Barriers to nurse-patient communication in primary healthcare centers in Bahrain: Patient perspective.

Objectives: Effective and efficient communication is a core element in healthcare systems, especially between healthcare providers and patients. This study aimed to identify communication barriers between nurses and patients in primary healthcare centers in Bahrain.
Methods: This is a cross-sectional study conducted across primary healthcare centers in Bahrain. Four hundred and two patients were recruited using convenience sampling. A self-administered questionnaire comprising 29 items on communication barriers was used.
Results: A total of 402 patients consented to participate. The majority of participants reported the following statements had large effects on communication: "shortage in the number of nurses compared to the large number of patients" (254/401, 63.3%), "lack of desire of nurse to communicate with patients" (246/402, 61.2%), and "negative attitude of the nurse toward the patient" (238/401, 59.4%). Further, "difference in language between nurses and patients," "lack of self-confidence by nurses," and "nurses overwhelmed by work" were ranked as top three statements with a significant influence on communication between nurses and patients. Conclusions: Communication between healthcare providers and patients is pivotal for an optimal healthcare service. Based on the findings of this study and the literature, we recommend formal training of health care workers in improving communication skills and including this not only in medical curriculum but also in the form of continuing medical education (CMEs).

What is known?

Communication has a significant impact on the relationship between nurses and patients, quality of healthcare and patient satisfaction. Successful communication skills can soothe a patient’s anxieties and pain, improve satisfaction, and help avoid harm.

In healthcare systems, errors in communication have been cited to be the primary reason behind many reported incidents and complaints.

What is new?

This cross-sectional study in the Kingdom of Bahrain showed that the most prevalent communication barriers between nurses and patients were differences in language, lack of self-confidence and negative attitudes towards patients.

Based on our findings, and after reviewing of the literature, we recommend improving communication skills of healthcare workers through embedding communication skills across the curriculums as a vertical and spiral theme. Further, this should be reinforced by continuing medical education activities after graduation, in addition to supporting nurses with personal development programs and workshops.

Introduction

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 [1]. When communication barriers arise, they can compromise the outcome of the care provided [2,3]. 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 [4,5]. Moreover, effective communication can increase patient satisfaction, acceptance, compliance, and improve the physiological and functional status of the patient [6,7]. 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 [[7], [8], [9]].

In the Kingdom of Bahrain, the first point of contact for patients in the healthcare system is the emergency department in hospitals and primary healthcare centers. There are 28 health centers divided among five health regions within the Kingdom [10], and they provide services to the Bahraini and Non-Bahraini population in the country, which is estimated to be a total of 1.5 million [11]. In primary healthcare centers, patients are seen by general practitioners, family physicians, radiology technicians, laboratory technicians, and nurses. Nurses in primary healthcare centers are responsible for services such as providing vaccinations and wound care, the monitoring of vital signs, as well as implementing treatment plans provided by the physicians. In 2019, over 2 million nursing activities were provided to patients, and over 500 thousand dressing wound services were completed in health centers alone [12]. Therefore, nurses are a frequent point of contact for patients in healthcare centers.

Based on the Bahrain National Health Regulatory Authority (NHRA) statistics, there were around 71 complaints filed against the healthcare system of Bahrain in 2013, 43.6% of which were against nurses or provided nursing care [13]. In 2019, 13 of the 33 reported incidents were against nurses [14]. However, these statistics did not outline the nature of filed complaints and reported incidents, and no prior studies have been conducted to explore this further. In other healthcare systems, errors in communication have been cited to be the primary reason behind many reported incidents and complaints, as seen with the National Health Service in the UK, which reported that in the first and second quarters of 2021 alone, most reported complaints were attributed to communication issues [15]. Therefore, it can be assumed that communication plays a huge role in healthcare quality.

A study published in 2012 objectively assessed the communication between physicians and patients visiting general practice and general surgery clinics for the first time in one of the main hospitals in Bahrain [16]. The study found that the communication skills of the physicians in both specialties were inadequate and that the consultation time was less than the recommended best practice guidelines [16]. This study gives a hint that there might be the same gap defect in nurse-patient communication, and having more research conducted in this field would guide higher institutions to improve the healthcare system in Bahrain.

Because nurses are a frequent point of contact, a study of communication and its barriers between patients and nurses is recognized as an important step in the improvement of the quality of healthcare. The objective of this study is to explore the quality of communication between nurses and patients and to identify the barriers that may impact it as perceived by nurses and patients in primary healthcare settings. Understanding the barriers to effective nurse-patient communication can provide an opportunity to minimize them.

Methodology

Study design

This is a cross-sectional study that aims to identify barriers to nurse-patient communication in primary health care centers in Bahrain using a self-administered questionnaire.

Sampling method

Ten primary healthcare centers were selected using multistage cluster random sampling from the 28 primary healthcare centers: two health centers from each of the five health regions. A total of 402 patients attending primary health care centers were recruited using convenience sampling. Inclusion criteria for the participants included: Having the capacity to communicate, being able to read and write, being 18 years of age and older. Exclusion criteria included: Communication or cognitive impairment.

The survey was conducted from December 2018 to January 2019. Participants were approached in the waiting areas of the healthcare centers and given a consent form, an information sheet, and a questionnaire paper according to the language most convenient to them (English or Arabic). Patients were given the questionnaire papers to answer alone, but were prompted to refer to the researchers if further clarification of the questionnaire items was needed.

Study instrument

The questionnaire consisted of 29 items that examined barriers in nurse-patient communication as well as demographic data. Each questionnaire item had 6 possible responses: not applicable, no effect, little effect, medium effect, large effect. At the end of the questionnaire, participants were prompted to rank three questionnaire items that they believed were the most important factors that had a big impact on communication with nurses. This questionnaire was adopted with permission from a study conducted at Tehran University of Medical Sciences. Content validity was assessed using the split-half method by eight professors at Tehran University of Medical Sciences, and the originally reported reliability value was 0.76 [7]. The questionnaire, originally in Persian, was translated by a professional translator and back-translated to Persian. Content validity has been tested by two experts in the field and amendments have been made accordingly.

Data analysis

Data analysis was performed using Statistical Product and Service Solutions (SPSS) software version 25. Descriptive analysis of all variables was conducted. Continuous data were presented as means and standard deviations. Categorical variables were summarized using frequencies and percentages. The associations between selected statements and categorical variables were tested using Pearson’s chi-square test. A P value of 0.05 was considered significant.

Three statements that were recognized by most participants as having a ‘big effect’ on the communication between nurses and patients, and three statements that were ranked by participants as the most affected communication with the nurse were selected for further statistical analysis. A Pearson’s chi-square test was used to test the associations between the questionnaire items and the categorical variables.

Ethical approval

This research was approved by the Research Ethics Committee at the Royal College of Surgeons in Ireland—Medical University of Bahrain in May 2018 and by the Research Ethics Committee of the Ministry of Health of the Kingdom of Bahrain in September 2018 (Approval No.: AURS/751/2018). No participant was coerced to participate in this study, and all participants were asked to provide verbal consent. All participants were provided with the option to withdraw from the study at any point. To ensure anonymity, no personal information such as the national identity numbers or participant names or any other information linking to a specific participant was collected. All data collected from participants is stored electronically within a password-protected document and will be deleted after three years of the publication of this study.

Results

Sociodemographic data of the participants

A total of 402 participants consented to participate. The mean age for participants was 36.83 years (SD = 11.66), and the median was 35 (range 18–80 years). The mean number of children was 2.37 (SD = 2.03), and the median was 2. Table 1 shows the sociodemographic data of the participants. The majority of participants were female (71.9%) and married (77.9%). Almost half of the participants (47.0%) were employed, and a small proportion (4.0%) were students. Further, 44.3% of participants had an undergraduate degree, and 38.6% had a high school diploma. About one-third of patients (36.1%) attended the healthcare center once a month, and 35.3% visited the healthcare center twice a year.

Table 1

Demographic data of participants (n = 402).

Characteristics	n	%
Age (years) ∗
18–25	67	16.8
26–35	144	36.2
36–45	100	25.1
46–55	53	13.3
>55	34	8.5
Gender
Female	289	71.9
Male	113	28.1
Educational status
Primary School	11	2.7
Intermediate School	26	6.5
High School	155	38.6
Undergraduate	178	44.2
Postgraduate	32	8.0
Employment
Employed	189	47.0
Unemployed	161	40.0
Retired	36	9.0
Student	16	4.0
Marital Status
Single	67	16.7
Married	313	77.9
Widowed	11	2.7
Divorced	11	2.7
Number of visits to health center during the year ∗
Once a year	45	11.3
Twice a year	142	35.6
Once a month	145	36.3
Once a week	40	10.0
More than once a week	27	6.8

Note: ∗ Sample size varied due to missing data.

Descriptive analyses of the responses to the questionnaire items

Table 2 shows the responses of the study participants to all questionnaire items. According to the participants’ responses, “shortage in the number of nurses compared to the large number of patients” (254/401, 63.3%), “lack of desire of nurse to communicate with patients” (246/402, 61.2%), “negative attitude of the nurse toward the patient” (238/401, 59.4%), and “lack of adequate understanding of the patient’s condition by nurses” (237/402, 59.0%) had large effects on communication. On the other hand, the majority (above 80%) of participants reported that differences in religion and age had no effect on communication between nurses and patients.

Table 2

Responses of the participants to the questionnaire items (n = 402).

No.	Item	Not Applicable	No Effect	Little Effect	Medium Effect	Large Effect
1	Difference in age between nurse and patient ∗	2 (0.5)	321 (80.1)	28 (7.0)	34 (8.4)	16 (4.0)
2	Difference in gender between nurse and patient	2 (0.5)	215 (53.5)	89 (22.1)	58 (14.4)	38 (9.5)
3	Difference in culture between nurse and patient ∗	5 (1.3)	211(52.6)	92 (22.9)	61 (15.2)	32 (8.0)
4	Difference in religion/religious affiliation between nurse and patient ∗	4 (1.0)	327 (81.8)	33 (8.3)	22 (5.5)	14 (3.5)
5	Difference in language between nurse and patient	1 (0.3)	115 (28.6)	98 (24.4)	90 (22.4)	98 (24.4)
6	Lack of job satisfaction by nurses ∗	20 (5.0)	51 (12.8)	50 (12.5)	54 (13.5)	225 (56.3)
7	Lack of knowledge of the definition of communication, its types, and communication skills by nurses ∗	11 (2.7)	40 (10.0)	46 (11.5)	94 (23.4)	210 (52.4)
8	Lack of self-confidence by nurses	17 (4.2)	42 (10.5)	51 (12.7)	87 (21.6)	205 (51. 0)
9	Negative attitude of the nurse towards the patient ∗	12 (3.0)	37 (9.2)	43 (10.7)	71 (17.7)	238 (59.4)
10	Lack of desire of nurse to communicate with the patient	8 (2.0)	46 (11.4)	38 (9.5)	64 (15.9)	246 (61.2)
11	Lack of adequate understanding of the patient’s condition by nurses	9 (2.2)	26 (6.5)	43 (10.7)	87 (21.6)	237 (59.0)
12	Past negative experience by nurses in dealing with the patient or other patients ∗	10 (2.5)	119 (29.7)	67 (16.7)	123 (30.7)	82 (20.5)
13	Reflection of the relationship of other members of the medical team with the nurse ∗	11 (2.7)	172 (42.9)	69 (17.2)	83 (20.7)	66 (16.5)
14	Shortage in number of nurses compared to the large number of patients ∗	9 (2.2)	32 (8.0)	38 (9.5)	68 (17.0)	254 (63.3)
15	Too much work and tasks to be done by the nurse throughout the day ∗	7 (1.8)	39 (9.8)	49 (12.3)	104 (26.0)	201 (50.3)
16	Lack of time to communicate with patients	4 (1.0)	45 (11.2)	65 (16.2)	123 (30.6)	165 (41.0)
17	Too many tasks that exhaust the nurse because of excessive work requirements	6 (1.5)	40 (10.0)	60 (14.9)	101 (25.1)	195 (48.5)
18	Low financial income for the nurse	27 (6.7)	215 (53.5)	36 (9.0)	59 (14.7)	65 (16.2)
19	Patient’s lack of understanding of the nurses’ job and duties ∗	8 (2.0)	87 (21.8)	87 (21.8)	98 (24.0)	122 (30.5)
20	Negative attitude of the patient towards the nurse ∗	5 (1.3)	77 (19.3)	50 (12.5)	100 (25.0)	168 (42.0)
21	Resistance and hesitation of the patient to communicate with the nurse ∗	10 (2.5)	80 (20.0)	73 (18.3)	104 (26.0)	133 (33.3)
22	Lack of interest or concentration of the patient ∗	13 (3.2)	59 (14.7)	49 (12.2)	100 (24.9)	180 (44.9)
23	Stress, pain and distress of the patient	6 (1.5)	93 (23.1)	56 (13.9)	114 (28.4)	133 (33.1)
24	Interference of family members/companions in communication ∗	8 (2.0)	89 (22.2)	60 (15.0)	120 (29.9)	124 (30.9)
25	The continuous presence of family members at the patient’s bedside	8 (2.0)	110 (27.4)	66 (16.4)	94 (23.4)	124 (30.8)
26	The presence of the patient in an unfamiliar environment (for example, the hospital)	10 (2.5)	181 (45.0)	75 (18.7)	81 (20.2)	55 (13.7)
27	Environmental disturbances (loud noise, continuous moving) ∗	6 (1.5)	35 (8.7)	57 (14.2)	103 (25.7)	200 (49.9)
28	Inappropriate environmental conditions (lack of air conditioning, too cold or too hot environment, inadequate lighting, unpleasant smells, etc)	8 (2.0)	40 (10.0)	50 (12.4)	85 (21.1)	219 (54.5)
29	Having a serious case in the department (where nurses would focus all their attention on that patient compared to other patients)	11 (2.7)	156 (38.8)	64 (15.9)	88 (21.9)	83 (20.7)

Note: Data are n (%).∗ Sample size for different items varied due to that one or two patients did not respond.

3.3 Statistical analyses of responses to questionnaire items and the sociodemographic data of participants

The items selected for statistical analyses were statements 5, 8, 9, 10, 14, and 15. Statements 9, 10, and 14 were selected on the basis that they were the three statements that were recognized by most participants as having a ‘big effect’ on the communication between nurses and patients, whereas statements 5, 8, and 15 were selected because they were ranked by participants as the statements that most affected communication with the nurse.

Association between the six selected questionnaire items and sociodemographic variables was analysed. There were statistically significant associations between responses to statement 8 (lack of self-confidence by nurses) and participants’ age and educational status (P < 0.05). The majority aged between 36 and 55 years agreed that the lack of self-confidence by nurses has a large effect on communication, whereas participants aged 18–25 years and participants over 56 years had more variation in their responses. Associations between responses to statement 9 (negative attitude of the nurse toward the patient) and participants’ gender and educational status were statistically significant, with P values of < 0.05. Among all participants who agreed that this statement was associated with a large effect on communication, 77.3% (184/238) of them were female. Similarly, participants with an undergraduate or postgraduate educational status mostly agreed that this statement had a big effect on communication, while there was more variation noted in the responses of participants with primary school or intermediate school educational status. For statement 10 (lack of desire of a nurse to communicate with the patient), 31.8% (36/113) of male participants had responded that this lack of desire had little to no effect on communication with nurses, or not applicable, whereas only 19.4% (56/289) of female participants had agreed on the same; 63.7% (184/289) of female participants believed that it had a large effect on communication (P < 0.05).

Discussion

The most important barriers to communication from patients’ perspective

The factors that most participants perceived as barriers to communication were differences in language between nurses and patients, lack of self-confidence by nurses, negative attitudes of the nurse toward patients, nurses’ lack of desire to communicate with patients, and a shortage in the number of nurses and being overwhelmed by various tasks. Similar findings have been reported in other studies [7,[17], [18], [19]]. For instance, the lack of desire to communicate with patients was noted to be a significant barrier affecting communication in studies conducted by Nourouzinia et al. and Amooh et al. [7,18]. In addition, in the study conducted by Park and Song and by Amooh et al., it was found that being overwhelmed by the various tasks and the shortage in the number of nurses throughout the day was perceived a significant barrier to communication with nurses [17,18].

Language difference was perceived to have a big effect on communication with nurses. This finding was consistent with the results of Anoosheh et al., del Pino et al., and Alshammari et al. [[19], [20], [21]]. This finding was expected given that the Kingdom of Bahrain has a diverse population of citizens and expatriates from different cultural backgrounds and ethnicities. 45% of the population are non-Bahraini [11,22], and other languages such as English, Hindi, Urdu and Tagalog are becoming more prevalently spoken, even though the Kingdom’s primary spoken language is Arabic [22]. In addition, 26.4% of nurses in primary healthcare are non-Bahraini [23], which makes good communication skills despite differences in language essential when providing healthcare, especially when language barriers have been associated with a negative impact on the quality of care, patient satisfaction and patient safety [24].

Another factor noted particularly by middle-aged participants or those with higher educational levels is nurses’ lack of confidence. The role of self-efficacy in communication was explained by Cicotto and de Simone, who found that amidst other factors, self-efficacy was positively correlated with patient satisfaction and negatively correlated with nurse turnover rate [25]. Nurses who were less self-efficacious were more likely to leave their jobs, and thus were less likely to engage with the workplace and patients [25].

An association was found between the gender of the participants and both the negative attitude and the lack of desire of nurses to communicate with patients. Female patients specifically had considered these two factors to have an impact on communication. In a study by Foss and Sundby, nurses perceived male patients to be more easy-going and appreciative of the nurses’ efforts, whereas female patients were more critical, making communication more difficult [26]. We did not investigate this hypothesis in our study. However, we found similar patterns from the patients’ perspectives; female patients considered statements such as “negative attitude of the nurse toward the patient” and “lack of desire of nurse to communicate with patients” to have a greater effect on communication compared to male patients.

Strengths and limitations of the study

One of the strengths of this study is the use of a multistage cluster sampling technique, which allowed the inclusion of health centers from five health regions across the country. On the other hand, one of the limitations is the lack of a total score that quantifies the overall effect of different factors and barriers; hence, it was difficult to perform a bivariate inferential analysis.

Implications on current practice

The aim of healthcare services is not limited to providing treatments but also comforting and supporting patients. Since communication has a pivotal role in achieving this, the elimination of communication barriers is paramount.

Overcoming language barriers in nursing is crucial to providing care for any patient who speaks Arabic only. When language barriers arise, medical interpretation services ensure quality, patient-centered care. The use of translated educational pamphlets can also aid in the delivery of accurate information to patients. Additionally, communication skills training should be integrated in the early years of nursing education and reinforced and continued throughout practice. Furthermore, negative attitudes of nurses need to be explored in detail to identify solutions for improvements, such as communication skills workshops on specific topics like burn-out and anger management. Self-confidence among nursing staff can be improved with further training, personal development programs, and experience.

Conclusion

Communication between healthcare providers and patients is pivotal for an optimal healthcare service. There are many contributing elements to good communication. In primary healthcare centers in the Kingdom of Bahrain, the factors perceived to most affect communication are differences in language, negative attitudes and lack of desire to communicate, lack of confidence by nurses, as well as shortage of nurses and work overload. Based on the findings of this study and the literature, it is recommended that efforts should be directed toward continuous monitoring and improvement of communication skills.

Declaration of competing interest

The authors have declared that there are no conflicts of interest with regard to the publication of this paper.

Funding

Nothing to declare.

Data availability statement

The authors declare the absence of shared data in the present study.

CRediT authorship contribution statement

Nada Mahmood Abdulla: Conceptualization, Methodology, Resources, Investigation, Writing – original draft, Writing – review & editing. Rula Jamal Naqi: Conceptualization, Methodology, Resources, Investigation, Writing – original draft, Writing – review & editing. Ghufran Ahmed Jassim: Supervision, Project administration, Conceptualization, Formal analysis, Writing – review & editing.

The authors declare that there is no conflict of interest. There are no funding sources for this research.