INTRODUCTION

1.1 BACKGROUND OF THE STUDY

Effective and efficient communication is a core element in healthcare systems, especially

between healthcare providers and patients. In a medical setting, communication is a core

element in the interactions between healthcare providers and patients, and it is with skillful

communication that a healthcare provider can earn their patients trust. When communication

barriers arise, they can compromise the outcome of the care provided. Effective communication

skills of health professionals are vital to effective health care provision, and for the easing of

anxiety, guilt, pain, and disease symptoms of patients, as well as avoiding patient harm.

Moreover, effective communication can increase patient satisfaction, acceptance, compliance,

and improve the structural and functional status of the patient. Communication is a fundamental

part of nursing, and the development of a positive nurse-patient relationship is essential for the

delivery of quality nursing care. (Maureen, 2021).

The interaction between a nurse and a patient goes a long way to influence treatment outcomes,

therefore, effective nurse patient relationship is a vital tool in the provision of quality health

care to patient. Nurse patient relationship is a helping relationship that is based on mutual trust

and respect, the nurturing of faith and hope, being sensitive to self and others, and assisting

with the gratification of your patients physical, emotional and spiritual needs through your

knowledge and skill (Albagawi, 2016). Nurse patient relationship is dialectic in nature,

involving both closeness as well as distance, meaning that, developing a nurse patient

relationship among patient involves two inter-related processes-development of connection

while maintaining a comfortable distance of respect and compassion. It is imperative to know

that nurse patient relationship is vital for patient recovery both physically and emotionally

(Maureen, 2021). Nurses can have good interaction with patients through developing awareness

of each age groups attitude to health, disease and body function (Bramhall, 2014). It is

incumbent upon nurses to perceive the barriers to effective nurse-client communication. When
nurses are able to recognize and correct their perceived barriers to communication, better client

outcomes may result. Effective communication is beneficial for both nurses and clients.

Communication begins every time a nurse enters a client room; it is an ongoing and dynamic

process that occurs throughout the delivery of care. Communication involves the transfer of

information by exchanging verbal and non-verbal messages. Effective communication allows

the senders messages to be received and understood by participant (Bramhall, 2014).

Hence, identifying the barriers militating against effective communication among nurses and

patients is very important, because knowing these barriers will help to improve the quality of

nursing services, increase patient satisfaction and nurse patient relationship.

1.2 STATEMENT OF THE PROBLEM

Therapeutic communication strengthens the nurse-patient relationship and creates a good

atmosphere for healthcare delivery. Therefore, ineffective nurse-patient communication may

lead to dissatisfaction with care, misdiagnosis, misunderstanding, uncertainty and frustration

for both parties. Information on communication barriers is therefore necessary to identify

possible causes of nurse-patient communication pit falls. Some studies have reported

positive outcomes when communication was effective, consequently leading to adherence

to treatment and patient involvement in their own care (Kullberg et al., 2015).

The value of effective communication in nurse-patient clinical interactions cannot be

overemphasized, as “research has shown that communication processes are essential to

more accurate patient reporting and disclosure” (Ruben, 2016). Respectful

communication between nurses and patients can reduce uncertainty, enhance greater

patient engagement in decision making, improve patient adherence to medication and

treatment plans, in- crease social support, safety, and patient satisfaction in care (Ruben,

2016; Bello, 2017). Thus, effective nurse-patient clinical communication is essential to

enhancing patient-centered care and positive care outcomes.

Effective therapeutic communication is considered as the primary tool used for exchanging

information and negotiating care between the nurses and patients and their families.
Unfortunately, there are many barriers that could hinder these communications. Some of the

identified barriers among others are: high workload, lack of time, lack of support, nurses’

fatigue, staff conflict and not having the skills to cope with difficult mothers’ reactions.

(Hemsley et al., 2012; Diaconescu & Moisa, 2015; Banerjee et al., 2017)

Given the interconnected nature of patient-centered care and communication, we must

identify the barriers to effective communication and proposed efficient ways to

enhance that because patient-centered communication is essential in achieving patient-

centered care. It is therefore the aim of this study to identify these barriers militating

against effective communication and propose possible solutions to them, using 461

NAF hospital, Kaduna as a case study.

1.3 OBJECTIVES OF THE STUDY

The main objective of the study is to determine the perceived barriers militating against

communication in 461 Nigeria Airforce Hospital, Kaduna. The specific objectives are:

1. To determine the nurse-related barriers affecting effective communication in 461

Nigeria Airforce Hospital, Kaduna.

2. To identify the health system-related barriers militating against effective

communication in 461 Nigeria Airforce Hospital, Kaduna.

3. To understand the patient-related barriers militating against effective communication in

461 Nigeria Airforce Hospital, Kaduna.

1.4 RESEARCH QUESTIONS

The study was guided by the following questions:

1. What are the nurse-related barriers militating against effective communication in 461

Nigeria Airforce Hospital, Kaduna?

 2. What are the health system-related barriers militating against effective communication

in 461 Nigeria Airforce Hospital, Kaduna?

3. What are the patient-related barriers militating against effective communication in 461

Nigeria Airforce Hospital, Kaduna?

1.5 SIGNIFICANCE OF THE STUDY

The findings from this study, if published will help to improve nurses’ attitude towards patient

thereby improving client’s condition and recovery as well as the client’s co-operation. The

findings of this study will also help to improve Nurse patient language differences thereby

improving the quality of care given to patient and increase public confidence in health care

services and it will enable institution to note the organizational factors and make necessary

amendments in order to improve the nurse-patient relationship among patient. The findings will

also help to enhance the knowledge of the researcher on the factors that enhance effective

therapeutic communication in the Nigerian healthcare system. Finally, the findings of this study

could be used for future references.

1.6 SCOPE OF THE STUDY

The study is to determine the perceived barriers militating against effective communication in

461 Nigerian Airforce Hospital, Kaduna.

1.7 OPERATIONAL DEFINITION OF TERMS

1. Barrier - A barrier is something that prevents movement or access or acts as an

obstacle. It can also refer to something that prevents communication or understanding

(Oxford English Dictionary, 2nd edition)

2. Influence - Influence refers to the capacity to have an effect on the character,

development, or behavior of someone or something. It can also refer to the power to

shape or change opinions or actions.( Merriam-Webster Dictionary, 11th edition)

3. Patient - A patient is a person who is receiving medical treatment, care, or attention. It

can also refer to a person under a doctor's care (Cambridge English Dictionary, 1st

edition)

4. Effect - Effect refers to a change that is a result or consequence of an action or other

cause. It can also refer to the power to produce results or influence outcomes. ( Collins

English Dictionary, 12th edition)

5. Nurse - A nurse is a person trained to care for the sick or infirm, especially in a

hospital. Nurses are responsible for providing medical treatment, monitoring patients'

health, and administering medications.(American Heritage Dictionary, 6th edition)

6. Relationships - Relationships refer to the way in which two or more people or things

are connected or in a particular association or situation with each other. It can also refer

to the state of being connected by blood or marriage.( Longman Dictionary of

Contemporary English, 5th edition)

7. Perceived - Perceived refers to how something is recognized, understood, or interpreted

by a person. It can also refer to how something is seen or regarded in a particular way.

( Macmillan English Dictionary for Advanced Learners, 2nd edition)

 CHAPTER TWO

2.0 LITERATURE REVIEW

This chapter consist of the conceptual framework, empirical review, theoretical review and

summary of literature review.

2.1 CONCEPTUAL FRAMEWORK

2.1.1 CONCEPT OF COMMUNICATION

Communication is the exchange of information between people by sending and receiving it

through speaking, writing or by using any other medium. Clear communication means that

information is conveyed effectively between people. To be a successful nurse, excellent

communication skills are required [4]. Nurses speak to people of varying educational, cultural

and social backgrounds and must do so in an effective, caring and professional manner,

especially when communicating with patients and their families [5]. The quality of

communication in interactions between nurses and patients has a major influence on patient

outcomes. This influence can play a very important role in areas such as patient health,

education and adherence [6]. Good communication plays an important role in the organization’s

effective functioning [7–9]. A nurse must therefore, continuously try to improve his/her

communication skills as poor communication can be dangerous and lead to confusion.

Research has shown that effective communication between patients and healthcare

providers is essential for the provision of patient care and recovery [5–8]. Madula et al.

[6], in a study on maternal care in Malawi, noted that patients reported being happy

when the nurses and midwives communicated well and treated them with warmth,

empathy, and respect. However, other patients said poor communication by nurses and

midwives, including verbal abuse, disrespect, or denial from asking questions, affected

their perceptions of the services offered [6]. Similarly, Joolaee et al. [9] explored patients’

experiences of caring relationships in an Iranian hospital where they found that good
 communication between nurses and patients was regarded as “more significant than

physical care” among patients.

According to Boykins [10], effective communication is a two-way dialogue between patients

and care providers. In that dialogue, both parties speak and are listened to without

interrupting; they ask questions for clarity, express their opinions, exchange information,

and grasp entirely and understand what the others mean. Also, Henly [11] argued that

effective communication is imperative in clinical interactions. He observed that health

and illness affect the quality of life, thereby making health communication critical and

that the “intimate and sometimes overwhelming nature of health concerns can make

communicating with nurses and other health- care providers very challenging” [11].

Furthermore, Henly [11] added that patient-centered communication is fundamental to

ensuring optimal health outcomes, reflecting long-held nursing values that care must be

individualized and responsive to patient health concerns. Given the prevalence of face-to-

face and device-mediated communications and interactions in healthcare settings, we

must explore and clarify who, what, where, when, why, and how interactions with

individuals, families, and communities are receiving care and health services [11].

The value of effective communication in nurse-patient clinical interactions cannot be

overemphasized, as “research has shown that communication processes are essential to more

accurate patient reporting and disclosure” [12]. Respectful communication between nurses

and patients can reduce uncertainty, enhance greater patient engagement in decision making,

improve patient adherence to medication and treatment plans, in- crease social support,

safety, and patient satisfaction in care [12, 13]. Thus, effective nurse-patient clinical

communication is essential to enhancing patient-centered care and positive care outcomes.

2.1.2 Principles of communication

Principles of communication can be summarized as follows:

• Communication is a process;
 • Communication is not linear, but circular;

• Communication is complex;

• Communication is irreversible; and

• Communication involves the total personality [5].

2.1.3 Communication Process

Interaction between people is cyclic, which means that what one person says and does evokes a

reaction from the other person, and this reaction again stimulates another reaction from the first

person [10, 11]. Three things are needed for successful communication. They are:

1. A sender;

2. A clear message; and

3. A receiver [12].

2.1.4 Purpose of communication

The purpose of communication is to inquire, inform, persuade, entertain, request and investigate. A

single message can have one or more of the following purposes:

• To convey information/opinion, for example, “I have headache” or “I am here to give you

medication”.

• To request information/opinion/behavior, for example, “Are you allergic to penicillin?” or

“Tell me more about the injury”.

• To give social acknowledgement, for example, “Hello” or “Good morning”.

These three primary types of messages can be combined in many ways so that they form an

interaction (conversation). The goals of the interaction can be comprehensive. Nurses strive to
 make all their communication with patients therapeutic, that is, their communication is

purposefully and consciously planned to promote the patient’s health and wellbeing.

2.1.5 Types of Communication

Verbal and non-verbal communications are the two main types of communication used by human

beings.

Verbal communication

Verbal communication is associated with spoken words and is vitally important in the health-

care context. Members of the multi-disciplinary healthcare team communicate verbally with one

another and with patients as well as family members.

Non-Verbal communication

Non-verbal communication is not reliant on words. It is sent through the use of one’s body rather

than through speech or writing. This kind of communication, called body language, can tell a

great deal or can totally the wrong impression. It is worth noting that body language may indicate

a different meaning to what is spoken. As approximately 60% of communication is non-verbal,

non-verbal skills are essential for effective communication [8]. Often non- verbal messages send

stronger signals than verbal messages. Non-verbal communication is made up of:

• Accent

• Bodily contact

• Direction of gaze

• Emotive tone in speech

• Facial and gestural movements

• Physical appearance

• Posture
• Proximity

• Speech errors

• Timing of speech [5, 8–10].

2.1.6 Barriers to Efective Communication

Barriers to Patient-Centered Care and Communication Nurses constitute a significant workforce

of care providers whose practices can severely impact care out- comes (both positive and

negative). Nurses spend much time with patients and their caregivers. As a result, posi tive

nurse-patient and caregiver relationships are therapeutic and constitute a core component

of care [9, 13]. In many instances, nurses serve as translators or patients’ advocates, in

addition to performing their primary care duties. Although good nurse-patient relationships

positively impact nurse-patient communication and interaction, studies have shown that

several factors impede these relationships with significant consequences on care outcomes

and quality [6, 16, 17]. Thus, these barriers limit nurses’ and other care providers’ efforts to

provide healthcare that meets patients’ and caregivers’ needs. We categorize the barriers to

patient-centered care and communication into four kinds: institutional and healthcare

system-related, communication-related, environment-related, and personal and behaviour-

related barriers. Although these barriers are discussed in separate subheadings, they are

interlinked in complex ways during clinical practice.

Institutional and Healthcare System Related Barriers

Many barriers to providing patient-centered care and communication during nurse-patient

interactions eman ate from healthcare institutional practices or the healthcare system

itself. Some of these factors are implicated in healthcare policy or through management

styles and strategies.

Shortage of nursing staff, high workload, burnout, and limited-time constituted one complex

institutional and healthcare system-level barrier to effective care delivery [18, 19]. For
instance, Loghmani et al. [20] found that staffing shortages prevented nurses from having

adequate time with patients and their caregivers in an Iranian intensive care unit. Limitations

in nursing staff, coupled with a high workload, led to fewer interactions between nurses,

patients, and caregivers. Similarly, Anoosheh et al. [16] found that heavy nursing workload

was ranked highest as a limiting factor to therapeutic communication in nurse-patient

interactions in Iran.

In a study on communication barriers in two hospitals affiliated with Alborz University

of Medical Sciences, Norouzinia et al. [21] found that shortage of nurses, work overload,

and insufficient time to interact with patients were significant barriers to effective nurse-

patient interactions. Similar factors are identified as barriers to nurse-patient

communication and interactions in other studies [13, 16, 18]. For instance, Amoah et al.

[16] re- ported that nursing staff shortage and high workload were barriers to patient-

centered care and therapeutic communication among Ghanaian nurses and patients.

Amoah and colleagues reported a patient’s statement that:

Because there are few nurses at the ward, some- times you would want a nurse to

attend to you, but he or she might be working on another patient, so in such case, the

nurse cannot divide him or herself into two to attend to you both [16].

Nurses and patients and their caregivers have noted that limited time affects nurse-

patient interactions, communication, and care quality. Besides, Yoo et al. [22] reported

that limited visiting hours affected communications between caregivers and nurses in a

tertiary hospital in Seoul, Korea. Since the caregivers had limited time to spend with

patients, they had little know- ledge about the intensive care unit and distrusted the

nurses.

Although nursing staff shortage is a significant barrier to patient-centered care and

communication that healthcare institutions and managers must know, some health- care

scholars have critique nurses’ complaints of time limitation. For instance, McCabe [7]
argued that the quality of nurse-patient interactions is what matters and not the quantity

of time spent with patients and their caregivers. McCabe maintained that “spending long

pe riods with patients does not always result in positive nurse-patient relationships” [7].

He argued that implementing patient-centered care does not require additional time;

hence, nurses’ perceptions of being too busy cannot excuse poor therapeutic

communication during clinical interactions. Instead, nurses are encouraged to develop

self-awareness, self-reflection, and a commitment to ensuring that patients receive the

needed care.

Another institution-related barrier to patient-centered care and communication is the

healthcare system’s emphasis on task-centered care. Care providers are more focused on

completing care procedures than satisfying patients’ and caregivers’ needs and preferences.

This barrier to patient-centered care and communication is acknowledged in several

studies [7, 14, 20, 22, 23]. For example, McLean [14] studied dementia care in nursing

homes in the United States. She found that patient- centered care and communication in

one nursing home (Snow I) were severely affected when nurses, physicians, and care

managers focused on completing tasks or observing care and institutional routines to the

detriment of satisfying patients’ care needs. However, in the other care home (Snow II),

patient-centered care was en hanced as nurses, physicians, and the care home man- agers

focused on addressing patients’ needs and values rather than completing care routines

and tasks.

Similarly, Yoo and colleagues [22] observed that nurse-patient communication was affected

when the ICU nurses placed urgency on completing tasks linked directly to patients’ health

(e.g., stabilizing vital signs) than communicating to addressed patients’ specific needs. This

evidence shows that when nurses are more task-focused, patients and caregivers are treated as

bodies and objects, on which medical and care practices must be performed to restore health.

Research has shown that when nurses focus on task-oriented care, it becomes hard to provide

holistic care to patients or teach and communicate with patients even when nurses are

less busy [20].

Nursing managers and their management styles can affect patient-centered care and

communication. Studies have revealed that the management styles that nursing managers

implement can either facilitate or impede patient-centered care [14, 22]. When nurse

managers orient their nursing staff towards task-centered care practices, it affects nurse-

patient interaction and communication. Moreover, when nurse managers fail to address their

staff’s mental health needs and personal challenges, it influences how nurses attend to

patients’ care needs. For example, nurses have indicated that nurse- patient communication is

affected when nurse managers are unsupportive or unresponsive to their needs [20].

In a study exploring nursing and midwifery man- agers’ perspectives on obstacles to

compassion giving and therapeutic care across 17 countries, Papadopoulos et al. [24]

discovered that nurses and midwifery managers’ characteristics and experiences could

facilitate or impede compassion and therapeutic interactions in nursing care. Negative

personal attitudes, including selfishness, arrogance, self-centeredness, rudeness, lack of

leadership skills, the desire for power, and feelings of superiority among nurses and

midwifery managers, were obstacles to compassion building. The study further showed

that managers who emphasize rules, tasks, and results do not prioritize relationship-

building and see their staff as workers rather than team members [24]. Therefore, nurse

managers and care administrators must monitor nurse-patient interaction and communication

to address nurses’ concerns and support them, especially in resource-constrained and high

patient turnover contexts [25, 26].

Communication-Related Barriers

Effective communication is essential to providing patient- centered care. Studies have

shown that poor communication between care providers and patients and their caregivers

affects care outcomes and perceptions of care quality [7, 16, 27, 28]. A consistent

communication-related barrier in nurse-patient interaction is miscommunication, which often

leads to misunderstandings between nurses, patients, and their families [20]. Other

communication-related barriers include language differences between patients and healthcare

providers [6, 16, 27], poor communication skills, and patients’ inability to communicate due

to their health state, especially in ICU, dementia, or end-of-life care contexts [13, 22]. For in-

stance, in their maternity care study, Madula et al. [6] noted that language barriers

significantly affected effective communication between nurses/midwives and expectant

mothers. A patient in their study indicated that although many nurses were polite and

communicated well, some nurses had challenges communicating with patients in the

Chitumbuka language, which affected those nurses’ ability to interact effectively with

patients [6].

To overcome the communication-related barriers, healthcare institutions must make it a

responsibility to engage translators and interpreters to facilitate nurse- patient

interactions where a language barrier exists. Moreover, nurses working in ICU and other

similar set- tings should learn and employ alternative forms of com- munication to

interact with patients.

Environment-Related Barriers

The environment of the care setting can impact nurse- patient communication and the

resulting care. Thus, “good health care experiences start with a welcoming environment”

[29]. Mastors believed that even though good medicine and the hands working to provide

care and healing to the sick and wounded are essential, we must not “forget the small

things: a warm smile, an ice chip, a warm blanket, a cool washcloth. A pillow flipped to

the other side and a boost in bed” [29]. The environment-related barriers are obstacles

within the care setting that inhibit nurse-patient interaction and communication and may

include a noisy surrounding, unkept wards, and beds, difficulties in locating places, and

navigating care services. Noisy surroundings, lack of privacy, improper ventilation, heating,

cooling, and light- ing in specific healthcare units can affect nurse-patient communication.

These can prevent patients from genu- inely expressing their healthcare needs to nurses,

which can subsequently affect patient disclosure or make nurs- ing diagnoses less accurate

[13, 18, 21]. For instance, Amoah et al. [16] revealed that an unconducive care en- vironment,
including noisy surroundings and poor ward conditions, affected patients’ psychological

states, imped- ing nurse-patient relationships and communication. Moreover, when care

services are not well-coordinated, new patients and their caregivers find it hard to navigate

the care system (e.g., locating offices for medical tests and consultations), which can

constrain patient-centered care and communication.

Reducing the environment-related barriers will require making the care setting tidy/clean, less

noisy, and coord- inating care services in ways that make it easy for pa- tients and caregivers

to access. Coordinating and integrating care services, making care services accessible, and

promoting physical comfort are crucial in promot- ing patient-centered care, according to

Picker’s Eight Principles of Patient-Centered Care [30].

Personal and Behaviour Related Barriers

The kind of nurse-patient relationships established be- tween nurses and patients and their

caregivers will affect how they communicate. Since nurses and patients may have different

demographic characteristics, cultural and linguistic backgrounds, beliefs, and worldviews

about health and illnesses, nurses’, patients’, and caregivers’ at- titudes can affect nurse-

patient communication and care outcomes. For instance, differences in nurses’ and pa- tients’

cultural backgrounds and belief systems have been identified as barriers to therapeutic

communication and care [12, 13, 21]. Research shows that patients’ be- liefs and cultural

backgrounds affected their communi- cation with nurses in Ghana [16]. These scholars found

that some patients refused a blood transfusion, and Muslim patients refused female nurses to

attend to them because of their religious beliefs [16]. Further, when nurses, patients, or their

caregivers have misconceptions about one another due to past experiences, dissatisfac- tion

about the care provided, or patients’ relatives and caregivers unduly interfere in the care

process, nurse- patient communication and patient-centered care were affected [16, 21].

Similarly, nurse-patient communication was affected when patients or caregivers failed to

observe nurses’ rec- ommendations or abuse nurses due to misunderstanding [20], while

patients’ bad attitudes or disrespectful behav- iours towards nurses can inhibit nurses’
ability to pro- vide person-centered care [31]. The above-reviewed studies provided

evidence on how patients’ and care- givers’ behaviours can affect nurses’ ability to

communi- cate and deliver patient-centered care.

On the other hand, nurses’ behaviours can also pro- foundly affect communication and care

outcomes in the nurse-patient dyad. When nurses disrespect, verbally abuse (e.g., shouting

at or scolding), and discriminate against patients based on their social status, it affects nurse-

patient communication, care outcomes, and pa- tient disclosure [6, 32]. For instance, Al-

Kalaldeh et al. [18] believe that nurse-patient communication is chal- lenged when nurses

become reluctant to hear patients’ feelings and expressions of anxiety. When nurses ignore

patients’ rights to share ideas and participate in their care planning, such denials may

induce stress, discom- fort, lack of trust in nurses, thereby leading to less satis- faction of

care [18].

Furthermore, when nurses fail to listen to patients’ and caregivers’ concerns, coerce

patients to obey their rules and instructions [16, 17, 20], or fail to provide pa- tients with the

needed information, nurse-patient com- munication and patient-centered care practices

suffer. To illustrate, in Ddumba-Nyanzia et al.‘s study on com- munication between HIV

care providers and patients, a patient remarked that: “I realized no matter how much I talked

to the counselor, she was not listening. She was only hearing her point of view and nothing

else, [and] I was very upset” [17]. This quote indicates how care pro- vider attitudes can

constrain care outcomes. Due to high workload, limited time, poor remunerations, and short-

age of personnel, some nurses can develop feelings of despair, emotional detachment, and

apathy towards their job, which can lead to low self-esteem or poor self- image, with

negative consequences on nurse-patient in- teractions [13, 18].

Given the significance of effective communication on care, overcoming the above personal

and behaviour re- lated barriers to patient-centered care and communica- tion is crucial.

Nurses, patients, and caregivers need to reflect on the consequences of their behaviours on

the care process. Thus, overcoming these barriers begins with embracing the facilitators of

patient-centered care and communication, which we turn to in the next section.

2.1.6 Guidelines for Successful Therapeutic Interactions

After the purpose of the therapeutic interaction has been established, the following guidelines

assist in conducting a successful interaction:

Maintaining a low-authority profile

The nurse must strive to maintain a low-authority profile at the beginning of the conversation. As

the conversation progresses, the nurse can use more directive techniques to find out spe- cific

information. There are usually differences in age, sex, occupation, cultural background, moral

and religious convictions between the nurse and the patient. These differences make it

impossible for the nurse to fully understand the patient’s behavior and reactions. It is there- fore,

important for the nurse to understand and accept differences in patients’ cultures and beliefs.

When in doubt, check with the patient. If trust is established, patient will be willing to teach the

nurse.

Use of understandable language

The nurse should determine the patient’s level of understanding and if necessary change the use

of language, comments and questions. Using the terminology which the patient does not

understand can also frighten the patient and make him/her think that he/she has a more serious

problem than he/she originally wanted help for. At the same time, the patient could give

incorrect information because due to confusion, he/she may give affirmative answers to

questions about symptoms that he/she has not actually experienced [18]. Nurses should share

their aims with patients before expecting them to participate in the interaction. They should

understand that there is a mutual understanding of each other’s point of departure. In an

assessment interview, the nurse can, for instance, say: “Mr Jones, I would like to give you

information on how to lose weight so as to bring down you high blood pressure, but I first need

to find out what you already know about the condition”. It is not only important that the patients

understand what nurses expect from the conversation; it is also essential that nurses understand

the patients and convey this understanding before they participate in the conversation. When

providing emotional support, this understanding is often all that is necessary. For nurses to
understand patients, they must encourage them to talk – not just about facts, but also about their

feelings. The nurse must listen more than speak, both to what the patient is saying verbally and

what is being said non-verbally. Having listened carefully, the nurse then concentrates and

responds empathetically to the patients’ feelings. Only when the nurse has a reasonably complete

understanding of the patient’s situation and has communicated this understanding, can she

proceed to interventions, such as giving information or solving a problem.

Tailor the message to the totality of the person

Saying something does not necessary mean that the message has been received and under-

stood. It is the responsibility of the nurse to ensure that the person with whom he/she is

conversing understands the message. To ensure this, the message has to be adapted to the

language, culture and socio-economic status of the patient. The emotional or physical condition of

patients may also make it difficult for them to receive long of complicated messages or even any

message. There may also be other disturbances in the immediate environment for example, noise

that can make the patient not to hear or understand the message. The message must also be adapted

to the age of the patient [10].

Validate the interpretation with the patient

Validation means that you ask the patient whether your interpretation is correct or not. You

therefore, ask him/her to confirm your understanding of what he/she said. Many mis-

understandings arise because people interpret other people’s words without checking their

interpretation. The nurse should try to eliminate misunderstandings in the conversations by

checking meaning with the patient.

Active listening

Active listening means concentrating all your senses and thoughts on the speaker. One can

usually deduce whether a person is listening actively by looking at the following non-verbal

indicators:

• Is the eye contact maintained with the person who is speaking?

• Are the body and face turned towards the speaker? It

is, of course, also clear from the verbal responses:

• Are there regular verbal responses, even if these consist only of encouraging sounds?

• Does the response indicate understanding, not only of the facts, but also of the feelings and

the implications of the facts?

It is much easier to speak than to listen. Nurses are, in general, very active people, who want help

b acting quickly. To ‘just listen’ without expressing opinions or offering advice is there- fore,

often not in their nature. Active listening is a valuable skill to acquire [10, 17, 18].

Evaluate own communication

In the interest of nurse–patient relationship, it is essential that they ascertain whether their

communication has been successful. The following criteria can be used:

• Simplicity: Say what you want to say concisely and without using difficult or unfamiliar

terms.

• Clarity: Say precisely what you want to say without digressing, and support your verbal

message with non-verbal indicators.

• Relevance: Make sure that your message suits the situation, the time and the person you

are speaking to.

• Adaptability: Adapt your response to the clues the patient that the patient gives you.

• Respect: Always show respect for the individuality and dignity of the person you are

speaking to [17].
2.2 THEORETICAL FRAMEWORK

2.2.1 The Person-Centered Care and Communication Continuum (PC4)

Nursing care practices that promote patient-centered communication will directly

enhance patient-centered care, as patients and their caregivers will actively engage in the

care process. To enhance patient-centered communication, we propose person-

centered care and communication continuum (PC4) as a guiding model to understand

patient-centered communication, its path- ways, and what communication and care

practices healthcare professionals must implement to achieve person-centered care. In

this PC4 Model, we emphasize the person instead of the patient because they are a

per- son before becoming a patient. Moreover, the PC4 Model is supposed to apply to

all persons associated with patient care; thus, respect for the dignity of their

personhood is crucial.

Although much is written about patient-centered com- munication in the healthcare

literature, there is a gap re- garding its trajectory and what communication content

enhances patient-centered communication. Also, little is known about how different

clinical discourse spaces in- fluence communication and its content during nurse- patient

clinical interactions. Using evidence from Johns- son et al. [3], Murira et al. [23], and Liu

et al. [35], among other studies, we outline the components of the PC4 Model and how

different discourse spaces in the clinical setting and the content of communication im-

pact patient-centered care and communication.

The proposed PC4 Model in this paper has three un- bounded components based on

the purpose of and how communication is performed among care providers, pa- tients,

and their caregivers. Figure 1 illustrates the PC4 Model, its features, and trajectory.

Task-Centered Communication

At the lowest end of the PC4 Model is task-centered communication. Here, the care

provider’s role is to complete medical tasks as fast as possible with little or no

communication with the patient and their caregivers. Patients and caregivers are treated as

bodies or objects whose disease symptoms need to be studied, identified, recorded, treated,

or cured. As Johnsson et al. [3] ob- served, communication content at this stage is mainly

biomedically oriented, where nurses and other health- care professionals focus on the

precise medical informa- tion (e.g., history taking, medical examination, test results,

medication, etc.) about the patient. With a task- centered orientation, nurses make journal

entries about their patients’ disease state and ensure that treatment plans, diagnostic tests,

and medical prescriptions are completed. Communication at this stage is often imper-

sonal or rigid (see [23] for details). Care providers may address patients and their

caregivers by using informal attributes (e.g., bed 12, the woman in the red shirt, card 8,

etc.), thereby ignoring patients’ and caregivers’ per- sonal and unique identities. Patients’

and caregivers’ nonverbal communication signs are mostly overlooked.

Motivations for task-centered communication can be attributed to time limitation,

high workload, and staff shortage, thereby pushing nurses and other care providers to

reach as many patients as possible. More- over, the healthcare system’s orientation

towards and preference for biomedically-focused care seems to favour task-centered

communication [7, 14].

Depending on the clinical discourse space under which patient-provider interactions

occur, different forms of communication are employed. Clinical discourse spaces can be

public (e.g., in the ward, patient bedside), private (e.g., consulting rooms, medical test

labs, nurse staff sta- tion, etc.), or semi-private (e.g., along the corridor) [35]. In these

clinical discourse spaces, nurse-patient commu- nication can be uninformed (patients

or caregivers are not informed about patients’ care conditions or why spe- cific data

and routines are performed). It can be non- private (others can hear what the nurse and

patient are talking about) or authoritative (care providers demon- strate power and

control and position themselves as ex- perts) [23]. Finally, in task-centered

communication, healthcare providers often use medical jargon or termin- ologies [3]

since the goal of communication is not to en- gage the patient in the process. Usually,

patients or their caregivers are not allowed to ask questions, or their questions get

ignored or receive superficial, incompre- hensible responses.

Process-Centered Communication

Process-centered communication is an intermediate stage on the continuum, which could

slip back into the task-centered or leap forward into person-centered com- munication.

Through process-centered communication, care providers make an effort to know patients

and their caregivers as they perform care routines. Care providers ask patients or their

caregivers questions to understand the care conditions but may not encourage patients or

caregivers to express their thoughts about their care needs. Patients and caregivers are

recognized as persons with uniques care needs but may not have the agency to influence
the care process. Care providers may chit-chat with patients or their caregivers to pass the

time as they record patients’ medical records or provide care. Unlike task-centered

communication, there is informative and less authoritative communication between nurses

and patients and their caregivers. The goal of process- centered communication could be a

mixture of instrumental and relational, with less display of power and control by nurses.

Person-Centered Communication

This is the highest point of the PC4 Model, where patient-centered care is actualized.

At this stage of the communication continuum, patients and caregivers are treated as

unique persons with specific care needs and are seen as collaborators in the care

process. As McLean

[14] observed, caregiving becomes a transactional rela- tionship between the care provider

and receiver at the person-centered stage of the continuum. The care itself becomes

intersubjective, a mutual relational practice, and an ongoing negotiation for care

providers and re- ceivers [14].

The content of communication at this stage of the continuum is both “personal” and

“explanatory” [3]. Nurses and other healthcare providers create meaningful relationships

with patients and their caregivers, under- stand patients’ concerns, needs, and problems,

use open- ended questions to encourage patients or caregivers to express their thoughts and

feelings about the care situ- ation. Nurses and other healthcare professionals explain care

routines, patients’ health conditions, and manage- ment plans in lay language to patients

and caregivers through person-centered communication. Accomplish- ing this level

includes employing alternative forms of communication to meet the needs of intensive

care unit patients, deaf patients, and ventilated and intubated pa- tients. For instance, it has

been shown that “deaf people […] frequently do not have access to clear and efficient

communication in the healthcare system, which deprives them of critical health

information and qualified health care” [36]. Empathetic communication practices, includ-

ing active listening, showing genuine interest in patients’ care, and respect and warmth,

become a significant part of nursing care [3, 7, 14, 22].

Different communication strategies are employed based on the care situation and

context. Chit-chatting, as a form of personal communication [3], use of humor as a

communication strategy [7, 8], and even maintain- ing silence [28] are essential in

enhancing person- centered care and communication. Both care providers and patients

or their caregivers use relationship-building and -protecting humor (see [28] for details)

to address difficult situations in the care process.

2.2.2 Implications of the PC4 Model for Nursing Practice

Given the values of effective communication in nurse- patient interactions and care

outcomes, nurses and other healthcare providers must ensure that they develop therapeutic

relationships with patients, their families, and caregivers to promote person-centered

care and communication. Achieving that begins with knowing and reflecting on the

barriers of therapeutic communica- tion and ways to minimize them. The PC4 Model

draws nurses and all healthcare providers’ attention to patient- centered care pathways

and how effective communica- tion is necessary. Healthcare professionals, including

nurses, must be aware of how their communication orientation–––either oriented

toward completing tasks, following care processes or toward addressing patients’ and
their caregivers’ needs––can impact patient- centered care. Healthcare providers must

observe the care context, patients’ unique situations, their non- verbal language and

action, and whether they belong to historically marginalized groups or cultures.

Mastors [29] has offered healthcare providers some guidance to reflect on as they

communicate and interact with patients and caregivers. Thus, (a) instead of asking

patients, “What’s the matter?“ care providers must con- sider asking them, “What’s

important to you?“ With this question, the patient is given a voice and empowered to

contribute to their own care needs. Care providers should (b) check with patients in the

waiting room to update patients whose waiting time has been longer than usual, based on

the care context. They should also (c) try to remember their conversations with

patients to build on them during subsequent interactions. This con- tinuity can be

enhanced by nurse managers reexamining how they deploy care providers to patients. The

same nurse can be assigned to the same patients for the dur- ation of the patient’s stay to

help patients feel valued and visible [29].

Knowledge of cultural competence, sensitivity, humil- ity, and interpersonal

communication skills will help achieve and implement the PC4 Model. As Cuellar [37]

argues, “[h]umility is about understanding and caring for all people [and] being

empathetic.“ Cultural competence is a “dynamic process of acquiring the ability to

provide effective, safe, and quality care to the patients through considering their different

cultural aspects” [38]. The concept of cultural competence entails “cultural open- ness,

awareness, desire, knowledge and sensitivity” dur- ing care [39]. It demands that care

providers respect and tailor care to align with patients’ and caregivers’ values, needs,

practices, and expectations, based on care and moral ethics and understanding [39].
 Active listening and showing compassion as therapeutic relationship- building skills are

essential, and continuous education and mentorship will be crucial to developing these

skills among healthcare providers.

2.3 EMPERICAL REVIEW

Jahromi & Ramezanli (2014) conducted a descriptive cross sectional study on evaluation of

Barriers contributing in the demonstration of an effective Nurse patient communication in

educational hospitals of Jahrom of shiraz. The sample size consisted of 100 patients hospitalized

in the internal surgical wards and 100 nurses working in these wards of the two hospitals. The

persons selected by proportional stratified random sampling technique. In the first step a total of

2 teaching hospitals that have the internal surgical wards selected as strata. Afterward sample

size in each hospital was determined according to the proportion of the beds and nurses in the

wards and random numbers for selecting required sample from each hospital, the data were

collected by interviewing the patients and Nurses based on two questionnaire structured by the

researchers. The data were analyzed using SPSS software (version 16), descriptive statistical

method (frequency distribution, percentage and mean) and correlation coefficient fest. The

results of the study showed that greatest barriers of nurse patient communication which include

heavy work load of the nurses, cultural and language difference. It is concluded that overcoming

barriers to communication and support are needed to enable nurses to communicate

therapeutically with patients in order to achieve care that is effective to their needs

A qualitative content analysis study on Nurses’ experiences of barriers to the Nurse patient

relationship in the psychiatric ward in the hospitals of Ahvaz (South Iran).purposive sampling

method was used to select a sample of 15 Nurses working in the psychiatric wards, the inclusion
criteria were having a Bachelor’s degree in higher in Nursing, having at least 6months of

working experience and those who wish to participate in the study. Semi-structured interviews

provided the source of data an inductive content analysis approach was used for data analysis.

According to pazargadi et al (2015) the findings of this study showed that the barriers were

classified into three main categories: Nurse related including lack of empathy inadequate skills,

negative attitude and negative personal characteristics, patient related and the findings also

showed organizational factors including, manpower shortage, large number of patients and work

overload leading to reduced communication. In conclusion, they recommended that greater

consideration of these barriers be given to care planning in psychiatric ward.

Norouzinia et al, (2015) conducted a descriptive cross sectional study on communication barriers

perceived by nurses and patients of two public hospitals affiliated to alborz university of medical

sciences, karaj, iran, simple random method was applied. study was conducted on 70nurses and

50patients two questionnaires were used for data collection. Descriptive and inferential statistics

were used and SPSS version 14 was utilized p-value less than or equal to 0.0s5 was considered

statistically significant for the analysis of the data, the findings suggest that among four

categories of communication barriers in nurse and patient groups, nurse related barriers (2.1.5)

the most frequent communication barriers from the nurses viewpoint were as follows difference

in colloquial languages of nurses and patients, work overload, family, interference and in

conclusion measures should be ensured to improve effective nurse patient communication.

Another study by Vaughn et al. (2016) focused on the role of trust in the nurse-patient

relationship. The study found that patients who trusted their nurses were more likely to adhere to

treatment plans and follow through with recommended care. Trust was also found to be

associated with higher levels of satisfaction and improved health outcomes.

Kissiwaa, et al (2019) conducted an exploratory based design which followed a qualitative

approach, on perceived barriers to effective therapeutic communication among nurses and

patients. The study population were all nurses working at Komfo Anokye Teaching Hospital,

Kumasi and patient who had been admitted for a minimum of 3 to 4 days. A purposive sampling

method was used to select 6 nurses and 7 patients who were interviewed, an in-depth interview

guide was used as the data collection instrument to gather information from the participants.

Thematic content analysis was used to analyze data collected based on aims of the study. The

result of the findings showed lack of knowledge, time constraints, lack of trust, all-knowing

attitude, work over load and dissatisfaction were identified as nurse-related barriers to effective

therapeutic communication. The result also identified environmental factors such as noise,

unconducive environment as some of the barriers to effective therapeutic communication.

 CHAPTER THREE

3.0 RESEARCH METHODLOGY

This chapter presents the research design, setting/location of study, target population,

sampling and sampling technique, instrument for data collection, validity and reliability of

instrument, method of data collection, method of data analysis and ethical considerations.

3.1 RESEARCH DESIGN

The research design used for this study is a non-experimental descriptive survey design. The

research design is important to link a methodology and an appropriate set of research

methods in order to tackle research questions and/or hypothesis that are established to

examine social phenomena.

3.2 RESEARCH SETTING

This study was carried out at 461 Nigerian Air force Hospital, Kaduna State. It is a military

hospital that serve several health care services in the state. The hospital has about 30 acres of

land. The hospital has over 30 bed, 8 wards, each department with their pharmacy and two

theater.

3.3 TARGET POPULATION

The target population used for this study comprise of 54 nurses and 150 patients in 461

Nigerian Air Force Hospital, Kaduna state. The 150 patients are those who have been

receiving care within the past three weeks in 461 NAF Hospital, Kaduna. This brings the

total target population to 204.

3.4 SAMPLE SIZE DETERMINATION

Sample size used for the study was 135 comprising of 36 nurses and 99 patients. Taro

Yamane (1967) Formula was adopted to determine the research sample size for the study.

Formula: N/1+n (e)2

Where:

N=population under study (target population)

n=sample size

E=margin error (0.05)

N=?

N=204

E= 0.05

n=204/1+200(0.05)2

n=204/1+204(0.0025)

n=204/1+0.51

n=204/1.51

n=135
 54
Sample size for nurses = x 135 = 36
204

150
Sample size for Hanyi Banki = x 135 = 99
204

Therefore, total sample size = 36 + 99

= 135 respondents

3.5 SAMPLING TECHNIQUE

The sampling technique used in the study is a probability simple random sampling technique

to distribute questionnaire to the respondent in the hospital who are ready and willing to

participate in each unit selected during the period of data collection.

3.6 INSTRUMENT FOR DATA COLLECTION

A structured questionnaire was designed by the researcher and comprised of 2 sections.

Section A comprises of questions on personal data of the respondent and contain 4

questions. Section B comprises of 4 questions on the perceived barriers infecting nurse-

patient relationship amongst patients attending 461 Nigerian Air Force Hospital Kaduna

state.

3.7 VALIDITY OF THE INSTRUMENT

A self-structured questionnaire was developed by the researcher and was presented to the

project supervisor for face and content validation to examine the purpose, research questions
 in the line with the specific items in the instrument. The language was also assessed and

necessary adjustment and suggestions made before final approval by the project supervisor.

3.8 REALIABLITY OF THE INSTRUMENT

In order to establish the reliability of the instrument, pilot testing of the instrument was done,

where 40 questionnaires which were distributed among patients in 461 Nigerian Airforce

Hospital, Kaduna . This is to ascertain the respondents understanding the questions. It was

found to measure what it was expected to measure.

3.9 METHOD OF DATA COLLECTION

To get the study population, the researcher obtained a letter of introduction from the Head of

nursing department of Nigerian Air Force Collage of Nursing Science, Kaduna state. These

were presented to the director of nursing services of 461 NAF Hospital, to obtain permission

before the distribution of questionnaires to patients. The researcher presented the

questionnaires to the patients in their wards for the period of two weeks. The questionnaires

were distributed, they were given time to fill it, it was cross checked and documented.

3.10 METHOD OF DATA ANALYSIS

A simple percentage method was used to analyze data collected from the respondents using

tables for percentage presentation and a brief interpretation. Data collected via the questionnaire

are tabled in serial order and presented using percentages. A description of the presented data

was written in prose form before analysis. This was done to ease understanding for proper

analysis.
3.11 ETHICAL CONSIDERATIONS

Ethical approval was obtained from the matron of 461 Nigerian Air Force Hospital Kaduna.

The researcher applied the following principles:

 The principle of confidentiality: this means that the respondents’ identifiable information

will be kept unknown and not disclosed to anybody.

 The principle of voluntary participation: this implies that the respondents will not be

forced or compelled to participate.