate with external stakeholders in their environment on a daily basis. During organisational communication with the external environment, communication should take the unique cultures of other organisations into consideration, and thus the messages and specific vocabulary that are sent out to these organisations need to be explained in unambiguous terms (Jooste 2010:209).

Characteristics of effective communication
Communication effectiveness, according to Cleary (2003:7), refers to communication that is effective when the message, as it was initiated and intended by the sender, concurs closely with the message perceived and responded to by the receiver.
Understanding is usually the result of communication effectiveness. The greater the overlap is between the meaning of the sender and the meaning of the receiver, the more effective the communication transaction will be (Cleary 2003:7).
Effective communication can therefore be viewed as the successful transmitting of a message between sender and receiver. Jooste (2009:47) concludes that "effective communication results in fewer misunderstandings among employees and provides them with a common vision and understanding and unity of direction and effort". It is thus essential for effective communication to occur between all health care professionals, administrators and the community.

Barriers to effective communication
Elaborating on the earlier definition provided by Van Staden et al (2002:13-14), Muller et al (2006:143) define a communication barrier as "anything that confuses or distorts the message, anything that competes against the communication or anything that prevents a message from being received", thus hampering the understanding between sender and receiver (Cleary 2008:18 Muller et al (2006:143) state that psychological barriers to communication refer to emotional barriers such as anger, fear and depression, and such barriers are "all in the mind", according to Cleary (2008:18). Van Staden et al (2002:31) explain that a positive or negative attitude, hostility, a relationship of fear, nervousness and poor self-image on the part of the sender or the receiver will influence the message.

Perceptual barriers
Perceptual barriers to communication refer to perceptual differences that stem from the frame of reference (gender, background, education and intelligence) of the people in the communication process and are based on cultural, biological and other differences such as background and experience (Meyer et al 2009:267;Cleary 2008:12-13). Insensitivity towards differences can lead to a judgemental attitude.
Many people with different perceptions are grouped together in a work situation and therefore, according to Van Staden et al (2002:31), employees must be aware of and be sensitive to perceptions different from their own. Jooste (2009:209) states that although "our cultural background and bias can be good if they allow us to use our past experiences to understand something new, it is when they change the meaning of the message that they interfere with the communication process".

Semantic barriers
Semantic communication barriers refer to level of language proficiency, abbreviations used (especially acronyms and abbreviations characteristic to the specific organisation) as well as accent, different interpretations, vague wording, jargon and slang (Muller et al 2006:143;Steinberg 2007:49-50). Words and expressions form the basis of most communication. Often the meanings of words used to communicate are misunderstood or different meanings are attached to a specific word or expression.

Cultural and language barriers
Culture and language can also form a barrier to effective organisational communication (Meyer et al 2009:266). South Africa, like other countries, has a unique cultural make-up in which different cultures have existed alongside each other for centuries with limited cooperation and collaboration. The new democratic dispensation in 1994 brought with it a cross-cultural cooperation which was responsible for the development of the intercultural "rainbow nation" (Lesch 2007:42 Therefore this population can be perceived as a multilingual and multicultural one. In certain situations the message can be lost when the sender is not linguistically skilled in more than one language.

Gender
To ensure effective communication in the workplace, gender should also be considered.
Although men and women work side by side in the workplace it has been shown that they communicate with different styles. Because of differences in the socialisation men and women receive in their societies, they tend to speak and act differently (Steinberg 2007:152-153;Grohar-Murray & DiCroce 2003:59). Women tend to use communication to establish or maintain relationships, to learn from others and to share themselves, whereas men tend to use communication in an instrumental wayto accomplish goals.
Furthermore, men tend to be more abstract, conceptual, general, theoretical and less personal than their female counterparts and are thus conditioned to assume a more direct and forceful approach to speaking, while women use a quieter, less forceful approach. Both genders, however, possess the ability to speak forcefully, directly and questioningly (Trenholm 2011:87-88;Grohar-Murray & DiCroce 2003:59). meetings) and informal communication channels (such as an accurate and active grapevine) can empower professional nurses to perform their nursing tasks with confidence because they are knowledgeable and skilful (James et al 2005:9). This type of empowerment can only exist when the professional nurse is satisfied with the level of communication within this climate.

Open channels of communication
To

Changing organisational communication style
The breaking down of communication barriers demands a change from the traditional organisational style of communication to one that empowers and motivates employees and fosters creativity in them. The result will be an organisational communication style that is based on efficiency and a high performance ethic, without taking away authority and responsibility but rather the sharing of decision making (Skiti 2009:27).

Bridging cultural and language barriers
Culture and language can become barriers to the communication process. People tend to communicate in the culture and language with which they feel most comfortable.
However, Fourie (2003:38) warns that repeated cross-cultural communications among the same people could eventually create an inter-culture with its own norms. The consequence of such an inter-culture could be cultural (communication) isolation. Lesch (2007:42) feels that for the linguistically challenged, the linguistic problem that arises is often solved by the mere provision of an interpreter, and interpreting becomes particularly informative and worthwhile when distinctive languages and cultures are involved. Interpreting then becomes the reproduction of culture, as it transfers certain aspects of culture belonging to one group to those of another. Therefore language should be viewed within culture and not separate from culture (Fourie 2003:36).

Adapting of communication practices
Communication practices need to be able to adapt to the specific communication requirement in a specific situation (Muller 2009:207). Adaptability, according to Muller (2009:207), also refers to increased use of electronic media, like management information systems, in organisational communication. The public health sector is still very paper bound, in that hard copies of documents are required for all transactions and interactions (Zuma 2007:52). A paperless system, where data are stored in electronic computerised format, would not only be more cost effective but also time saving, as retrieval time would be halved.

Refinement of feedback
The feedback experience is often perceived by subordinates as a need to know activity that is handled by managers as less important. Feedback is a very responsible action, whose impact should not be underestimated. It is the manager's responsibility to provide feedback to subordinates to enable them to grow and develop, but this is only if they consider the outcome of the feedback to be developmental for both of them (Jooste 2009:405). It should be a positive learning experience for the subordinate (Jooste 2009:233).
According to Muller et al (2006:310), feedback must be planned. After the topic or event for feedback has been established, it is necessary to refine the topic to what exactly it is about the topic that needs to be conveyed. Feedback must be provided as soon after the event as possible, and should be specific and impersonal (Jooste 2009:405). The manager should also take care about the manner of providing feedback in cross-cultural settings (such as is the case in public health services). Misinterpretations and misunderstandings can occur in giving feedback across cultures, and therefore different styles of giving feedback are required. Feedback in cultures that are more task orientated will focus on how to do the task well; feedback in relationship-orientated cultures will focus on both the person and the task; feedback in egalitarian (equal) cultures will focus on two-way feedback between superior and subordinate; and feedback in cultures where rules and procedures are applied more universally will be work related and provided at work (Jooste 2009:441).

CONCLUSION
This chapter presented a literature review as a background to the study. It described the theoretical framework underlying the study, namely the dimensions of the communication satisfaction framework by Downs and Hazen (1977), The next chapter will discuss the research methodology followed when conducting this study.

INTRODUCTION
This chapter describes the research design and methodology followed during this study.
The research design will be discussed under the headings of the research approach and design, and the research methodology will be described under the headings of the population and sample, questionnaire development, the pre-test, and validity and reliability of the instrument. Notes on the actual data-collection process are also included.

RESEARCH DESIGN
Polit and Beck (2008:765) define a research design as the researcher's overall plan for obtaining answers to the research question, including specifications for enhancing the study's integrity. It spells out, in advance, the strategies the researcher plans to adopt in order to develop information that is accurate and interpretable.
The research design of this study was typified as a quantitative, exploratory and descriptive study design by means of a survey.

Quantitative approach
According to Burns and Grove (2009:22), quantitative research is a formal, objective, systematic process in which numerical data are used to obtain information; it is further used to describe variables, examine relationships between variables and determine cause and effect interactions among variables.
The quantitative research design was selected for the purposes of this study as the researcher aimed at describing and testing cause and effect interactions between the variables of the communication phenomenon among professional nurses.

Exploratory design
An exploratory research design, according to Polit and Beck (2008:21), will provide understanding of the underlying causes or full nature of a phenomenon. It will conduct research into an area that has not been studied and in which a researcher wants to develop initial ideas and a more focused research question (Neuman 2003:535).
The aim and objectives of this study were exploratory in nature and attempted to explore what constitutes effective communication in public health care services and the extent to which the professional nurses in these services are satisfied with the existing formal communication processes.

Descriptive design
The descriptive research design refers to an accurate portrayal or account of the characteristics of a person, situation or group in real life, and/or the frequency with which a certain phenomenon occurs, and implies the categorising of information (Burns & Grove 2009:45).
The researcher attempted to explore the communication phenomenon in real-life situations and to describe the research findings with regard to specific communication satisfaction dimensions that could possibly impact on the satisfaction of professional nurses in public health care services with their communication climate and to make recommendations to address the aspects with which they were dissatisfied. Baxter and Babbie (2004:168) state that the aim of survey research is to describe and explain statistically the variability of certain features of a population. The survey research method was appropriate to this study and was utilised for the data gathering and data analysis of this study because it has the ability to quantitatively measure answers to questions concerning the attitudes, beliefs and behaviour of a specific group (such as professional nurses) about a communication climate (such as that of the public health care services).

RESEARCH METHODOLOGY
Research methodology refers to the process or plan for conducting the specific steps of the study (Polit & Beck 2008:719). The steps may include the population, sampling and sampling method, data collection, validity and reliability of the data-collection instrument as well as the data analysis. For the purposes of this study the following were included:

Population and sample
The population of a study, according to Burns and Grove (2009:714), refers to all the elements including individuals, objects or subjects that meet the criteria for inclusion in a given universe. The sample refers to a subset of the population that is selected for the study (Polit & Beck 2008:731).

Population
The population for this study consisted of professional nurses, ranging from professional nurse (PN) to nurse manager categories such as Deputy Director (DD), Assistant Director (AD), Chief Professional Nurse (CPN) and Senior Professional Nurse (SPN).
The population in this study was divided into three strata. Strata, according to Polit and Beck (2008:340), are mutually exclusive segments of a population, established by one or more characteristics (in this study nursing rank). The three strata comprised nurse managers, operational managers and professional nurses. The aim of dividing the population into different strata was to enhance representativeness of diverse segments of the study population, and also to seek comparisons between these strata. The total nurse manager, operational manager and professional nurse population for the three hospitals used in the study were 1001 (of which 20 were nurse managers, 300 operational managers and 681 professional nurses).

Target population
According to Burns and Grove (2009:724), the target population consists of a group of individuals who meet the sampling criteria and to which the study findings will be generalised. In order for a respondent to be included in this study, the respondents had to be a professional nurse with at least one year's work experience (in the capacity of professional nurse) in one of the three selected public hospitals.
The rationale behind selecting only professional nurses for this study was twofold in nature. Professional nurses are decision-makers, implementers and supervisors of all nursing care activities in the wards/units, and therefore are very important recipients of and participants in health care service communication. Secondly, "practical constraints and people's ability to participate in a study", according to Polit and Beck (2008:338), might be a factor, considering the complex nature (English wording and level of insight required) of the questionnaire. Nursing staff hail from a multitude of vernacular and educational backgrounds and it might be challenging for especially lower category nursing staff to complete the questionnaire satisfactorily.
A total sample of 265 professional nurses working in the three selected hospitals was targeted in the study (of which 20 were nurse managers, 75 operational managers and 170 professional nurses).

Sample
A disproportionate stratified sampling method was used as a random sampling method to select the population for this study. Disproportionate sampling in stratification means that each stratum has an equivalent number of subjects in the sample despite the size of the strata (Burns & Grove 2009:697;Polit & Beck 2008:345-346). A sample of 265 professional nurses was drawn from professional nurses functioning in all departments within the three selected major public hospitals. The researcher used these three hospitals as they are situated in the City of Johannesburg and adhere to the criteria of the study. The three hospitals were numbered A, B and C in no particular order to ensure confidentiality.
A simple formula was initially used to determine the sample size. A sampling proportion of 25% was taken from the total population of each of the three strata, which delivered the following sample ratio for the three categories of professional nurses: 5:75:170, providing a rounded total of 250 respondents in the sample. The three strata were, however, greatly unequal in size. The nurse manager stratum was very small in this study, and therefore a larger proportion of the total population had to be utilised to be truly representative.
Because the nurse manager stratum was so small, the sampling proportions were altered to include 100% of the nurse managers, resulting in a sample of 20:75:170 to be more representative of the different strata (Table 3.1) and to represent the minority population stratum more adequately (Polit & Beck 2008:346). The target population (TP) indicates the total population that was initially intended, and the actual population (AP) the actual total population that was realised in the study (Table 3.2).  Polit and Beck (2008:338) view inclusion criteria as "eligible criteria that determine the characteristics that delimit the population of interest". The selection of subjects for this study was based on the specific selection criterion that participants had to be professional nurses who had worked in the public health care service for at least one

Criteria for inclusion
year.

DATA COLLECTION
According to Burns and Grove (2009:43), data collection can be defined as a "precise, systematic gathering of information relevant to the research purpose or the specific objectives, questions or hypotheses of a study". The theoretical basis of a survey and the conceptualisation of the concepts of a study will guide the researcher as to which structured variables and attributes of variables will be measured (Botma et al 2010:131).

Data-collection method
The researcher handed participants consenting to participate in the study a questionnaire (see Annexure E) with a separate covering letter (see Annexure F). The covering letter clarified the purpose of the study and introduced the researcher. The letter noted the objectives of the study and approximate time required to complete the questionnaire, as well as the ethical requirements, stressing that participation was voluntary. The consent to partake in this study formed part of this letter.
The respondents were requested to read and sign the consent in the covering letter and hand it back to the researcher immediately after signing. They were then requested to deposit their completed questionnaires in containers placed at the offices of the Assistant Directors of Nursing of their hospitals. The researcher collected the completed questionnaires on a daily basis.

Data-collection instrument
In quantitative research there are several methods of data collection/gathering that are frequently used. Health professionals most frequently use self-report, observation and physiological measurement, followed by existing data and critical incidents (Botma et al 2010:133).

Type of instrument
The type of data-collection instrument the researcher used was a self-report consisting of a structured questionnaire (see Annexure E), using a five-point Likert scale. The communication satisfaction questionnaire by Downs and Adrian (2004) was selected for this study on the basis of a literature study that was conducted to ascertain what research had been done in the domain of communication satisfaction, and specifically the communication satisfaction of professional nurses.

The development and application of the Communication Satisfaction
Questionnaire (CSQ).
The Communication Satisfaction Questionnaire (CSQ) for this study was adapted from the questionnaire created by Downs and Adrian in 2004, which in turn was based on the Downs and Hazen model (1977) for assessment of organisational communication.
Permission was obtained to utilise and adapt the Downs and Adrian questionnaire from the original creator (Annexure D). (1977)

Assessment of effective organisational communication
Before To determine the effectiveness of the flow of information through the public health care service's formal and informal communication channels, the focus was directed to the questions which dealt with the formal channels (questions 10, 16, 17, 20, 21, 28, 37, 39, 40, 42)    For questions pertaining to the dimensions measuring communication satisfaction variables (where participants were asked to select responses from a 5-point Likert scale ranging from very dissatisfied to very satisfied), an item analysis had to be conducted.
In other words, an item was considered to load significantly on a dimension if it had a primary component loading of .70 or above (Burns & Grove 2009:379).
The adapted CSQ as presented to the participants was constructed in two parts: Part 1 consisted of the biographical data of respondents, including age, gender, home language, professional qualifications, present rank and work experience in nursing.
Part 2  The order of the questions was designed to follow a logical flow and specific topics were grouped together. Information required was grouped from general to specific. Two open-ended questions were included to allow the participants to record responses not covered by the preceding items.

VALIDITY AND RELIABILITY
The "heart of trustworthy survey research lies," according to Baxter and Babbie (2004:168), "with the reliability and validity of questions asked". It is the reliability and validity of the questions asked that ensure the quality of survey research.
For the purposes of this survey the questions were derived from the well-established CSQ developed by Downs and Adrian (2004). The researcher also conducted a review of published information with regard to the use of the CSQ in previous research studies to ensure the validity and reliability of the instrument.

Validity of the instrument
Validity, according to Burns and Grove (2009:380), refers to the extent to which an instrument "actually reflects the abstract construct being measured". Validity is a complex yet important aspect of research to both the researcher and to those parties who will read the report and who may consider using the findings in their practice (Burns & Grove 2009:380). To be judged as a valid instrument, an instrument needs to adhere to the principles of criterion validity, construct validity, face validity and/or content validity. The validity of the instrument used in this study was assured by adhering to the principles of face and content validity. thus ensuring that all the major elements relevant to the construct being measured were examined.

Reliability of the instrument
According to Burns and Grove (2009:377), reliability refers to the consistency of a measure obtained in the use of a particular instrument and is an indication of the extent of random error in the measurement methods. It also refers to the degree of consistency or dependability with which an instrument measures the attribute it is designed to measure (Polit & Beck 2008:764). In other words, the reliability of a data-collection instrument refers to the consistency with which an instrument measures a specific construct (Burns & Grove 2009:377), thus the degree to which the instrument can be depended on to yield consistent results if used repeatedly over time, on the same individuals.
The reliability of the CSQ developed by Downs and Adrian (2004)  A Cronbach's alpha internal reliability test was performed to assess the reliability of the data-collection instrumenta test to prove that performance on any one item of the instrument is a good indicator of performance in any other item in the instrument. In this study the reliability of the instrument was enhanced by formulating the items as clearly as possible and refining them during the pre-test, for example by rephrasing questions.
This was done to make it easier to complete the questionnaire.
Due to the validated status of the instrument, item analysis and a Cronbach's alpha internal reliability test were performed to assess the reliability of the instrument.

PRE-TEST
According to De Vos et al (2005:206), the pre-testing of a measuring instrument implies that the instrument is tried out on a small number of persons displaying characteristics similar to those of the target group of respondents. A pre-test was conducted on a population in a fourth public hospital on a population representative of the three strata of the study population (2 nurse managers, 4 operational managers and 10 professional nurses), with the same inclusive sampling criteria as the target population. The pre-test was done to assess the time required to complete the questionnaire, as well as the clarity of the questions. The results were presented to subject experts (senior lecturers in nursing administration) and one adjustment was made to the instrument in terms of its legibility. The font size used on the questionnaires had to be enlarged before it could be administered to the rest of the study population.

ETHICAL CONSIDERATIONS
To verify the integrity of the researcher, he hereby declares that he has acknowledged all sources and reference material utilised for the compilation of this research study in full to avoid the possibility of plagiarism.
During the conducting of any research study it is vital that the research procedures adhere to professional, legal and social obligations towards the participants (Polit & Beck 2008:753). In this study the following ethical considerations were adhered to in order to uphold the moral integrity of the study:

Acquiring permission
The final questionnaire and proposal were submitted to the Higher Degree Committee

Right to self-determination or autonomy
The right to self-determination, according to Burns and Grove (2009:720), is based on the ethical principle of respect for people and indicates that persons have the right to self-determination and the freedom to participate or not to participate in research.
People are in control of their own destiny and they should be treated as autonomous agents, who must be allowed to conduct their lives as they choose with no external control. A violation of this right will be coercion (when an overt threat of harm or excessive reward is presented to obtain compliance).
All nurse managers and professional nurses working in the three selected public hospitals were invited to participate in the study by means of a covering letter attached to the questionnaire. This letter explained the goals of the research and contained information pertaining to the identity and qualifications of the researcher, the institute where the research was registered and the methodology of the research. The covering letter particularly stressed the right to privacy of each participant and that participation was voluntary, without any risk of penalty or prejudice if nurses did not partake in the study. The respondents were also informed (via the covering letter) that they might withdraw at any stage and that if they did not wish to answer a specific question, they might choose not to do so without any negative consequences. Furthermore, the nurse managers and professional nurses serving as respondents were notified via the covering letter that the research report would be made available to them on request.
The researcher included an informed consent section with the covering letter that the participants had to sign. The informed consent section clearly and fully informed the respondents about what the research entailed and the tasks that they would be expected to perform, as advised by Terre Blanche, Durrheim and Painter (2006:66).

Anonymity and confidentiality
According to Bell (2007:48), anonymity is a promise that even the researcher will not be able to tell which responses came from which respondent. The signed consent forms were handled separately from the completed questionnaires throughout the entire data collection and data analysis processes to ensure the anonymity of the respondents.
Confidentiality, according to Polit and Beck (2008:750), refers to the protection of participants in a study, and a promise that their individual identities will not be linked to the information they provide and will not be publicly divulged. This information should not be divulged or made available to any other person. Confidentiality is a promise that the respondent will not be identified or the findings presented in an identifiable form. In this study anonymity and confidentiality were guaranteed because the respondents were not required to identify themselves on the questionnaires. Furthermore, the identity of the public hospitals that participated in the study will not be disclosed as a means of ensuring confidentiality.
The data gathered need to be released for the facilitation of positive guidelines, and this can only be achieved if the information is shared. The researcher was the only person who had access to the raw collected data. Confidentiality in this study was ensured in that the data collected and information supplied would be used only by the researcher for the purposes of this study.

Right to privacy
Privacy, according to Burns and Grove (2009:715), can be defined as the freedom of an individual to determine the time, extent, and general circumstances under which private information will be shared with or withheld from others. Based on the prescription of Levine (1986) in Burns and Grove (2009:193), the researcher made use of a covering letter with a separate informed consent form (Annexure F), which was voluntarily signed by all participants in the study to protect their right of privacy. In addition to the right of the participants to privacy the right to equality was also adhered to in this study, as all nurse managers and professional nurses were invited to participate on an equal footing.

Beneficence
Beneficence, according to Burns and Grove (2009:689), requires the researcher to actively promote good and do no harm. It was anticipated that this study would result in positive outcomes for the selected hospitals and the nurse managers and professional nurses employed in their service by means of recommendations on communication satisfaction to be applied.

DATA ANALYSIS
Data analysis refers to the categorising, ordering and summarising of data to obtain answers to research questions. The purpose of analysis is to reduce data to an intelligible and interpretable form, so that the relationships of the research problems can Furthermore, a one-way Analysis of Variance (ANOVA) test was performed in case of statistical significant differences between the three different strata of the study population in relation to their mean communication satisfaction scores.

CONCLUSION
This chapter discussed the research design and methodology and the compiling of the questionnaire as the research instrument by utilising literature guidelines. The method of data collection was explained. Validity and reliability, ethical considerations and the methods that were used for the data analysis were also included in this chapter.
Chapter 4 will have as its main focus the statistical analysis, description and interpretation of the research data and the findings will be discussed.

INTRODUCTION
The aim and objectives of this study were to determine what constitutes effective organisational communication, referring to the effectiveness of communication channels and the level of communication satisfaction of professional nurses working in selected public hospitals in the City of Johannesburg. This chapter will discuss the findings of the analysis performed on the collected data. Discussions will be integrated in presenting the findings and will include references to the literature.

APPROACH TO DATA ANALYSIS
The target population included three strata, namely Nurse Managers (NMs), Operational

Managers (OMs) and Professional Nurses (PNs) who had been working in three
hospitals for a minimum of one year. The operational managers are the direct supervisors of the professional nurses in the wards/units. The nurse managers, operational managers and professional nurses of the three hospitals are viewed as three homogeneous groups, and the data obtained were analysed accordingly. No differentiation was made between the hospitals; only between the identified strata. The different hospitals will only be mentioned in the biographical information section for statistical purposes.
A structured questionnaire, using a five-point Likert scale ranging from "very dissatisfied" to "very satisfied", and open-ended questions, were used to collect the data. The response alternatives were adapted from five to three to simplify the discussion by grouping together two positive response alternatives (very satisfied and satisfied) and two negative response alternatives (very dissatisfied and dissatisfied) into satisfied and dissatisfied respectively. Polit and Beck (2008: 345) state that N indicates the total sample for a study; responses were indicated as percentages and rounded off to the first decimal point.

RESULTS
This section of the study will report on the research findings. Of the 265 questionnaires administered, 130 were returned; therefore a 49% response rate was obtained. This response rate is not unusual, because according to Polit and Beck (2008:305), the response rates of mailed questionnaires are usually less than 50%.
During the data-collection process the researcher discerned a disturbing indifference and lack of interest among the professional nurses towards not only the completion of the questionnaires but towards their work ethic in general.

Biographical information
For the purposes of describing the respondents, the following biographical variables are discussed:

Age
The results indicate that of the three respondent strata, 80 (88.9%) of professional nurses were aged between 21 and 49 years, falling into the younger age groups,

Gender
It was necessary to determine the gender of the respondents in order to establish the gender mix among respondents and whether or not the male nurses experienced  Table 4.2.

Duration in health care service and duration of position held
This item was divided into two sections: Section A inquired about the respondent's duration of service in the current health care service. Seventy (53.8%) of the respondents had been working in their current health care service for 9 or more years, 19 (14.6%) for 5 to 8 years, 34 (26.2%) for 1 to 4 years and only 7 (5.4%) of the respondents had been employed at their current health care service for less than one year.
These results can be viewed as an indication of work stability amongst the respondents, as the majority of the respondents (89 or 68.4%) had been working in their current health service for more than five years. Table 4.3 illustrates the duration of the respondents' employment in their current health care service.  From the findings it is evident that the majority (n=11; 61.1%) of nurse managers had

Type of nursing unit
This item inquired from the respondents the type of nursing unit in which they were currently working in their health care service. The motive behind this inquiry was that the flow of communication to and from different units/wards could vary depending on the type of unit; in other words on the degree to which a unit/ward had opened or closed accessibility. The findings are displayed in Figure 4.2, which indicates the combined figures of the three strata.

Highest educational qualification
Inquiring about the respondents' highest educational qualifications was important in order to establish the respondents' academic level of functioning. According to the findings the respondents of this study seem to be well qualified, as at least 16.2% (n=21) held a university degree in nursing.
The findings also indicate that 36 (27.7%) of the respondents held post-basic diplomas in speciality areas such as ICU and operating room nursing science. Table 4.5 illustrates the highest educational qualifications of the respondents.

Home language
This item inquired about the home language of the respondents, and was important in view of effective communication being the focus of the study. It is national policy that English is the official language to be used in all public service institutions for any form of  The findings indicate that most of the professional nurses (n=85; 94.4%) do not speak English as their mother tongue. Only five (5.6%) of the professional nurse respondents speak English as a home language. This language barrier could form a stumbling block in the way of effective communication in the hospitals. It is an occupational expectation in the public health care service sector to deliver care, assist the multi-disciplinary team, write progress reports and give feedback to supervisors and managers in English.

Assessment of effective organisational communication
Objective

Formal communication channels
The two communication dimensions applicable to the formal communication channels are corporate information and media quality.

Corporate information
The corporate information dimension represents official organisational information that needs to travel through formal channels of communication, in order for information to filter through to all levels of the organisation. It includes information related to policies, governing regulations, organisational change, profits and/or financial standing and achievements/failures of the organisation. Hospitals as organisations also deal with the same corporate information items. The content of the corporate information dimension was obtained from items 10, 16, 17, 20 and 21 of the questionnaire. The findings are displayed in Table 4.6.  The analysed data indicated that 16 (88.9%) of the nurse managers were satisfied with this information. This is not unexpected, as the nurse manager is usually the first line of nursing authority to receive such information from the GDHSD. On the other hand, 7 (31.8%) of the operational managers and 34 (37.8%) of the professional nurse respondents indicated that they were dissatisfied with this information, an indication that this information does not filter through to lower-category staff members. It is disconcerting that 13 (59.1%) and 28 (31.1%) of operational managers and professional nurses respectively were indifferent to this information. This is an area of concern, as government regulations should be strictly adhered to by all public sector employees to ensure that operational aspects are handled in the correct way, thus avoiding the need for disciplinary action.

 Information about change in the respondents' hospital
Item 17 assessed the respondent's level of satisfaction with regard to information about change in their hospitals. Muller et al (2006:520) state that employees need to be aware of all changes occurring in their organisation, as they might influence them personally or professionally.
A total of 11 (61.1%) nurse managers indicated that they were satisfied with the information they received, in contrast to both the operational managers (n=8; 36.3%) and professional nurses ( The findings indicate that 9 nurse managers (50.0%) and 8 operational managers (36.3%) were satisfied with this information, contrasted with the 42 (46.7%) of the professional nurse respondents who indicated their dissatisfaction with this information.
The professional nurse respondents indicated on the open-ended items that information about events in their hospitals often did not filter through to them. This is not a positive tendency, as relevant information has to filter through to all levels of the hospital, to ensure that every nurse is aware of the achievements and failures of the hospital.
The professional nurses also indicated that e-mails and text message services, as other means of communication, are not utilised enough. These forms of communication are quick and reach a large number of receivers in a short space of time and can be used to great effect when information needs to be disseminated to a large audience. In order for subordinates to provide a good service, they need to be informed about the service they are providing. This information can be provided on a consultation basis by their supervisor to the subordinate (Dolamo 2008:42  The operational managers indicated that they were satisfied with the way meetings were organised, but that they would also appreciate short interim meetings with nurse managers to discuss unplanned events in the hospital.  between information that nurses receive and information that is sent on. From the findings it seems as though a great deal of uncertainty was experienced by the respondents in answering this question. Fifty-five (42.3%) indicated indifference to this item. This could indicate that they find themselves in a situation where in some instances they do get enough information but in other instances they do not.

Informal communication channels
In assessing the satisfaction with informal communication channels, only the horizontal communication is applicable, according to the Downs and Hazen (1977) model.

Horizontal communication
Horizontal    The findings indicate that of the three strata of respondents, the professional nurse stratum indicated a high level of satisfaction (n=53; 58.9%), while the nurse managers indicated a low satisfaction level (n=7; 38.9%) with the extent to which their work groups were compatible. This low score could be an indication that they did not experience their own work group as compatible. The operational managers and the professional nurses indicated in the open-ended items that they generally felt part of a work group, but as regards communication, the professional nurses indicated that they did not feel part of the team due to the lack of communication with them. They also indicated that they experienced very little direct communication with the nurse managers.

 Extent to which informal communication is active and accurate
Item 41 sought to explore how active and accurate respondents felt informal communication in their various hospitals to be. Informal communication forms an essential part of an organisation's communication network, but it needs to be active and accurate to be effective. The findings are illustrated in Figure 4.8.

Assessment of the level of communication satisfaction
Objective two of this study sought to determine the level of communication satisfaction among nurse managers, operational managers and professional nurses working within the selected hospitals. The communication satisfaction of these three strata of nurses were analysed against the three communication contexts and eight communication dimensions of the Downs and Hazen (1977) model.

Interpersonal communication context
The first of these contexts is the interpersonal communication context, which has three dimensions: personal feedback, supervisor-communication and subordinate communication.

Personal feedback dimension
The personal feedback dimension refers to the information that employees in an organisation receive about their actual work and work performance. Successful feedback, according to Muller et al (2006:356), is when the results of such feedback provide employees with clear and direct information on work performance. This dimension includes aspects such as how the work of the employees compares with that of others and how this performance is managed. It also addresses aspects such as the recognition of the employees' efforts, reports on the handling of problems in the employees' jobs and the extent to which the employees' manager understands problems faced by employees in their jobs. According to the Downs and Hazen (1977) model, items 11, 12, 13, 18 and 22 were applicable to this dimension.
In the hospital environment and the nursing profession, feedback (especially personal feedback) is regarded by most nurses as a measurement of their work performance.
Not all nurses perceive personal feedback as positive, due to a number of reasons, but Jooste (2009:405) states that feedback should be provided only if the outcome thereof is considered to be developmental to both parties involved. Booyens (2008:246) echoes this statement and adds that feedback should be provided close to an event to ensure that the experience remains fresh in the minds of both the parties. The responses for the personal feedback dimension are reflected in Table 4.8.  Information about how the job performance of the respondent compares with others Item 11 sought to establish the level of satisfaction of the respondents with information about how the job performance of the respondent compared with that of others. It is human nature for employees to compare their performance with others in an effort to assess whether their performance is better or worse than that of the next person.
Booyens ( 1998:275) states that managers are often reluctant to provide feedback to employees with regard to their work performance because the manager is afraid that positive feedback might prompt the employee to demand an increase in salary or a promotion, while negative feedback might elicit arguments.
From the findings it is clear that the operational managers experienced the personal feedback dimension as unsatisfactory (with reference to all five items). Nine (40.9%) of them experienced comparison of their job performance with that of others as either satisfactory or unsatisfactory, indicating that not all of the respondents were satisfied with this feedback. Nine (50.0%) of the nurse managers indicated their satisfaction on this item but commented in the open-ended items that due to communication problems the feedback from professional nurses was not always complete or accurate. The operational managers indicated that they did not receive enough feedback regarding their job performance from the nurse managers. In the open-ended items the professional nurses indicated that the feedback they did receive from their supervisors (operational managers) about their jobs was adequate but that the feedback they received from the nurse managers was inadequate. This was reflected in the data, with 34 (37.8%) of the professional nurses indicating satisfaction and 27 (30.0%) dissatisfaction with the information on how their job performance compared with others.

 Information respondents receive about their performance management
Item 12 sought to determine the respondents' level of satisfaction with the amount and quality of information they received about their performance management. Mashiane According to Jooste (2009:330-331), performance management is a continuous communication process which is undertaken as a partnership between managers and subordinates. Performance management therefore establishes clear expectations and understanding with regard to the subordinate's job description. It establishes the manager's contribution to meeting the goals of the hospital, sets concrete terms on how to do the job well, establishes how job performance is measured and identifies barriers to performance (and how they can be overcome).
In response to this item, 7 (38.9%) of the nurse managers were indifferent and 6 (33.3%) were dissatisfied with the amount and quality of information they received about their performance management. This indicates an apparently negative view held by nurse managers with regard to the amount and quality of information they received about their performance management. (It could also possibly indicate that they were unsure as to how to approach this item.) The performance management of the nurse managers is not hospital based (internally) but performed by a central office (which is a managerial entity external to the actual hospital). They indicated in the open-ended items that professional nurses were not very receptive to evaluations and suggestions from nurse managers.
Eight (36.4%) of the operational managers were also indifferent about the amount and quality of information they received about their performance management. This is disconcerting, as the performance management of operational nurses is done internally at hospital level; therefore it would be expected that they would take a greater interest in information regarding their own performance management. The operational managers indicated that the performance management process could be more transparent. They also indicated that their subordinates were not informed regarding their performancethey had to assume that it was good or bad. The latter sentiment was also reflected in the responses of the professional nurses, 32 (35.6%) of whom expressed their dissatisfaction and 28 (31.1%) their indifference to the amount and quality of information they received about their performance management.

 Recognition of efforts
Item 13 sought to determine the respondents' level of satisfaction with the recognition they received for their efforts. According to Jooste (2009:168), subordinates working in teams, led by competent leaders, will have an opportunity for personal development and recognition.
The findings indicate that 13 (59.1%) of the operational managers and 41 (45.5%) of the professional nurses were dissatisfied, in comparison to only 4 (22.2%) of the nurse managers that expressed dissatisfaction with the amount and quality of recognition they received for their efforts. In the open-ended items the professional nurses indicated that too little praise was given to them by their supervisors/managers for work well done.
Some indicated that there was too much shouting at staff. Others stated that they needed more acknowledgement of good work in order for them to feel motivated in their job.
 Reports on how problems in the respondent's job are being handled Item 18 sought to determine the respondents' level of satisfaction with the amount and quality of reports on how problems in their jobs were being handled. The main focus of problem solving is on finding a solution to a certain problem, and once a decision has been set in motion, evaluation must follow to provide the necessary feedback on its outcome to employees (Muller et al 2006:80-84).
The findings indicate that only 35 (26.9%) of all the respondents were satisfied with the amount and/or quality of the reports they received on how their job-related problems were handled. Thirteen (59.1%) of the operational managers and 36 (40.0%) of the professional nurses were dissatisfied with the amount and or quality of such reports. This is disconcerting, as it indicates that almost two-thirds of the respondents may feel that management does not take heed of their problems or that management does not consider them important enough to provide sufficient feedback at regular intervals.

The nurse managers indicated in the open-ended items that two-way communication to
share problems and/or ideas did not occur in the hospitals. The operational managers stated that staff problems were often not addressed by the nurse managers. The professional nurses indicated that communication regarding problems in the units mostly flowed one way (upwards). They (especially the junior professional nurses) felt that their problems were ignored by nurse managers. This is a worrying tendency because, according to Muller (2009:191), problem solving is an essential part of nursing management and therefore the nurse manager must consistently demonstrate problemsolving skills.

 Extent to which managers/supervisors understand problems faced by staff
Item 22 sought to determine the extent to which managers/supervisors understand problems faced by staff. Jooste (2009:235) states that leaders should be sensitive to the expectations of subordinates in the provision of problem-solving solutions by honouring appointments with them, opening discussions with them and where necessary assisting them with their problems.

 Extent to which the supervisor listens and pays attention to the respondent
Item 24 sought to determine the level of satisfaction among respondents with regard to the extent to which their supervisor listens and pays attention to them. Nurses view their relationship with their managers as an important factor in their overall job satisfaction and intention to remain in their hospitals (Dhlamini 2012:62-63).
The findings indicate that 11 (61.1%) nurse managers were dissatisfied with the extent to which their supervisors (managerial committees and central office) listened and paid attention to them, as against 50 (55.5%) of the professional nurses and 9 (40.9%) of the operational managers that indicated their satisfaction with the extent to which their supervisors (nurse managers) listened and paid attention to them. The fact that nurse managers were dissatisfied with this item could indicate a breakdown in communication between the nurse managers and their managerial committees at central office.
 Extent to which the respondent's supervisor offers guidance for solving job-

related problems
Item 26 sought to determine the level of satisfaction of the respondents with the extent to which their supervisors offered guidance for solving job-related problems. According to Enslin (2005:31), nurses in the South African nursing profession feel that no one cares and that they have no support for the problems experienced on a daily basis like shortages in stock, equipment and staff. Yoder-Wise (2003, cited in England 2005 states that nurses look up to nurse leaders for guidance and learning experiences; thus nurse leaders can bring out the best in their personnel by guiding them.
The findings indicate that, except for a small percentage of operational managers (n=4; 18.2%) that indicated indifference, the majority of the operational managers were in two minds about the extent to which their supervisors offered guidance for solving jobrelated problems; they indicated both their satisfaction and dissatisfaction as regards this item at the same percentage (n=9; 40.9%). Nine (50.0%) of the nurse managers and 47 (52.2%) of the professional nurses were satisfied with the extent to which their supervisors offered guidance for solving job-related problems.

 Extent to which supervisors trust their subordinates
Item 29 sought to determine the level of satisfaction of respondents with the extent to which their supervisor trusted them. It is not a given that all managers trust their nurse subordinates. James et al (2005:9) found that professional nurses experience not being trusted to make sound judgements, however they want to be recognised as professionals and not merely as workers.
The findings indicate that 76 (58.4%) of the respondents were satisfied with the trust placed in them by their supervisors. However, this is not the opinion held by all.
Professional nurses indicated in the open-ended items that communication between the nurse managers and professional nurses was not transparent and that openness was sometimes lacking. They stated that too often communication was done in secret.

 Extent to which your supervisor is open to ideas
Item 33 sought to determine the level of satisfaction among the respondents with the extent to which their supervisors were open to ideas. Professional nurses should be allowed the opportunity to experiment with new ideas as they strive for autonomy. Sengin (2003:317) states that autonomy is to be independent within one's practice and to take responsibility and accountability for practising according to one's discretion.
The findings indicate that half (n=9; 50%) of the nurse managers were dissatisfied,

 Extent to which the amount of supervision given to you is about right
Item 38 sought to determine the level of satisfaction of the respondents with the extent to which the amount of supervision given to them was about right. Supervisors are, according to Muller et al (2006:351-352), responsible for directing work towards attainment of unit/ward objectives, and thus they have to inspect, guide, support, evaluate, approve and correct the work of others. To succeed the supervisor should have good interpersonal relations and communicate effectively laterally as well as vertically.
The findings revealed that 77 (59.2%) of the respondents were satisfied with the amount of supervision given to them. The professional nurses, however, indicated in the openended items that their nurse managers displayed an autocratic leadership style in which staff were told and not asked. They further indicated that openness (transparency) was not adequate in their hospitals. for granted that their subordinates have an automatic impulse to send useful information up to them, though this is definitely not the case.
The findings indicate that 20 (50.0%) of both strata of respondents were satisfied with the level to which their subordinates anticipated their need for information. It must, however, be borne in mind that the nurse manager requires information from the operational manager and the operational manager requires information from the professional nurse.
The slight dissatisfaction (n=3; 7.5%) with this item could stem from the fact that nurse managers seldom receive information directly from professional nurses. In the openended items the nurse managers indicated that the professional nurses did not communicate spontaneously with them regarding patient-related issues; for example, after a doctor's rounds the nurse manager seldom received vital patient-related information. This comment and the 17 (42.5%) respondents from both strata that indicated their indifference on this item could indicate that information is not following the hierarchical structure correctly, whereby patient information needs to travel vertically from the professional nurse to the operational manager and then on to the nurse manager.
It is imperative that the nurse manager be informed of the status of all patients at all times. This is a point of concern because in the absence of the operational managers, as direct supervisors of the professional nurses, the nurse managers could encounter a lack of vital patient information from professional nurses.

 Extent to which the supervisor can avoid having communication overload
Item 45 sought to determine the level of satisfaction of nurse managers and operational managers with the extent to which they avoided having communication overload.
Communication overload refers to the amount of information that managers receive.
When the amount of information exceeds the need for information the manager can experience information overload.
According to Muller et al (2006:147), one of the critical factors associated with internal formal communication in an organisation is to avoid information overload by selecting the appropriate communication channels. The suitability of the selected communication channel should be investigated: whether it is the right channel for the specific information. More than one channel can be used in the case of general information, so as to avoid managers having to deal with information that does not pertain to them.

 Extent to which staff are receptive to evaluation, suggestions and criticism
Item 46 sought to determine the level of satisfaction of nurse managers and operational managers with the extent to which their staff were receptive to evaluation, suggestions and criticism. Two-way communication between the managers and their subordinates is essential to create a platform where opinions can be raised and criticism given openly (Jooste 2009:235).
The findings indicate that more than half (n=22; 55%) of the respondents were satisfied with their subordinates in this regard. It is a positive sign when managers perceive their subordinates as receptive to evaluation, suggestions and criticism. It cannot, however, be stated as a generalisation that all subordinates will accept evaluation and criticism without some form of resistance. In the open-ended items the nurse managers indicated that their staff perceived "correctional communication" as punishment. The more junior nurses in particular did not want to be told that they were making mistakes. One nurse manager stated that "staff take criticism very personallyit often turns into a union or labour issue".

 Information about the progress of respondents in their jobs
Item 8 sought to determine the respondents' level of satisfaction with the amount and quality of information about their job progress.
The findings indicate that 71 (54.6%) of all the respondents were satisfied with the information they received about the progress in their jobs; however the professional nurse stratum indicated a lower satisfaction level (n=44; 48.9%), contrasted with 14 (77.8%) nurse managers and 13 (59.1%) operational managers that expressed their satisfaction with this item. The majority of the professional nurses (n=62; 68.8%) indicated in the open-ended items that they were not informed about the progress in their jobs. This is a worrying tendency, as all employees should be informed regarding their job progress on a regular basis.
Managers have control over the individual goal-setting and planning of the progress and appraisal of the subordinates' performance (Muller 2009:354); therefore the task of teaching them about the performance appraisal and informing them of their progress in their jobs also rests with the manager.

 News regarding personnel
Item 9 sought to determine the respondents' level of satisfaction with news regarding personnel. Jones (2006:14) states that an important factor in the psychological wellbeing of employees in organisations is news they receive about fellow personnel.
The findings indicate that most of the nurse managers (n=16; 88.9%) were satisfied with this news regarding personnel. In the open-ended items the nurse managers indicated that their hospitals did not have a functional newsletter that could highlight positive incidents in the hospitals to motivate staff and boost morale. The operational managers echoed this statement in their responses by stating that they too saw the need for newsletters in their hospitals. The professional nurses were indecisive about this item but did indicate that notices about personnel news were lacking in their hospitals.

 Information about departmental policies and goals
Item 14 sought to determine the level of satisfaction of the respondents with the amount and quality of information about departmental policies and goals. Jooste (2010:94-95) states that information about departmental policies and goals should be written, understandable, clear, concise and stored in an easy accessible policy manual format.
Departmental policies and goals could also be, and in some public hospitals are, stored in electronic format in a computer file system.
The findings indicate that the majority of the respondents (n=85; 65.4%) were satisfied with the amount and quality of information they received about departmental policies and goals. All three strata of respondents indicated in the open-ended items their satisfaction with this item; however, the professional nurses indicated that, like hospital policies and goals, departmental policies could also be simplified for all levels of staff to understand them. This simplification refers, according to the professional nurses' comments in the open-ended items, to "the wording of the policies and goals" that are "incomprehensible for most professional nurses".

 Information about the requirements of the respondents' job
Item 15 sought to determine the level of satisfaction of respondents regarding the amount and quality of information about their job requirements (job description). The job description, according to Muller (2009:123), spells out the responsibilities and duties of the employee and the authority relationship in a unit.
The findings indicated that the majority of the respondents (n=85; 65.4%) were satisfied with the information about the requirements of their job. All three strata of respondents indicated in the open-ended items that they were satisfied with such information they received. This is a very good indicator of organisational communication effectiveness because, as Jooste (2009:405) states, job requirements have to be communicated to each employee as early as possible to eliminate the chances of mistakes to the maximum.

 Information about employee benefits and pay
Item 19 sought to determine the respondent's level of satisfaction with the amount and quality of information about employee benefits and pay. Mashiane (2006:53) questions the quality of information that nurses in the NDOH receive regarding their remuneration, by querying the number of nurses who know what determines the salary they are paid and the incentives they receive. Jooste (2009:288) states that in any employment relationship, sustaining leadership and managing performance will become difficult if employees do not perceive their compensation as fair and equitable. Therefore it is important for employees to have insight into their remuneration system.
The findings indicated that 62 (47.7%) of the respondents were dissatisfied with information about their benefits and pay, indicating that there exists a lack of quality information in this regard, affecting the professional nurses at all levels in the hospitals; especially the operational managers (n=13; 59.1%) and professional nurses (n=43; 47.8%) who expressed their dissatisfaction.
The professional nurses indicated in the open-ended items their experience of communication, especially with the human resources departments in their hospitals, as very problematic. They stated that their supervisors had no human resources-related knowledge and thus were unable to deal effectively with their human resource-related issues such as benefits, salary and promotional and leave issues.

Organisational communication context
The  Table 4.12.  The professional nurse respondents indicated that the nurse managers did not respond to staff spontaneously. According to the professional nurses, the nurse managers were not visible enough because they did not visit the units often enough to speak to the staff, thus creating an illusion of being separate from the staff.
 Extent to which respondents receive the information required to do their jobs in time Item 30 sought to determine the level of satisfaction of the respondents with the extent to which they receive the necessary information to do their job in time. According to Kekana et al (2007:34), staff should regularly be updated with information on how to do their jobs.
The findings indicate that 73 (56.1%) of the respondents were satisfied with the extent to which they received information to do their job in time. In the open-ended items, however, the operational managers indicated that staff were often informed only two to three weeks afterwards of an event that had occurred at their hospitals and could influence their jobs. Professional nurses indicated that information was forwarded to them at the last minute and not in good time. Information was often delayed in the absence of operational managers.

 Extent to which conflicts are handled appropriately through proper communication channels
Item 31 sought to determine the level of satisfaction of the respondents with the extent to which conflicts were handled appropriately through proper communication channels.
Van Staden et al (2002:37) state that if conflict is managed well it can establish a work environment that is creative, stimulating and vibrant, but if it is handled incorrectly it will result in further destructive behaviour and hostility.
The findings indicate that only 51 (39.2%) of the respondents were satisfied with the extent to which conflicts were handled appropriately, utilising communication channels.
In the open-ended items the nurse managers and operational managers pointed out that staff in the hospitals displayed a general disregard for communication channels.
These managers viewed the communication practices of professional nurses, especially junior professional nurses, as very disrespectful.
For their part, the professional nurses indicated that misunderstandings led to conflict in the units, stating that nurse managers did not intervene in these conflicts soon enough.
They also indicated that communication was not always conducted in a professional manner; they felt that more senior professional nurses did not respect junior professional nurses during communication. The inputs of the junior professional nurses were not respected.

Cronbach's alpha internal consistency analysis
Item analysis was done to assess the reliability of the different dimensions or constructs in the questionnaire via Cronbach's alpha values. Dimensions can also be referred to as constructs or concepts. The overall Cronbach's alpha value for reliability can be stated as follows: a Cronbach's alpha above 0.8 indicates good reliability; a Cronbach's alpha between 0.6 and 0.8 indicates acceptable reliability; and a Cronbach's alpha below 0.6 indicates an unacceptable reliability. (Some authors use a cut-off of 0.7, which is suggested by Nunnally (1978) for acceptable reliability.) A reliable Cronbach coefficient alpha value is a validation that the individual items of a dimension measure the same dimension (concept) in the same manner (or consistently). Burns and Grove (2009:379) suggest that a Cronbach's alpha coefficient value of 1.00 denotes optimal reliability, in that each item in the instrument measures exactly the same thing.
To ensure that the CSQ dimensions were all computed at a coefficient value of 0.7 or above, a Cronbach's alpha internal reliability analysis was conducted. The results of this internal reliability coefficient of the communication satisfaction dimensions are displayed in Table 4.13: From the findings it is evident that all of the constructs were measured with good reliability. Therefore it can be accepted that the reliability of the data collection instrument is good as well.

Rank mean scores
The mean scores of each of the five questions for the respective CQS dimensions were totalled to establish the ranking order of these dimensions from the strongest to the weakest, according to the ranking of the questions within these dimensions. In the formal channel dimension, the corporate information items totalled 2.91; the media quality finished for the respondents at 2.96. The horizontal communication items in the informal channel dimension finished at 3.21. These scores were analysed according to a rank order of means on a 1-5 scale and are displayed in Table 4.14:

One-way Analysis of Variance
A one-way Analysis of Variance (ANOVA) test was performed to identify statistically significant differences between the communication satisfaction dimension mean scores of the three strata of respondents (Burns & Grove 2009:505). The analysis of variance in statistics refers to a collection of statistical models and their associated procedures whereby the observed variances are partitioned into components according to variables.
Thus ANOVA refers to a statistical technique that assists with inferring whether there are real differences between the means of three or more groups or variables in a population, based on the sample data (HR Statistics 2011:14).
The results revealed statistically significant differences between the different strata of nurse managers and operational managers in two of the communication satisfaction dimensions tested, namely the organisational integration and corporate information dimensions. These differences are displayed in Table 4.15 and Table 4.16 respectively: The p-value of 0.0079 (F 2,129 ≈5.03), which is smaller than 0.05, indicates that there is a significant difference between the mean organisational integration scores of the different management levels in the hospitals at a 95% level of confidence. The p-value of 0.0129 (F 2,129 ≈4.50), which is smaller than 0.05, indicates that there is a significant difference between the mean corporate information scores of the different management levels in the hospitals at a 95% level of confidence.
The nurse managers reported a higher level of satisfaction with both the organisational integration (average mean score of 3.66) and corporate information (average mean score of 3.39) dimensions than the operational managers in both dimensions (see Table   4.14). This phenomenon could be due to the high level of exposure the nurse managers enjoy and their direct contact with these dimensions due to their post status in the health service. There were no other significant differences between the strata of respondents.

CONCLUSION
This chapter discussed the data analysis and findings of the study by utilising descriptive and inferential statistics. The analysed data included the biographical data of the respondents, the assessment of effective communication channels and the assessment of the level of communication satisfaction of the respondents. The analysed data were displayed using tables, pie graphs and bar graphs.
Chapter 5 will conclude the study and will discuss the conclusions, recommendations and limitations of the study. research. In this chapter the findings, conclusions, recommendations, limitations and areas for further research will be presented.

INTERPRETATION OF THE RESEARCH FINDINGS
The results derived from the collected data were presented and interpreted in Chapter 4, thus generating the findings, which will be presented in line with the objectives of the study under the following headings: biographical information, effective organisational communication and communication satisfaction. The following concluding statements can be made:

Biographical information
Of the total number (N=130; 100%) of respondents, 18 (13.85%) were from the nurse

Formal channels of communication
Questions related to the formal channels of communication (corporate information and media quality) produced the following results:  Satisfaction with corporate information On the other hand, the respondents indicated a higher level of satisfaction with the extent to which meetings were well organised (n=54; 41.5%) and the extent to which written directives are clear and concise (n=75; 57.7%).  Marquis and Huston (2012:425), due to the prominence of grapevine communications in organisations.

Communication satisfaction
The second research objective for this study sought to determine the extent to which professional nurses in the public health care services experience communication

Interpersonal communication
In the Interpersonal Communication context, the satisfaction of the respondents with the personal feedback, supervisor and subordinate communication dimensions will be discussed.

 Satisfaction with personal feedback
This dimension rated among the lowest of the levels of satisfaction among all three strata of respondents. They indicated that none of them felt satisfied with the supervisor's/manager's understanding of their job-related problems because of the ineffective way problems were handled, because their efforts were not properly recognised, because they received inadequate information on how they were being performance managed and because they did not receive information about how their job performance compared with that of others. According to Dolamo and Peprah (2011:180), evaluation of staff performance in hospitals is often problematic because some staff feel victimised by their supervisors and others feel that their supervisors do not understand the process. In the data obtained, this was reflected in the low number of professional nurses (n=34; 37.8%) who indicated satisfaction with the information on how their job performance compared with that of others.
 Satisfaction with supervisor communication.
More than half of the respondents indicated satisfaction with their supervisors' 22.7%). They form the link between the nurse manager and the professional nurse and therefore also bear the burden of forming the information link between the three strata.
Yoder-Wise (2011:565) states that information overload occurs when one is overwhelmed by too much information too fast and too often, and does not have the skills to interpret the data into useful information. By developing data-and informationcollecting methods, as well as receiving and sending skills, this overload could be reduced and efficiency and productivity increased (Yoder-Wise 2011:565).

Group communication
In the Group Communication context, the satisfaction with the organisational integration dimension will be discussed.

 Satisfaction with organisational integration
The survey results indicated that although all three strata of respondents were satisfied with this dimension, the nurse managers were satisfied with information about their progress in their jobs (n=14; 77.8%), news regarding personnel (n=16; 88.9%) and information about departmental policies and goals (n=16; 88.9%)understandably so, as they are at the helm of the nursing sections of their hospitals. The professional nurses were satisfied with information about departmental policies and goals (n=59; 65.6%) and information about the requirements of their jobs (n=63; 70.0%).

Organisational communication
In

GENERAL CONCLUSIONS
The general conclusions for this study are founded on the three communication contexts and eight communication dimensions defined by the conceptual framework for this study designed by Downs and Hazen (1977).
Considering the population used in this study, the majority of the professional nurses fell into the age group of 21-49 years, the operational managers into the age group 40-59 years and the nurse managers into the 40-60 years plus group. The findings of the study can be summarised as follows:  Information regarding performance management received by the professional nurse stratum was insufficient.
 The operational managers and professional nurses felt that their efforts were not properly recognised.
 The professional nurses felt that nurse managers did not seem to understand the job-related problems of subordinates and appeared not to have effective problemsolving skills.

Supervisor communication
 Professional nurses indicated satisfaction with how open their supervisors were to their ideas and how much their supervisors listened to and paid attention to them.
Only the nurse manager strata indicated dissatisfaction with the latter aspect.
 The professional nurses were satisfied with the guidance their direct supervisors (operational managers) offered on solving job-related problems and with the extent to which their direct supervisor trusted them.  Nurse managers and operational managers remarked that staff were not very receptive to evaluation and not very open to suggestions and criticism.
 Operational managers indicated information overload as a problem.

Group communication
Communication in group context delivered the following areas of dissatisfaction within the horizontal communication and organisational integration dimensions:

Horizontal communication
 Nurse managers and professional nurses were dissatisfied with the extent to which the grapevine and informal communication were active in their hospitals.
 Nurse managers indicated their dissatisfaction with the extent to which their work groups were compatible.
 Operational managers experienced dissatisfaction with how active and accurate the informal communication networks in their hospitals were (if indeed they were working at all).

Organisational integration
 Both nurse managers and professional nurses were satisfied with the information received about departmental policies and goals and the requirements of their jobs, but only the nurse managers were satisfied with the information received about progress in their jobs.

Organisational communication
The results for the corporate information, communication climate and media quality dimensions of the organisational communication context included:

Corporate information
 Professional nurses were dissatisfied with the amount, availability and accuracy of information about governing regulations affecting the hospital where they were employed.
 Professional nurses were dissatisfied with the amount and quality of information about change, profits and financial standing and achievements and failures of their hospitals.

Communication climate
 Nurse managers reported an apparently poor communication ability among professional nurses.
 More than half of all three strata of the respondents indicated dissatisfaction with the extent to which they received timely information related to doing their jobs.
 Professional nurses indicated dissatisfaction with the extent to which conflicts were handled appropriately through the proper communication channels in the hospital.

Media quality
 Most of the respondents in all three of the strata indicated their dissatisfaction with the extent to which the hospital's communications were interesting and helpful, attitudes of staff were healthy and the amount of information they received in their hospitals.
 Most of the respondents in all three of the strata indicated satisfaction with the organisation of meetings and with the extent to which written directives and reports were clear and concise.  Table   5.1. Acknowledge nurses who deliver quality and excellent work inputs, not only by means of material rewards but also by means of verbal and or written recognition.
The direct supervisor of each employee, thus nurse and operational managers for professional nurses, and heads of departments at central office for nurse managers On a continuous basis, but especially after review interviews by direct supervisors and annually by management.
 Supervisors not understanding the job-related problems faced by staff Be more attentive to job-related problems experienced by nurses, by knowing what issues are at stake in the operational areas and by being more visible in the functional units/departments/areas of the hospital.
Guide professional nurses in workrelated problem solving by encouragement, directing and mentorship.

Nurse managers and operational managers
Operational managers On a continuous basis by observing, listening and identifying problem areas or aspects. Use face-to-face communication, presenting the manager to staff as a real person that understands their needs and challenges.
Keep operational managers informed about relevant matters.

Nurse managers and operational managers
Nurse managers and operational managers

Nurse managers
Continuously, by actively listening and by practising two-way communication.
Operational managers to share information as soon and as comprehensively as possible with their work groups.
 Sensitivity of subordinates to evaluation, suggestions and criticism Reduce sensitivity of staff to evaluation, suggestions and criticism from managers by providing feedback in a tactful, supportive and one-to-one way focused on developmental needs.

Nurse managers and operational managers
During all forms of feedback by focusing on both positive and negative aspects.

 Information overload
Individuals should prioritise information and assignments into high, medium and low priority categories in order to effectively manage the demands.
Operational managers As soon as information is received.
The recommendations for improving communications in the group communication context are displayed in Table 5.2. Preferably only information with a low priority should be sent through the grapevine.
Provide staff with accurate information to avoid distortion of information by hearsay and gossip.
All managers/staff that deal with the distribution of information in the hospital During all forms of communication which involve change and which will affect employees.

Dimension 5: Organisational integration:  Lack of information on job progress
Update staff on progress in their jobs (how well they are developing in their jobs) by providing them with feedback and guiding career planning.

Nurse managers and operational managers
Job progress meetings annually would be sufficient.
 Incomprehensible departmental policies Policies should be written in a simple, clear and concise format enabling easy comprehension.
All new and key concepts should be defined and explained, and a list of abbreviations should be included.
All managers who develop and distribute policies to staff During the development and revision of policies.   Nurse managers and/or operational managers to conduct unit rounds with junior staff too, to encourage staff commitment to two-way communication.
Provide a space on documents where staff can sign after reading the information to ensure that they have received the information.
All categories of nursing staff. Nurse managers can set the example to the juniors.
All categories of nursing staff, and once again nurse managers can act as role models for junior staff.

Nurse managers and operational managers
During all forms of communication in the hospital.
On all documents distributed in the hospital.

LIMITATIONS OF THE STUDY
The limitations applicable to this study are as follows:  The questionnaire was available only in English, as English is the official language medium in all government institutions; however, the majority of the respondents do not speak English as their home language.
 The third response alternative of the Likert scale in the questionnaire, namely indifferent, appears to have been an unsuitable term, affecting the interpretation of the data. Using the term uncertain instead could have facilitated a better understanding of what was expected and would have provided valid data.
 The open-ended items elicited many irrelevant comments. Some of the respondents, for example, used the opportunity to deviate from the topic and commented on job satisfaction. However, this option also seems to have elicited a great deal of useful information of which reference was made in the findings of the study.

RECOMMENDATIONS FOR FURTHER RESEARCH
In view of the findings of this study, the following recommendations for further research are suggested:  Similar studies should be conducted within other public health care services in other demographic areas to establish the effectiveness of their communication channels and explore the level of the communication satisfaction of their staff, as valuable information was gathered in the present study.
 A follow-up study is to be conducted at these particular three hospitals  Similar studies could be conducted in private health care services to determine the challenges experienced in private hospitals with regard to communication channels and communication satisfaction.
 Qualitative follow-up studies could be performed to elicit more information from respondents, due to the limiting nature of the quantitative methodology of this study.

CONCLUSION
The researcher conducted this study with the aim of determining what constitutes effective organisational communication and to establish the extent of communication satisfaction amongst professional nurses in selected public hospitals in the City of Johannesburg. A quantitative study with an exploratory and descriptive design was conducted to this end.
A disproportionate stratified sampling method, whereby professional nurses were selected according to nursing rank, was chosen for this study. The response rate was 49% and a total of 130 respondents participated in the study. These professional nurses were requested to complete a questionnaire to assess their levels of communication satisfaction. Recommendations were formulated to address the communication dimensions that were rated as unsatisfactory by the three different strata of respondents. Realising these recommendations in the practical setting would demand the involvement and active participation of all stakeholders, from the most senior of managers down to the junior professional nursesas they will become the supervisors or nurse managers of tomorrow.