Patients' perceptions of nurses' communication in public hospitals of Harari Regional State, Eastern Ethiopia.

Introduction: The quality of nursing care has been evaluated using patient perception. Patients' participation in nursing care and decision-making is regarded as a prerequisite for effective clinical practice; however, poor communication can lead to incorrect diagnosis and delayed, or ineffective medical treatment.
Objectives: This study sought to assess admitted adult patients' perceptions of, and factors influencing, nurse communication at public hospitals in Harar, eastern Ethiopia.
Methods: Facility-based cross-sectional study was conducted among 377 admitted adult patients in Harar Town public Hospitals from 15 April to 30 May 2020. A proportionate stratified sampling technique was used to select the study participants. A pretested and structured questionnaire was used to collect data through a face-to-face interview and which were entered into EpiData and analyzed using SPSS. Bivariate and multivariate logistic regression analyses were conducted, odds ratio and confidence intervals were calculated and statistical significance was declared at p < 0.05.
Results: This study outlined that the overall prevalence of good perception toward nurses' communication was 41.9% (95% confidence interval = 37.1%, 46.9%). Patients whose age group were 26-35 years (adjusted odds ratio = 0.46 (95% confidence interval: 0.24, 0.86), Being female patients (adjusted odds ratio = 1.89; 95% confidence interval: 1.20, 2.98), admitted in private room (adjusted odds ratio = 3.25; 95% confidence interval: 1.91, 5.51), patients who have family support (adjusted odds ratio = 2.56; 95% confidence interval: 1.16, 3.64), urban residence (adjusted odds ratio = 0.65; 95% confidence interval: 0.02, 0.66) and language difference (adjusted odds ratio = 0.61; 95% confidence interval: 0.40, 0.94) were statistically significant.
Conclusion: This study pointed out that less than half of the study participants had good perceptions toward nurses' communication. As a result, increasing the number of health care providers who speak the same language as the patients and communication and behavioral change training must be prioritized.

Introduction

Communication is a vital means of interaction in any type of relationship. Clear communication and proper information delivery in health care facilities are critical in engaging patients to participate in their care and management. Effective communication boosts clinical competence while also assisting patients in developing confidence and successful self-care.[1-3]

Nursing care is an essential service offered to hospitalized patients. The holistic approach, which is the heart of the profession, allows nurses to diagnose and manage patients who have actual or potential health problems.[4,5] Nurses influence patient satisfaction and overall quality of care because they make up the majority of the health care workforce.

Nurses have to teach, advocate, build trust and maintain confidentiality with patients and family members. The success of these roles is highly dependent on the quality of the nurse–patient relationship.[4,7] One of the prominent nursing theories, Hildegard Peplau’s “Interpersonal Relations Theory,” defines nursing as “an interpersonal, therapeutic process that takes place when professionals, specifically educated to be nurses, engage in therapeutic relationships with people who require health services.” This theory emphasizes that therapeutic communication is the cornerstone of the nurse–patient relationship, a fundamental component of the care continuum, and significantly impacts the quality of patient-centered care.

Patient satisfaction surveys solicit feedback from patients or family members about the overall quality of health care services. Metrics that assess patients’ perceptions of nursing care have also gained popularity and are widely accepted as a measure of nursing care quality.[9-11] Patients’ perceptions of nurses’ communication are defined as the patients’ emotions or perspectives on their interactions with nurses during their hospital stay.

Patients’ perceptions of nursing communication could be influenced by factors such as socioeconomic status, age, educational level, monthly income, cultural background, previous hospital experiences, nurse support and respect, nurses’ consistent availability and appropriately supplied responses.[6,13]

Several studies on patient satisfaction with nursing care have been conducted. However, in the majority of these studies, nurse–patient communication has been overshadowed by other components.[1,6,9,14-16] Research on patients’ perceptions of nurses’ communication is critical for improving clinical service quality and patient satisfaction, adding to the body of knowledge in nursing and generating evidence that can be used to guide interventional strategies.

Ethiopia’s health care is inadequate and substandard, and the country’s health status is worse than other low-income countries.[15,17,18] Several bottlenecks hinder the nation’s path to an improved and efficient health care delivery. Part and parcel of the problem is the poor quality of nursing care offered in tertiary health facilities. Despite this, the specific root causes impacting quality are yet to be further investigated. The issue of the patient–provider relationship in health care facilities is frequently ignored in medical research and rarely subjected to scientific investigation. To this end, this study inquired about admitted adult patients’ perceptions of nurses’ communication and the influencing factors in public hospitals in Harar, eastern Ethiopia.

Method

Study design, study setting and period

Institutional-based cross-sectional study was conducted from 15 April to 30 May 2020, in Hiwot Fana Specialized University Hospital (HFSUH) and Jugol Hospital (JH), Harari region, Ethiopia. The region is one of Ethiopia’s 10 regions, and it is located in the country’s east. Harar, the region’s capital city, is situated on a hilltop in the eastern extension of the Ethiopian highlands, approximately 510 km from Addis Ababa. It has an elevation range of 1800 to 2000 m. The region has a total area of 342.2 km2, of which 323.7 km2 is rural. The total population is estimated to be 203,834 based on FMoH, Health, and Health-Related Indicator data. The region comprises 19 urban and 17 rural kebeles. There are 45 health facilities serving the population with preventive and basic curative services, including 31 health posts, eight health centers, and six hospitals (two military, two private, and two governmental). HFSUH is a University teaching hospital that serves as a referral center for residents of the Harari region and surrounding areas. It has one medical ward and one surgical ward, each with 39 and 46 beds. The nurse–bed ratio in the medical ward is 1:2, while it is 1:3 in the surgical ward. JH, on the other hand, is a referral hospital affiliated with the Harari regional health bureau. There are 97 nurses working in the hospital, with 12 working in the medical ward and 12 working in the surgical ward. In both wards, the nurse–bed ratio is 1:2.

Study population and eligibility criteria

All admitted adult patients at both HFSUH and JH were the source population. Patients aged 18 years and above, admitted to medical and surgical wards for more than 2 days, were included. Those who were unconscious, with cognitive problems, and were unable to communicate during the data collection period were excluded.

Sample size determination and sampling techniques

The sample size was determined using the single population proportion formula for infinite population upon the following assumptions, the proportion of population possessing characteristics of interest (43.4%), level of significance 5%, and margin of sampling error tolerated (5%). After accounting for a 10% non-response rate, the final sample size was 414.

A proportionate stratified sampling technique was used to recruit the desired number of patients from the two governmental hospitals based on patient flow. Using the proportional allocation formula, ni = (Ni/Nt)*n where ni = number of samples from each hospital, Ni = total number of patients in the last 1 month in a hospital, Nt = the total number of patients in the two selected hospitals and n = total sample size. Accordingly, 292 patients from HFSUH and 122 patients from JH were proposed to enroll.

Data collection tools

A structured interviewer-administered tool was used to collect data. The questionnaire was divided into three sections with a total of 43 items: 8 items in part 1 about socio-demographic factors (sex, age, residence, religion, ethnicity, marital status, educational status, occupation), 10 items in part 2 assessing hospital and admission-related characteristics, and 25 items in part 3 assessing patients’ perception of nurses communication. Data on the patients’ perception toward nurses’ communication and influencing factors were collected using a pretested structured questionnaire prepared after an intensive literature review and were measured using the Likert-type scale of 5 points (1 = Strongly disagree, 2 = Disagree, 3 = Neutral, 4 = Agree and 5 = Strongly agree).[4,11,18,23,24] The questionnaire was translated to Amharic and Afaan Oromo then translated to English to maintain consistency (Supplemental material).

Data collection tools and procedures

Data collection was carried out by four diploma midwifery data collectors and two BSc midwifery supervisors proficient in Amharic and Afaan Oromo. Before starting the data collection, the principal investigators provided 2 days of training about the study’s objectives and the procedures of data collection.

Data quality control

The questionnaire was initially prepared in English and then translated into the local languages (Afaan Oromo and Amharic). Language experts then translated it back into English to ensure consistency. The data collectors and field supervisors received training on the data collection tool and procedures. The questionnaire was pretested among 5% of the sample, and necessary adjustments were made based on the findings. The principal investigators and assigned supervisors provided regular supervision.

Statistical analysis

Prior to entering the data into the EpiData 3.1 software, it was checked for accuracy and completeness. Following that, the data were exported to SPSS version 22 for further analysis. To summarize the data and observe for patterns, descriptive analysis was used.

The outcome variable was recoded as “good perception = 1” and “poor perception = 0.” To test the relationship between the predictor variables and the outcome variable, a bivariate logistic regression was used. All variables with a p value of 0.25 or lower were included in the multivariate logistic regression analysis. To assess model fitness, Hosmer–Lemeshow statistics and omnibus tests were used, and the adjusted odds ratio (AOR) with 95 percent confidence interval (CI) and a p value <0.05 was used as a measure of statistical significance.

Results

Socio-demographic characteristics

Three hundred seventy-seven patients took part in the study out of the total 414 expected participants, for a response rate of 91%. The mean (±SD) age of the study participants was 36.7 (SD ± 13.9) years. Among this, 107 (28.4%) were in the age range of 26–35 years. More than half, 203 (53.8%), of the respondents were male. Two hundred twenty-six (59.9%) were urban dwellers, and 227 (60.2%) were Muslim by religion. More than half, 225 (59.7%), were married, 204 (54.1%) were Oromo by ethnicity, and 77 (20.4%) were farmers. Three hundred three (80.4%) reported having family support (Table 1).

Table 1.

Socio-demographic characteristics of study participants in public hospitals, Harar Town, eastern Ethiopia, 2021 (n = 377).

Variables	Category	Frequency	Percentage
Sex	Female	174	46.2
	Male	203	53.8
Age (years)	<25	84	22.3
	26–35	107	28.4
	36–45	88	23.3
	>46	98	26
Residence	Urban	226	59.9
	Rural	151	40.1
Religion	Muslim	227	60.2
	Orthodox	114	30.2
	Protestant	36	9.6
Ethnicity	Oromo	204	54.1
	Amhara	102	27.1
	Harari	34	9.0
	Tigray	23	6.1
	Gurage	14	3.7
Marital status	Married	225	59.7
	Single	99	26.3
	Widowed/Divorced	53	14
Educational status	Unable to read and write	61	16.2
	Able to read and write	67	17.8
	Primary level	137	36.3
	Secondary level	61	16.2
	College and above	51	13.5
Occupation	Farmer	77	20.4
	Housewife	66	17.5
	Merchant	83	22.0
	Governmental	68	18.0
	Daily labourer	24	6.4
	Student	59	15.7
Family support	Yes	303	80.4
	No	74	19.6

Hospital and admission-related characteristics of the study participants

From 377 study subjects, 140 (38.7%) had a previous history of admission, and 259 (68.7%) were admitted to the medical ward. Two-hundred ninety-three (77.7%) were admitted to a common room, and 194 (51.4%) stayed in a hospital for more than 5 days. There were differences in age, gender, and language between nurses and patients, as reported by 272 (72.1%), 170 (45.1%) and 164 (43.5%) patients, respectively. The majority of patients, 303 (80.4 %), reported having family support, and 208 (55.2 %) reported low hospital costs (Table 2).

Table 2.

Hospital and admission-related characteristics of the study participants in public hospitals, Harar Town, eastern Ethiopia, 2021 (n = 377).

Variables	Category	Frequency (N)	Percent
Duration of admission	1–2 days	99	26.3
	3–4 days	84	22.3
	>5 days	194	51.4
Ward of admission	Medical ward	259	68.7
	Surgical ward	118	31.3
Previous history of admission	Yes	146	38.7
	No	231	61.3
Room of admission	Common room	293	77.7
	Private room	84	22.3
Hospital environment (noisy and abundant traffic)	Yes	121	32.1
	No	256	67.9
Age difference between nurse and patient	Yes	272	72.1
	No	105	27.9
Gender differences between nurse and patient	Yes	170	45.1
	No	207	54.9
Language differences between nurse and patient	Yes	164	43.5
	No	213	56.5
Feeling about hospital cost	High cost	23	6.1
	Medium cost	146	38.7
	Low cost	208	55.2

Mean response of patient’s perception toward nurse’s communication

The mean response of patients’ perception toward nurse communication was scored and depicted in the following table. Among the various variables considered, concern regarding health-related problems and improvement, maintaining privacy and confidentiality, name introduction by the nurse and being helpful and showing concern to reduce or eliminate any stress, anxiety, hopelessness and pain were some of the lowest mean responses of patients with mean values of 2.082, 2.138, 2.183 and 2.191, respectively. In contrast, entrusting with secrets and nurses’ request of patient’s authorization when performing procedure were responses with the highest mean scores of 2.867 and 2.981, respectively (Table 3).

Table 3.

Mean response of perception toward nurses’ communication among study participants in public hospitals, Harar Town, eastern Ethiopia, 2021 (n = 377).

	Variable	Mean	SE
1	The attending nurse greeted me on my admission	2.602	0.0749
2	Nurses were helpful and showed concern to reduce or to eliminate any stress, anxiety, hopelessness and pain	2.191	0.0733
3	Nurses kept my privacy and confidentiality	2.138	0.0734
4	Nurses showed me an empathetic response	2.273	0.0727
5	Nurses made me feel that I could trust them	2.257	0.0695
6	Nurses gave me a proper and necessary response when I needed them for my physical and psychological needs	2.228	0.0652
7	Nurses were attentive to my physical and psychological needs	2.215	0.0661
8	Nurses introduced their names	2.183	0.0690
9	Nurses were concerned regarding my health-related problem and improvement	2.082	0.0641
10	Nurses believed my concerns/complaints	2.371	0.0691
11	Nurses gave me time to explore my feeling in front of them	2.570	0.0716
12	Nurses used to call me by my name	2.509	0.0719
13	Nurses responded to my calls for help	2.454	0.0715
14	Nurses maintained proper eye contact during communication	2.507	0.0725
15	Nurses communicated to me about my preferences in giving and taking medication	2.496	0.0728
16	Nurses immediately informed me of the result of my investigation report	2.474	0.0705
17	Nurses encouraged me and my family not to shy away from communicating	2.422	0.0680
18	Nurses were humble and polite during communication	2.443	0.0707
19	Nurses clarified all my doubts	2.703	0.0726
20	Nurses showed pleasant non-verbal gestures	2.751	0.0740
21	Nurses provided proper information about my health status and treatment	2.828	0.760
22	Nurses requested consent when performing a procedure	2.981	0.0747
23	Nurses used appropriate tone and voice	2.867	0.0781
24	Nurses communicated with my family and involved them in the care process	2.817	0.0724
25	Nurses implemented care as per communicated	2.706	0.0687

SE: standard error.

Overall perception of patients toward nurses’ communication

In this study, 158 (41.9% (95% CI = 37.1%, 46.9%)) patients had a good perception toward nurses’ communication. Of the 158 patients who had good perception, 65.2% were from the medical ward, and 34.2% were from the surgical ward. About 34.8% of patients admitted to private rooms of either ward had good perceptions (n = 158). Of the total 259 admitted patients enrolled from the medical ward, 40.2% had good perception, while 45.8% of the 118 patients from the surgical ward had good perception. About 65.5% of 84 patients who were in a private room indicated a good perception of nurses’ communication (Figure 1).

Figure 1.

Percentage of patients who had good perception toward nurses’ communication by ward and room of admission in public hospitals, Harar Town, eastern Ethiopia, 2021 (n = 377).

MW: medical ward; SW: surgical ward; PR: private room; CR: common room.

Factors associated with perceptions of patients toward nurses’ communication

Variables with p-value <0.25 in the bivariate model were entered into the multivariate model to control for confounders. The age group of 26–35 years, being female, patients admitted to private rooms, patients with family support, urban residents, and language difference between nurses and patients were all significantly associated with the outcome variable in the multivariate analysis.

Patients whose age group were 26–35 years were 54% less likely to have a good perception than their counterparts (AOR = 0.46 (95% CI: 0.24, 0.86) and the odds of good perception was 1.89 times higher among female patients than that of male patients (AOR = 1.89; 95% CI: 1.2, 2.98). Those patients admitted in private rooms were 3.25 times more likely to have a good perception toward nurses’ communication than those admitted to common rooms (AOR = 3.25 (95% CI: 1.91, 5.51). Patients who have family support were 2.56 times more likely to have a good perception than those who did not have it (AOR = 2.56 (95% CI: 1.16, 3.642). Those patients who were urban residents and had language differences were 65% and 61% less likely to have good perception toward nurse’s communication as compared to their counterparts (AOR = 0.65 (95% CI: 0.02, 0.66) and (AOR = 0.61 (95% CI: 0.40, 0.94) (Table 4).

Table 4.

Factors associated with the perception of patients toward nurses’ communication in public hospitals, Harar Town, eastern Ethiopia, 2021 (n = 377).

Variables	Perception		COR (95% CI)	AOR( 95% CI)	p value
	Good n (%)	Poor n (%)
Age (years)
⩽25	31 (36.9%)	53 (63.1%)	0.50 (0.27, 1.01)	0.57 (0.28, 1.18)	0.007
26–35	36 (33.6%)	71 (66.4%)	0.43 (0.24, 0.76)*	0.46 (0.24, 0.86)**
36–45	38 (43.2%)	50 (56.8%)	0.65 (0.36, 1.15)	0.82 (0.43, 1.56)
⩾46	53 (54.1%)	45 (45.9%)	1	1
Gender
Female	88 (50.6%)	86 (49.4%)	1.94 (1.28, 2.94)*	1.89 (1.20, 2.98)**	0.005
Male	70 (34.5%)	133 (65.5%)	1	1
Education
Unable to read and write	27 (44.3%)	34 (55.7%)	2.20 (0.98, 4.95)	2.04 (0.85, 4.90)	0.010
Read and write	31 (46.3%)	36 (53.7%)	2.38 (0.71, 5.28)	2.24 (0.96, 5.19)
Primary education (1–8)	66 (47.1%)	74 (52.9%)	2.47 (1.21, 5.05)*	2.66 (1.26, 5.59)**
Secondary education	21 (35.0%)	39 (65.0%)	1.49 (0.46, 1.85)	1.89 (0.79, 4.48)
College and above	13 (26.5%)	36 (73.5%)	1	1
Residence
Urban	83 (36.7%)	143 (63.3%)	0.59 (0.38, 0.89)*	0.65 (0.02, 0.66)**	0.041
Rural	75 (49.7%)	76 (50.3%)	1	1
Type of room admitted to
Private room	55 (65.5%)	29 (34.5%)	3.50 (2.10, 5.82)*	3.25 (1.91, 5.51)**	<0.001
Common room	103 (35.2%)	190 (64.8%)	1	1
Family support
Yes	165 (54.5%)	138 (45.5%)	0.44 (1.16, 3.76)*	2.56 (1.16, 3.64)**	0.013
No	54 (73.0%)	20 (27.0%)	1	1
Language difference
Yes	59 (36.0%)	105 (64.0%)	0.65 (0.41, 0.98)*	0.61 (0.40, 0.94)**	0.025
No	99 (46.5%)	114 (53.5%)	1	1

COR: crude odds ratios; AOR: adjusted odds ratio; CI: confidence interval.

COR < 0.25; **AOR < 0.05.

Discussion

This study outlined that the overall prevalence of good perception toward nurses’ communication was 41.9% (95% CI = 37.1%, 46.9%). The age group of 26–35 years, being female, patients admitted to private rooms, patients with family support and urban residents and language differences between nurses and patients were significantly associated with the outcome variable.

The overall prevalence of good perception toward nurses’ communication in this study was 41.9%. The magnitude of good perception in this study is in harmony with the institutional-based cross-sectional survey conducted in Kenya. According to a Saudi study, a relatively higher percentage (59.2%) of patients were satisfied with nurses’ communication. However, according to the findings of this study, the communication domain had the lowest reported average agreement rate of patient satisfaction. Two Indian studies found that participants rated nurses’ communication as excellent, very good or good.[12,26] The difference between the current and previous studies could be attributed to differences in measurement parameters. Furthermore, the overall quality of service provided in health facilities in more developed countries is thought to be higher than in less developed countries such as Ethiopia. The prevalence of good perception in this study is slightly lower than a report from local studies done in public hospitals of Benishangul Gumuz Regional State, North West Ethiopia (49.3%) and Mekelle (49.7%).[9,16] This magnitude difference could be attributed to factors such as sample size, study area and perception measurement.

The global literature indicates that the elderly are mistreated in health facilities and have less satisfaction toward the nursing care they receive, including nurses’ communication.[27,28] On the contrary, this study found participants in the age group of 26–35 years were 54% less likely to have good perception toward nurses’ communication when compared to patients who are greater than or equal to 46 years of age (AOR = 0.46 (95% CI: 0.24, 0.86). This finding was in line with the study conducted in Debre Markos Hospital Amhara region, and Addis Ababa, Ethiopia. In Ethiopia, the elderly are generally treated with more respect and humility. Empathy may have a higher value in the clinical setting for older patients than for younger patients because most people consider their parents to be heroes and heroines in their lives. This phenomenon could have been replicated among the participants, as older patients rated nurses’ communication higher than younger patients. Furthermore, this group of respondents may be appreciative of today’s relatively better health services and have expressed positive feelings about them.

In this study, most nurses were female; due to this, most male patients may have felt uncomfortable being handled by a female nurse. In addition, female patients attach more importance to their health than male patients and tend to control things happening around them if they sense things aren’t going on the way they feel they should. In this study, female patients were about 1.9 times more likely to have good perceptions than male patients. This finding is in line with the survey conducted in Kenya.

The study found that the odds of good perception were 35% less likely among patients from urban residences when compared to their counterparts. This finding was inconsistent with the study conducted in Benishangul Gumuz Regional State, North West Ethiopia, where there was no association. The governmental institutions included in this study are referral centers that see a high volume of patients from neighboring regional states and rural cities. When compared to nurses working in private settings, this significantly increases the workload of nurses working in these facilities, and may cause them to overlook some aspects of care, such as proper communication. As a result, when compared to rural residents, most Harar city residents seeking medical care at these public institutions may compare the overall quality and nurses’ communication to private clinics and hospitals, which tend to respect and care for their clients.

In this study, patients admitted in private rooms were 3.2 times more likely to have good perceptions than those admitted in common rooms. This finding was in congruence with the study conducted in Benishangul Gumuz Regional State, North West Ethiopia. This could be because there is more work engagement in common admission rooms, and the complexity of work required in inpatient care can also increase the demands placed on nurses, limiting the time devoted to the patients’ needs entirely, which can influence how patients perceive the care provided to them. Furthermore, the skills required to manage multiple patients in a single room, as well as the limited freedom to communicate privately and confidentially with patients, may have an impact on nurses’ communication with patients admitted to shared rooms.

The study found that patients with family support were 2.5 times more likely to have good perceptions than those who did not. This finding was supported by the study conducted in Benishangul Gumuz Regional State, North West Ethiopia, and Black-Lion Hospital, Addis Ababa, Ethiopia.[9,29] This may be because getting emotional support could be of paramount importance in alleviating the fears and anxieties of patients. In addition, the involvement of the patient and family in the care improves patients’ expectations from the caregivers.

In this study, patients with language differences were 39% less likely to have a good perception toward nurses’ communication when compared to their counterparts. This finding aligns with the study conducted in Benishangul Gumuz Regional State North West Ethiopia. This indicates that language difference makes nurses unable to understand patients’ values, opinions and feelings.

Strengths and limitations

The study adds to the limited body of knowledge available and is one of the few studies addressing therapeutic communication among nurses and patients. The findings can be used as a benchmark to improve the quality of care delivered at health care facilities. However, the study is not without limitations. The cross-sectional study design used in this study was unable to demonstrate a causal relationship between the independent variables and the outcome variable. Even though patients were assured that the information they provided would be kept anonymous and confidential, they may have had the impression that a negative response would have an impact on their care. Memory recall may also have influenced the participants’ responses.

Conclusion

According to the findings of this study, less than half of the study participants had good perceptions toward nurses’ communication. Patients expected nurses to be kind, friendly, knowledgeable and responsive, but they did not expect nurses to be rude and harsh to them, and patients believed that nurses did not always explain treatment and procedures to them. The most important factors influencing patients’ perceptions of nurses’ communication were age, sex, residence, family support and language difference.

Assessment of patients’ care expectations must be part of the admission process as this would be an input to the nursing careplan. Nurses in the studied health facilities should be advocating for patients’ rights in the wards. They should be the first to respect patients’ rights, such as the right to privacy and information. The hospital management should consider employing more nurses as this would significantly enhance individualized care and therapeutic communication. The respective hospitals must use the findings to address the challenges that patients encounter in medical and surgical wards. Furthermore, the regional health bureau is recommended to facilitate in-service trainings for nurses to enhance their knowledge about the advantages of therapeutic communication and promote implementation. It is recommended that future studies include nurses as part of their research to identify and compare their perspectives.

Click here for additional data file.

Supplemental material, sj-docx-1-smo-10.1177_20503121221097270 for Patients’ perceptions of nurses’ communication in public hospitals of Harari Regional State, Eastern Ethiopia by Yazew Bekele, Teshager Worku, Genanaw Atnafe, Adera Debella, Sisay Habte, Abel Tibebu Goshu and Tesfaye Assebe in SAGE Open Medicine