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Communication Barriers in Nursing and their

Influence on patient safety-Literature Review

Millicent Eränen, James Kungu

2021 Laurea

Laurea University of Applied Sciences

Communication Barriers in Nursing and their influence on

patient safety

Millicent Eränen, James Kungu Degree programme in Nursing Bachelor Thesis February, 2021

Table of contents

• 1Introduction
• 2Theoretical framework-Key concepts
  • 2.1Nursing
  • 2.2Communication
  • 2.3Communication Barriers
  • 2.4Patient Safety
• 3Problem statement, Justification and Research Question
  • 3.1Problem statement
  • 3.2Justification
  • 3.3Research Questions
• 4Methodology
  • 4.1Data Collection
  • 4.2Data Analysis
• 5Results
  • 5.1Communication barriers on Nurses side
    • 5.1.1Language, religious and cultural differences
    • 5.1.2Nurse-patient ratio
    • 5.1.3Fatigue
    • 5.1.4Low or insufficient salary
    • 5.1.5Working environment
  • 5.2Communication barriers on patients’ side
    • 5.2.1Anxiety, pain and discomfort
    • 5.2.2High interference with attendants
    • 5.2.3Presence of family on bedside
    • 5.2.4Lack of trust, privacy and confidentiality
    • 5.2.5Power imbalance
  • 5.3Impact of communication barriers on patient safety
  • 5.4Ethical Consideration, Reliability and Validity
• 6Discussion and conclusion
  • 6.1Discussion
  • 6.2Conclusion
• 7List of Abbreviations and acronyms
  • 7.1Figures and Tables
• 8References
• 9Appendix

1 Introduction

Nursing is one of the essential elements of healthcare provision which involves collaborative care that is non-discriminatory of age, race, gender, or setting (WHO, 2020a). It includes health promotion, prevention of disease, treatment of illness, provision of terminal care, and rehabilitation (WHO, 2020a).

For a long time, nursing has primarily focused on provision of care to individuals unable to meet their self-care needs. However, as healthcare needs and challenges evolve, nursing has evolved to include complex roles in provision of healthcare services (Morin, 2014). While care services are still at the core of nursing practice, nursing currently includes advanced roles such as patient assessment, implementation of healthcare interventions, healthcare promotion, among others (Delamaire & Lafortune, 2010). These new roles demand that nurses be vigilant in order to deliver quality services to patients. Failure to adhere to strict standards and protocols while performing these advanced roles can be catastrophic to the patient (Odell, 2015).

For nurses to deliver quality healthcare that places patient safety at the pinnacle of care, one of the most essential elements of care is communication (Banerjee et al., 2016a). Communication is the exchange of information, thoughts and feelings through speech or other means. In the context of nursing, the parties of interest are the nurses and the patients (Kourkouta & Papathanasiou, 2014).

Nurses play an important role in provision of care by linking the patient to the healthcare service (Sibiya, 2018). The quality of communication between the patient and the nurse therefore has a huge bearing on patient safety (Vermeir et al., 2015). For instance, one of the ways through which poor communication can affect patient safety is through misunderstanding instructions (Vermeir et al., 2015). In such a case, if nurses wrongly interpret information such as medication dosage and administer the wrong dosage, the patient is at risk for adverse medication reaction. Patient safety is defined as the reduction of risk of unnecessary harm to acceptable minimum levels (Müller et al., 2018).

Barriers to communication increase the risk of negative outcomes in patient care (Norouzinia et al., 2016). Barriers to communication in nursing are defined as factors impeding the effective flow of communication between nurses and patients (Norouzinia et al., 2016). They include physical barriers such as noise, language barriers, cultural differences, bias and prejudice, interpersonal barriers, and emotional barriers (Amoah et al., 2019). In a recent study, communication errors were the cause of 70% of the major adverse effects in healthcare settings (Ot et al., 2018).

Gender is only one of many inherent characteristics that may create biases that set up barriers to communication. In this sense, an individual’s values and beliefs can affect their communication with others (Gault et al., 2016). For instance, a male nurse may consider it inappropriate to care for an elderly female patient or a female patient and their family may assume that a male nurse cannot be a midwife. Such biases can affect the communication and relationship between the patient and nurse (Gault et al., 2016).

Another characteristic that is worth noting is the age distribution of nurses. The average age of registered nurses is about 50 years, with the current average in the United States being about 53 years (Smiley et al., 2018). The age difference between the nurse and patients has also been cited as a barrier to communication (Norouzinia et al., 2016; Wune et al., 2020a).

Table 1: Table showing the age distribution of Registered Nurses according to the 2017 Nursing Workforce Survey

Nursing has traditionally been oriented towards provision of care to individuals unable to meet their self-care needs. However, as healthcare needs and challenges evolve, nursing has evolved to include complex roles in provision of healthcare services (Morin, 2014). It includes roles such as health promotion, prevention of illness, advocacy, provision of care for the sick, disabled, and dying individuals, among others (Schroeder & Lorenz, 2018).

2.2 Communication

The WHO defines communication in the healthcare setting as not only the exchange of information, but also the exchange of meaning (WHO, 2020c). The goal of communication is the exchange of ideas to foster understanding between parties (Smith, 2019). One of the most significant elements that nurses must master to deliver healthcare services that places patient safety at the pinnacle of care goals is communication (Banerjee et al., 2016a). Communication between the nurse and patient fosters a relationship between the patient and the healthcare system, but additionally influences the patient’s perception of the therapeutic process and the outcome of care (Alshammari et al., 2019a).

Figure 2: Image showing the process of communication (Smith, 2019).

Effective communication can have positive outcomes on the patient including decreased pain, guilt, anxiety, and disease symptoms along with increased patient satisfaction, acceptance, and compliance and cooperation with the medical team (Norouzinia et al., 2016).

Communication barriers between nurses and patients affect patient safety in several ways. For example, breakdown in communication may result in higher incidence of adverse effects which are not addressed in time (Burgener, 2017). Important information may be lost because of the use of medical terms and may result in reduced patient safety, especially when medical terms are used with patients (Lippke et al., 2019).

2.4 Patient Safety

A patient is defined by the WHO as any recipient of healthcare (WHO, 2020b). Patient safety is a healthcare discipline that is targeted at the prevention and reduction of errors, risks and harm that a patient is exposed to as they receive health care (WHO, 2020b).

Patient safety is an essential prerequisite for any healthcare service to be considered effective and of good quality (Ammouri et al., 2015). The WHO allows for a certain acceptable minimum exposure to harm and risk as virtually every phase in the care-giving process has a particular extent of inherent unsafety (WHO, 2020b). Proper communication is crucial to establish patient safety, and to guarantee sustainable improvements in patient safety (Burgener, 2017).

Barriers and errors in communication have been cited as the major cause of most of the preventable adverse effects in healthcare settings (Müller et al., 2018; Ot et al., 2018). Therefore, the link between the quality of communication between the patient and the nurse and patient safety is strong and worth paying attention to (Vermeir et al., 2015).

3 Problem statement, Justification and Research Question

3.1 Problem statement

Nurses play an important role in provision of care by linking the patient to the healthcare service (Sibiya, 2018). The quality of communication between the patient and the nurse therefore has a huge bearing on patient safety (Vermeir et al., 2015). Barriers to communication potentially increase the risk of negative outcomes in patient care (Norouzinia et al., 2016). In a recent study, communication errors were the cause of 70% of the major adverse effects in healthcare settings (Ot et al., 2018). Another study found communication breakdown to be responsible for about 80% of preventable adverse effects in the healthcare setting (Burgener, 2017). Furthermore, communication barriers lead to patient dissatisfaction and subsequently higher rates of work-related violence in the healthcare setting (Alshammari et al., 2019a).

3.2 Justification

Barriers to communication potentially increase the risk of negative outcomes in patient care (Norouzinia et al., 2016). The purpose of this study was to assess the available knowledge on communication barriers between nurses and patients and to assess the impact of these barriers on patient safety.

The aim of this study was to produce evidence-based knowledge on the communication barriers that exist between nurses and patients and to assess the influence of these barriers on patient safety in order to influence nursing education for student nurses, current practice by practitioner nurses, and policy by hospitals and hospices where nurses provide care. The ultimate goal was to improve patient safety.

3.3 Research Questions

What communication barriers exist between nurses and patients, and what is the influence of these barriers on patient safety?

4 Methodology

4.1 Data Collection

Data was extracted from studies which fit the predetermined inclusion criteria for the study. Elsevier, PubMed, ProQuest and Google Scholar databases were searched for studies that fit in the criteria below. The key words used in the searches were “COMMUNICATION”, “NURSING”, “BARRIERS” and “PATIENT SAFETY”. The searches were limited to a time range of between 2010 and 2020.

full-text review. Finally, the full texts were screened in order to select those that would be included in the final synthesis.

Figure 3: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow

chart for the current study

Studies identified through database

searching (n = 28)

Studies after duplicates were

removed (n = 23)

Records assessed against inclusion

criteria (n = 22)

Full-text review of records for

eligibility (n = 20)

Studies included in synthesis

(n = 20)

By searching for the key word ‘COMMUNICATION’ alone, Elsevier generated 667,602 results, PubMed generated 348,637 results, ProQuest generated 1,193,863 results and Google Scholar generated 1,830,000 results. The keywords ‘COMMUNICATION’ and ‘NURSING’ generated 50,244 results in Elsevier, 28,293 results in PubMed, 104,759 results in ProQuest and 1,630,000 results in Google Scholar. By entering the key words ‘COMMUNICATION’, ‘NURSING’ and ‘BARRIERS’, the search generated 18,366 results in Elsevier, 2,462 results in PubMed, 40,255 results in ProQuest and 93,300 results in Google Scholar. The final search was done by entering the keywords ‘COMMUNICATION’, ‘NURSING’, ‘BARRIERS’ and ‘PATIENT SAFETY. This generated 8,458 results in Elsevier, 227 results in PubMed, 15,844 results in ProQuest and 19,500 results in Google Scholar.

Keyword(s) searched (^) Databases Number of results generated

Communication Elsevier PubMed ProQuest Google Scholar

Communication, Nursing

Elsevier PubMed ProQuest Google Scholar

Communication, Nursing, Barriers

Elsevier PubMed ProQuest Google Scholar

Communication, Nursing,

Barriers, Patient Safety

Elsevier PubMed ProQuest Google Scholar

Table 3: Summary of results from database searches

8. van Rosse et al., 2016 Google Scholar Mixed methods
9. Wittenberg-Lyles et al., 2013 Google Scholar Mixed methods
10. Newell & Jordan, 2015 Google Scholar Qualitative
11. Bramhall, 2014 Google Scholar Qualitative
12. Taylor et al., 2013 Google Scholar Qualitative
13. Norouzinia et al., 2015 Google Scholar Quantitative
14. Ali & Watson, 2018 Google Scholar Qualitative
15. Banerjee et al., 2016 Google Scholar Qualitative
16. Zamanzadeh et al., 2014 Google Scholar Qualitative
17. Bach & Grant, 2015 Google Scholar Qualitative
18. Arkorful et al., 2020 Google Scholar Qualitative
19. O’Hagan et al., 2014 Google Scholar Qualitative
20. Tay et al., 2011 Google Scholar Qualitative

Table 4: Characteristics of the studies included in the synthesis.

5 Results

The 20 studies that were included in the final synthesis covered 10 countries from 5 continents. These included Ethiopia and Ghana from Africa, Netherlands and England from Europe, United States of America from North America and Australia from Australia continent. The countries covered from Asia were Saudi Arabia, Japan, Iran and Singapore.

Three (3) of these included studies used quantitative methods, 15 used qualitative methods and 2 used mixed methods. The studies also had diverse sample sizes, ranging from as low as 7 to as high as 576. The study populations included nurse-only populations, patient-only populations and mixed populations comprising of both patients and nurses.

The major themes were grouped into three, based on the objectives:

1. Communication barriers on the nurses’ side
2. Communication barriers on the patients’ side
3. Impact of these barriers on patient safety

The sub- themes identified from ‘communication barriers on the nurses’ side’ were language, religious and cultural differences, nurse-patient ratio, fatigue, low or insufficient salary and working environment. From “communication barriers on the patients’ side” the identified sub-themes were anxiety, pain and discomfort, high interference with attendants, presence of family on bedside, lack of trust, privacy and confidentiality and power imbalance between the nurse and patient.

THEME SUB-THEME NUMBER OF PAPERS

Communication barriers on the nurses’ side

• Language, religious

and cultural differ-

ences.

• Nurse-patient ratio
• Fatigue
• Low or insufficient

salary

• Working environ-

ment

This is because patients may explain symptoms in a language that nurses do not understand and thus, the nurses misunderstand their condition. Alshammari et al. stated that some of the patients’ cultural practices may seem irrational to nurses such as covering their hair and face as well as gender segregation (Alshammari et al., 2019b). Differences in language, religion and culture between nurses and patients affects the provision of appropriate, timely, safe and effective care (P. A. Ali & Watson, 2018).

5.1.2 Nurse-patient ratio

Human resource in the health care sector is very limited (Arkorful et al., 2020). Five studies showed that the number of nurses is very low compared to the number of patients (Wune et al., 2020b; Arkorful et al., 2020; Chan et al., 2018; Norouzinia et al., 2015; Zamanzadeh et al., 2014). This means that nurses move from one patient to another quickly and the time spent with each patient is limited, thus they do not get a chance to establish an interpersonal relationship with the individual patients (Banerjee et al., 2016b). This becomes a barrier to communication because the nurses do not take the time to understand each patient’s condition (Wune et al., 2020b).

5.1.3 Fatigue

Several studies indicated that nurses’ fatigue is a major communication barrier between nurses and patients (Wune et al., 2020b; Kwame & Petrucka, 2020; Arkorful et al., 2020; Chan et al., 2018; Norouzinia et al., 2015; Zamanzadeh et al., 2014; Amoah et al., 2018). Kwame and Petrucka found that many nurses often work for several long-hour shifts, leading to them having burnout (Kwame & Petrucka, 2020). Such nurses may not communicate effectively with their patients. In addition, due to the several roles that nurses play in healthcare, they often end up having an overwhelming workload and may not be able to have quality communication with their patients for this reason (Arkorful et al., 2020).

5.1.4 Low or insufficient salary

Wune et al reported that low or insufficient salary is also a barrier in nurse-patient communication (Wune et al., 2020b). Nurses who are overworked and underpaid often lack the motivation and drive to do their work effectively. Consequently, this affects the interaction between the nurse and their patients and in turn affects the quality of communication between the two parties.

5.1.5 Working environment

Another major communication barrier on the nurses’ side is unsuitable working environment. This may be in terms of the physical environment itself or in terms of the organizational structure. Several studies showed that background noise in the wards greatly affects the quality of communication between nurses and patients (Kwame & Petrucka, 2020; Chan et al., 2018; Amoah et al., 2018). Noise interferes with the concentration of nurses and also the clarity of messages passed. Organizational structure, as reported by several studies, acts as a communication barrier when there are unclear clinical practice roles (Wittenberg-Lyles et al., 2013). This creates confusion in the communication cycle because nurses are not sure or aware of the information they are supposed to pass to their patients.

5.2 Communication barriers on patients’ side

For communication to be considered successful, the communication cycle between the sender (nurse) and receiver (patient) has to be complete. However, this is often not the case because of several factors on the patients’ side that may hinder communication. These are discussed below.

5.2.1 Anxiety, pain and discomfort

Four studies highlighted that anxiety, pain and discomfort is a major communication barrier on the patients’ side (Wune et al., 2020b; Chan et al., 2018; Norouzinia et al., 2015; Amoah et al., 2018). Most patients are not entirely comfortable in the hospital setting. Some fear needles, while some do not bode well with the smell or taste of medication (Amoah et al., 2018). In addition, depending on the patients’ conditions, they may almost always be in some sort of pain (Norouzinia et al., 2015). All these conditions affect the patients’ ability to communicate effectively with their nurses and hence, the quality of communication is poor.