Socio-demographic characteristics of nurses
Seven nurses have participated in the in-depth interviews and eight in focused group discussion. Of which 9 (60%) of them were male. The age of the participants ranged from 26 -50 with a mean age of 37.13 years. More than 73% of the participants were orthodox religion followers.
Socio-demographic related barriers
Those are barriers that arise in both nurses and patients socio-demographic characteristics. It includes; age, sex, religion and marital status.
“Age of the nurses also affect communication. Elder nurses refuse the questions of the patient due to physical fatigue while younger nurses are not interesting to care for elder patients (INT 2, 3 and FGD).” As the patients get aged they easily forget what we have told them. For example old age patients with stroke, hypertension, and diabetes mellitus after we taught them, forget everything. Then we lost energy for recurrent taught, and finally, our communication with them was decreased (INT 4 and 6). “It is difficult to communicate with old patients. They cannot
understand easily what we want to communicate with them (FGD).” “When the patients age greater than 60 years old they cannot understand what the nurses said; especially the young nurses are fast, and they cannot understand the patients’ age condition (INT 5).” “It is difficult to communicate with old patients. As their age increases, they cannot easily understand us. For example when I was care patients with hypertension who develops stroke. He could not understand what I told. Finally, he said I longer live with this disease, now this may be God want to punish me. One side of my arm and leg is paralyzed; God wants to take me, so whatever you told me I cannot hear you (INT 7).”
Sex is another challenge for the nurse to patient communication. Some patients need the same sex to care for them while others show interest in the opposite sex. This happens especially at a younger age. For example, at one time the elder nurse goes to give care to young patients. She was not interested in care by the elder nurses rather she calls another young nurse that she knows before. What we did during this time was to change the elder one by the young (INT 7). “Female patients prefer male nurses to care for them while male prefer female nurses especially the young ages. This makes disrupted communication between nurses and patients (INT 4, 5 and FGD).”
“Religion is one barrier to communication. For example, at one time I was doing the nursing process of my patient. She was a Muslim religion follower. Then I was trying to perform a physical examination for her. She refused me for touch and she said her religion is not allowed to touch by men (INT 4).” One male nurse added “It is also one barrier of communication. Female Muslim patients are not allowed to touch by the male. This alters our communication with them (INT 7).” Thirty years old nurse continued “If the patients are orthodox they need orthodox nurses, and Muslim also need Muslim nurses. I am working in the operation room now. When patients entered the operation room or undergone surgery; they want to check our neck whether we have a neck loop or not (INT 6).
Being single is another challenge to communicate with the patients. One female nurse said that I have faced many challenges by the patients for marriage questions (INT 2). The other male nurse supports this idea. Once upon a time, I was given care for young female patients. During discharge from the hospital, she asked me to give my phone number as a reason for consultation if something gets worsen from illness. After discharged she told me as she has fallen in deep love with me. This leads to a decrease in my communication with the other single young female patients (INT 3).
Common-related communication barriers
Common barriers are those barriers that could arise from both sides of the nurse and patients, which can decrease the nurses to patients' communication. The barrier included under this was language difference.
Persons without having common language cannot communicate effectively or properly to express their feeling as those who have a common language.
One of the participants said that the difference in language affects communication with the patients. The patients give other meanings as we told positive things for them (INT 5). The other nurse continued that we have face difficulty in communication with those patients who speak other than Amharic like “Awigna”, and “Afan Oromo” language speakers cannot understand us whatever we talk good thing for them (Participant 6). The 50 years old nurses spoken that language difference with the patients also affect our communication for example; we cannot easily communicate with those patients who speak “Agewigna” (INT 1).
These are barriers that arise from the nurses, which can inhibit the nurse to patient communication. The barriers under this include workload, shortage of nurses, and lack of communication skills.
The presence of workload from the nurses is the potential threat of better care. When nurses carry out activities, more than their capacity they became burnout and unable to satisfy the patients' care needs.
There is a shortage of nurses, as a result, we serve the patients more than our capacity and we feel fatigued, exhausted, and burnout. This damages our communication with the patients (Participant 3). The other participant also continued we faced physical fatigue when we did more than our capacity; this leads to the obstacles of communication (INT 6 and FGD). I cannot give adequate time to communicate with the patients rather I prefer to do the routine activities because of workloads (INT 7).
Shortage of nurses
The presence of inadequate nurses in the hospitals or few nurses during their shift can damage communication with their patients because of unable to address all demands of the patient very well.
Especially at night shift nurse to patient ratio is one to ten up to twelve (Participant 5 and FGD). A 38 years old nurse said that there are a limited number of nurses compared to the flow of the patients. Therefore, during this time, we prefer to do our routine activities like medication administration, doing the nursing process without listening to the patient idea. As a result, our communication with patients is affected (INT 4 and FGD). The other nurse continued we serve more than twenty patients, especially during duty time. If there is a shortage of nurses, we cannot give the required services timely for our clients (Participant 6).
Lack of communication skill
Communication skill for nurses is very essential to communicate effectively with their patients. Nurses without good communication skills, cannot provide better care for the patients.
One nurse told that some nurses have natural behaviour that cannot shape with training (Participant 2). The other nurse continued we most nurses have lacked the skills to communicate with the patient like the place we select for communication, how to start communication, and are patients understand me or not...is not considered (INT 4). Some nurses cannot fully explain what things are going to do for their patients about care or treatments (INT 6). The other nurse said that I know one nurse she was assigned to work with me together in the pediatric ward. She was having an ethical problem. She made conflict most of the time with the patients. The entire mother knows her ethical problem and they always complained that we are not voluntary if this red nurse gives our children’s medication. Therefore, this was a great barrier to communication with the patients (INT 7 and FGD).
Patient-related barriers are these obstacles that arise directly from the patients that inhibit nurse to patient communication. The barriers included under these were pain and family interference.
Pain is a general term that describes uncomfortable sensations in the body. It can change the behaviour of the patients from stable to irritable mood and results in refuses to make contact with their caregiver.
One nurse revealed that the presence of pain decreases the communication between nurses and patients. If the patients are, in the good condition, they have a good facial expression for nurses greeting but if they are in the pain, they cannot respond to our greeting (INT 1). The other participant also said that as the patients suffering from the pain, they are not voluntarily communicating with us (INT 4). One of the participants also continued if the patients get pain they are not voluntary to communicate with the nurses (INT 5 and FGD). The 47 years old nurse said that patients with severe pain cause to disrupt our communication. Patients are not voluntary to give accurate data to us unless we give anti-pain and were reliving from pain (INT 7).
Conflict in the caring environment is common between care providers and the patients' attendants either intentionally or unintentionally. This is because of the unnecessary interferences of family or attendant with the caring process.
One of the nurses told us that during we give care for the patients the family interferes with our activities. This makes angry for the nurses and leads to conflict with them and finally, communication with the patients inhibited. For example, one day the patient medication was discontinued in around session then the attendant comes and complained that why not give the medication. The nurse responds for the attendant as it was discontinued, finally the attendant fight with the nurse why you discontinued it as it is already prescribed by the physician (INT 5). The other nurse continued that at one-time one-college students come to us because of illness. During this time, we were trying to help her but; her friends come and disturbed us. They said this is not the disease rather she attacks by an evil eye person so, this cannot be treated by modern medicine, and they try to hit one of the nurses with us (INT 7).
These barriers are arising directly from the health care setting which caused the barrier of the nurse to patient communication. The barriers included under these were lack of continuous training, lack of medical facilities for the patients, inappropriate and busy environment.
Lack of continuous training on communication
If nurses do not get continuous training regularly, they cannot update themselves and they may easily subject to tradition as well as lacked basic caring skills.
To increase our communication with the patients we need to have continuous training. But there is no training to enhance the nurse capacity especially on communication skills (INT 4 and FGD). The other nurse continues, we need to have training on communications skill to enhance our communication with the patients (INT 5). Lack of training on communication is the major barrier to communication with the patients so, short training needs to enhance the nurse to patient communication (INT 7 and FGD). The other nurse continued training is not given; even it provided for those who not concerned about it (INT 6).
Lack of medical facilities
If the hospitals cannot provide the necessary medical equipment or materials for the patients; the patients complained goes to their immediate caregiver or nurses. This is the main cause of the communication barrier.
All participants said that a lack of medical facilities was a barrier to communication. One female nurse said the hospitals could not provide all necessary medical facilities for the patients like a drug. For example, most societies in this surrounding area used health insurance. We prescribe drugs to the patients but they cannot get the drug inside the hospital rather they pushed to buy out of the hospital or in the private pharmacy. Then the patients complain to us, as they cannot afford to buy the drug. We told the truth as it is not our responsibility and if hospitals can list out the non-available drug and post it to the working unit, we cannot prescribe it. They did not listen to us. This leads to conflict between nurses and patients and decreases communication (INT 1). The other nurse continued that the health institution related issues are affecting our communication. For example, we send the patient to buy the drug out of the hospital then the patient made conflict with us. This is happening because the hospital cannot provide an adequate supply of drugs. This alters our communication with the patients (INT 2). Health insurance is another challenge for communication. The hospital cannot fulfil all the necessary drugs and the patients bought them out of the hospital. After that, they ask us to audit the cost of the drug. We respond to them our duties is to prescribe the drugs not auditing cost. This affects the communication we have with the patients (INT 3). One male nurse also stated that the patient comes to the hospital with their health insurance, and drugs are not available adequately. During this time, the patient is not interested to listen to us whatever we talk about. This challenges our communication with the patients (INT 4). The patients come with their health insurance, and they expect everything inside the hospital. If they did not get the services as they expected they shout towards us. In this condition, our communication with the patients is affected (INT 5 and FGD). Almost all persons use health insurance and the hospital cannot provide all the patient medical facilities like drug supply. If they cannot afford to buy the drug out of the hospitals, their treatment may discontinue and they complain to us why the treatment discontinued. In this time, we lead to an unnecessary verbal fight with the patients (INT 6). Patients come with health insurance for free services but the hospital cannot provide all the services like drug supply; when they ordered to buy out of the hospital the make conflict with us (INT 7).
Unsafe caring environments are among the obstacles of the nurse to patient communication. Unattractive health care environments can hinder the interaction between nurses and patients.
Participants reported that poor sanitation of the room also affects the communication between nurses and patients (INT 4, 7 and FGD).
A busy environment or the crowdedness of the health care environment is can inhibit nurse to patient communication.
One of the nurses said that the place of the hospital is nearing the road especially the emergency ward, the sound of the cars also affects us (INT 5). The other nurse also continued his idea for example when I enter the ward to care for my patient I saw the persons who make crowded rooms at that time I prefer to leave the room; because the environment was not suitable for me to communicate with my patient (INT 7).