Background: Acquisition of efficient communication is based on particular techniques and skills and requires the participation of at least two people, namely the addresser or transmitter of the message and the addressee or receiver of the message.
Aim: The aim of the present study was to assess and compare patients? and nursing staff's opinions relating to the communication developed between them during hospitalization and to explore possible correlations with demographic characteristics.
Methods and Material: A comparative, descriptive / correlational design was utilized to accomplish the purpose of this study. Study sample were 120 nursing staff working in a University General Hospital of Crete. Sample included 120 internal patients admitted in clinics of the same hospital. Data was collected through the use of a questionnaire, created by the researchers for the needs of the present study. The survey was conducted from June 2013 to August 2013. Statistical analysis was performed with the statistical package SPSS, version 21.0.
Results: The 58,7% of the patients considered the frequency of information given by nurses not be satisfactory. Instead, the 34.2% of the nursing staff was satisfied with the time they dedicated on communicating with their patients. Appeared that patients with a higher education express a significantly higher disagreement concerning information (r=-0.247, p=0.008), care (r=-0.366, p<0.001) and communication (r=-0.296, p=0.001) they receive from the nursing staff.
Conclusions: Based on the obtained results, a bidirectional communication is efficient when the objectives of the communication are accomplished, and thus interactive relationship is enhanced. Therefore, common codes of communication promote an appropriate and effective attitude of the nursing staff towards patients.
Communication; Hospital care; Nurses; Patients
The importance of communication and its impact on nursing was defined by Florence Nightingale in the 19th century and is still valid today. It approaches methods in order to describe the phenomenon of interaction between patients and nursing staff along with the peculiarities of their communication. Hospital care consists mainly of time devoted, adequate information provided to patients and constant communication so that patients’ needs are covered .
In this paper, the communication between the nursing staff and the patient will be explored. This sort of communication must display certain characteristics which contribute in the accomplishment of an effective interaction. Respect and understanding are significant characteristics of the development of this relationship as they are the tools through which the nursing staff is able to understand the patient’s inner world. Through this understanding a therapeutic interactive relationship is formed and the nursing staff comprehends the patient’s feelings .
The fact that there are many different definitions of communication shows its importance. Communication, according tο bibliography, is a bidirectional process of interaction between two (or more) individuals with the intention of exchanging messages using a blend of verbal and non-verbal signs and thus developing a relationship [3,4].
In social interactions the individuals or the group involved share the roles of the addresser and the addressee having mutual responsibility of establishing a common understanding and forming a common code of communication .
In general, communication is the exchange of a sort of “understanding” between the individuals through a common “symbol” system. Every type of communication between the individuals has a “history” and is influenced by the individuals' previous experiences. Communication can bring about results since it can influence the receiver’s opinion, feelings, course of action, thoughts and attitude. It is therefore a reciprocal and constant process in which both parties are responsible for establishing a common understanding [5,6].
Communication between patient and nursing staff includes a lot more than the conveyance of information. In nursing, ideas and feelings are transmitted and recognized through communication. However, it has to be pointed out, that nursing staff, despite their higher literacy level do not approach patients because they have not grasped the meaning and importance of communication .
Effective communication has a positive impact on patients because it gives them the sense of security and protection and as a result increases their level of satisfaction and brings about better results on the progress of their therapy. Patients are informed about their health condition and with the guidance of the nursing staff decide about a common course of action concerning their therapy .
In conclusion, communication is a continuous process of information which constantly changes and alternates according to the patient’s needs. This process however requires experience, dedication of time and most importantly skills on the part of the nursing staff [8,9].
The aim of the present study was to record and compare patients’ opinions with those of nursing staff regarding the communication that develops between them during patients’ hospitalization and to explore possible correlations with demographic characteristics.
A descriptive comparative/correlational design was utilized to accomplish the purpose of this study.
The study was conducted in pathology and surgical clinics of Tertiary University Hospital of Crete. The sample of study was composed of 240 people, 120 of whom were nursing staff working at the hospital and 120 patients hospitalized in the same hospital. The study lasted for 3 months, from June until August 2013, and convenience sampling was applied. A criterion for the participation of patients was the duration of their hospitalization which was set at 5 days or more.
For data collection purposes, two identical anonymous questionnaires were designed consisting of 26 questions for the nursing staff and 25 questions for the patients both divided into three thematic sections. The questionnaires were designed by the researchers and was based on international bibliography [10,11]. The first section included 10 closed-type questions regarding communication during hospitalization, while the next section comprised of 8 closed-type questions which were relevant to the care provided by the nursing staff and applied to both questionnaires. The third section included 8 closed-type questions concerning communication during hospitalization in the staff’s questionnaire and 7 closed-type questions in the patients’ questionnaire followed by 1 open-ended question concerning factors that affect the communication between the subjects of the survey. There were also some questions for the purpose of demographic data collection. The validity was subjective and determined by the researchers during the creation and face validity . The final form of the questionnaire was achieved after it had been tried out in a pilot study. Patients and nursing staff were asked to answer the questions using a 5 point Likert type scale. With being “totally disagree” up to 5 “totally agree”. In the phase of the pilot study were selected five nurses and five patients to determine test-rest reliability. The completion of the questionnaires again after two weeks and by controlling the degree of correlation "Nursing care evaluation scores" (Table 4) yielded correlation by Spearman: r=0.85, p<0.001 by nursing staff, and r=0.89, p<0.001 by patients.
In order for this research project to be conducted a research register was set up and written permission was issued by the hospital’s Scientific Board of Directors along with the permission by the heads of the department in each clinic.
Briefing about the study and oral consent were also necessary requirements for participation in the study. Briefing included clarification of information concerning the purpose and aims of the study, whereas participants were assured of their anonymity and of the fact that the use of the data will be used for research purposes only. Furthermore, participants were assured by the researchers that they were free to withdraw from the study at any time they wished to do so, and that their denial in participating would not in any way influence the care they were provided with.
Data were analyzed using SPSS software (IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp). Cronbach’s a was estimated in every section, according to structure as it described in unit of “Data collection” and its value ranged from 0.845 to 0.867 or 0.930 in patients’ questionnaire and from 0.755 to 0.864 or 0.897 in nursing staffs’ questionnaire.
In patients’ questionnaire the answers left blank or otherwise missing values were assessed at 1.4% percent of the questions overall (0.8% in nursing staffs’ questionnaire). Due to their substantially low volume they were replaced with the mode value.
Distributions of descriptive characteristics from both groups were also assessed. Pearson correlation coefficients were used to assess the relation of three sections on communication (information, care and communication) of patients and staffs’ characteristics, while multiple analysis of covariance was used to compare opinions of both groups relating to the information and the communication between them as well as their evaluation scores. Statistical importance was set at p<0.05.
To accommodate the purpose of this study, both questionnaires were divided in three different sections: information during hospitalization, care during hospitalization and communication during hospitalization.
The sample consisted of 120 hospitalized (n=120) in general pathology and surgical clinics. Additionally, the sample was also made up of 120 nursing staff members (n=120) who worked in the same clinics.
Out of the patients who participated, 51.7% were female and 48.3% male. The average patient age was 45 years with an average duration of hospitalization 7.8 days. All participants were of Greek origin. As regards to the literacy level, 20.2% had no education or elementary education, 44.7% had secondary level of education, while 35.1% of the patients were university graduates. Finally, the majority of patients (61%) belonged to the middle class whereas 42.9% belonged to the lower class and 2.7% to the upper class.
The highest percentage of answers expressing total agreement (5 on a 5-point Likert scale) was given in the “care provided by nursing staff” section with a percentage of 65% in a question concerning the nursing staff's friendliness and politeness.
On the other hand, the lowest percentage, 20%, expressing total agreement was given by patients in the first section "information during hospitalization". The above percentage is allocated to the question about information given to patients about their rights and to the question about information orientation in the department and its facilities.
41.3% of the patients considered the frequency of information given by nurses to be satisfactory, while 87.5% of them were not satisfied with the time the nursing staff dedicated to them, while 7 out of 10 thought that the nursing staff was not responsive to their worries (Table 1). As for their satisfaction in communication with the nursing staff and their satisfaction in overall care the scores given were 7.8 and 7.9 respectively on a 10 point Likert scale. Highly educated patients expressed significantly lower agreement in the provision of information (r=-0.247, p=0.008), care (r=-0.366, p<0.001) and communication (r=-0.296, p=0.001) they received from the nursing staff (Table 2).
b) Nursing Staff
The majority of the sample were women with a percentage of 87,5% and 12,5% were men. The average age was 37.5 years with an average of 13.4 years of working experience. 62.5% of the nursing staff sample were Technological Education graduates, 5% had a University degree and 32,5% were nurses assistants. 11 nurses (9,2%) out of 120 possessed a postgraduate degree. The patient-nursing staff ratio was 22:1 on average, per shift.
The highest percentage expressing total agreement was given in the section "Care provided by nursing staff" in a question relating to friendliness and politeness displayed by nursing staff.
In contrast, the lowest percentage of total agreement was found in the first section "Information during hospitalization" with a percentage of 29.2%. This percentage was noted on the nursing staff's level of satisfaction concerning the frequency of patients’ briefings.
Additionally, 34.2% of the nursing staff was satisfied with the time they dedicated on communicating with their patients, while 57.5% of them considered that there was sufficient information about patients’ rights. As far as their response to patients’ worries and complaints is concerned the nursing staff with a percentage of 49.2% thought their level of response was satisfactory (Table 3).
Moreover, the nursing staff estimated their communication with the patients with 8.4 (10 point Likert scale) and the care they provided with 8,6. Finally, when comparing demographic data from all three sections it was shown that the answers provided by the nursing staff were not influenced by any demographic factors in contrast to the patients’ results as mentioned above.
The correlation of answers given by patients to those given by nursing staff did not present any statistical significant difference despite the fact that patients tended to give lower scores than the nursing staff in the questions overall (Table 4).
The results of the study indicated that patients’ opinions and those of the nursing staff regarding their bidirectional communication fluctuate at satisfactory levels. However, in particular sections, as, for example, in the section concerning the patients’ rights, the prompt response of the nursing staff and the devotion of adequate time showed no significant statistical differences.
Effective communication between individuals depends on various factors. One factor which negatively affects communication and thus quality of care is the patients’ low literacy levels and their comprehension abilities [13,14]. In this study, literacy level plays an important role since the higher the patients’ literacy level, the bigger their demands. A possible explanation may be the fact that the patients’ needs gradually change as their illness progresses and hence are subject to the individual’s intellectual level .
The correlation of work experience in terms of developing a therapeutic relationship and in terms of providing quality care from both groups did not show any significant statistical difference.
On the contrary, results in related studies [15,16] have shown that the more experienced the nursing staff is the more confident they feel about the hospital care they provide. Specifically, Mackintosh , in his study in 2002 on 16 nurses working in surgical departments, indicated that nurses with long work experience can handle stressful situations more efficiently. Therefore, more experienced nurses, despite the work load and the pressure in the work environment, feel better qualified to develop a satisfactory therapeutic relationship with patients. Nurses with many years of work experience manage to adapt to developing situations and develop as a result a sense of sympathy . Furthermore, in a research conducted in 2013 in surgical clinics in Crete, results indicated that nursing staff with the longest work experience provided hospital care of better quality
This was not however observed when taking their work load into account since these nurses mentioned that their work load is one of the main factors that impedes effective communication . Lampraki et al.  indicated in their study that there is lack of information due to time limitations and the increased work load of the nursing staff.
On the other hand, another important factor which can cause emotional distress to patients is the hospital environment. The nurses’ role in this environment is to encourage and urge patients to express their complaints, worries and fears to the nurses [18,19]. Patients indicate that the behavior of nursing staff is significant. Many studies claim that a feeling of acceptance and trust can have a positive effect on the treatment of the illness [4,20].
Another very important factor which should not be underestimated during briefing sessions is the patients’ isolation and privacy so that there are no distractions . In this study, half of the patients seem to be satisfied with privacy in particular,. A possible explanation may be the increase in the number of patients in hospitals due to the financial crisis and the insufficient accommodation infrastructure (there are rooms with five beds) where privacy hardly exists. In a study conducted in 6 general hospitals in Athens it is indicated that quality is an important factor and that it decreases the patient’s level of satisfaction since they distinctively mention that patients pay attention to conditions of hospitalization and staff’s behavior .
Another major part in communication is information provided to patients and their immediate families, as it contributes to the decrease of stress, has a positive impact on the patient's therapy and helps them accept their condition . Patients in this study seem to have a satisfactory level of understanding without having adequate facts. In a relevant study conducted in Greece on 139 patients, 24.5 were very well informed about their health problem .
There have been no violations reported in this study concerning patients’ rights; a small percentage of satisfaction, if any, concerning information about their rights. Contrary to this, in a research conducted in 6 general hospitals in Athens in 2008, patients mentioned a weakness in the protection of their rights with a percentage of 93.5% .
The development of trust and politeness towards patients has positive effects on the individual [16,18]. In this study, 65% of the patients described the nursing staff as polite and friendly. In a similar study conducted by Lampraki et al.  240 patients, 98.1% stated they were satisfied with the nurses’ polite behavior.
Two main elements in the relationship between two individuals are respect of personality and individual needs. The results of this study, however, indicated that nurses consider that they display such characteristics when dealing with patients, whereas patients considered there was room for improvement. Similar results were also observed in a study conducted in hospitals of Crete where 66.7% of the nurses believed that they covered their patients’ personal needs at a satisfactory level .
The simple execution of duties does not result to the satisfaction of users. An organized course of action aiming at discovering patients’ needs and having their personality as a priority needs to be set. Communication strategies help in attaining the above because they successfully contribute in the feeling of security and confidence. Moreover, developing listening skills as well as being a good listener promotes sympathy and definitely promotes good communication with positive effects on the patient’s health [3,21-23].
The above mentioned results are confirmed by the present study where the percentage of patient satisfaction concerning information provided by staff was 41.7%. Social skills as well as communication techniques used by health professionals are essential to the provision of information in order for communication to become more effective; this conclusion was evident in a research conducted in 2001 in New Zealand . In order for effective communication to exist, there has to be adequate time devoted to it. In a study conducted in 2007 on 114 nurses, a big percentage of them answered that there was not enough time to listen to the patients’ concerns . In our study, with a similarly high percentage, the nursing staff expressed that lack of time was a factor which impedes the provision of effective communication.
Lack of time in the development of effective communication is closely related to the shortage in nursing staff. The nursing staff taking part in this study declared by 28% that the shortage in staff leads to time limitation and in turn to non-effective communication with the patients.
In the present study, the choice of convenience sample does not allow generalizations as the results do not express the total of the subjects but only those who met the participation requirements. A larger, random sample including nursing staff and patients from other areas of Greece would have perhaps allowed a generalization on the conclusions. Moreover, although the questionnaire was used for the first time and its level of credibility seemed to be valid.
This study evaluates the bidirectional communication between nursing staff and patients during their hospitalization. It can be inferred by results of the study that communication is effective in information and care provided to the patients. Specifically, patient satisfaction exists when patients are encouraged to express their fears and desires and develop interpersonal relationship. Improvement of communication and sensitization of the nursing staff result in better cooperation which is beneficial for both parties.
It is the nursing staff’s duty to comprehend and handle patients’ problems in the best possible way. Politeness is important since it positively contributes in the development of a sense of safety and security. The frequency of information provided and the time devoted by medical staff is an important role as well as it expresses the staff’s concern for patients.
The authors report no conflict of interest.
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