Abstract

Pediatric nurses with effective therapeutic communication skills play a critical role in assess hospitalized children’s needs and provide them with the appropriate care. In addition, minimizing the stress associated with hospitalization for both children and their mothers. Aim of the present study was to assess perceived barriers to effective therapeutic communication between pediatric nurses and mothers of hospitalized children. Method: a descriptive research design was utilized to accomplish this study. The study was conducted at Alexandria University Children Hospital Egypt. Purposeful sample, 330 pediatric nurses and mothers included in the study (165 nurses and 165 mothers). The data was collected over a period of three months (January, February and March) 2019. Self-administered questionnaire was used to collect the required data. Results: The findings revealed that the main barriers of communication reported by the nurses were being overworked, shortage of nurses, fatigue and lack of enough time. Meanwhile, the main barriers of communication mentioned by the mothers were reluctance to communicate, language barrier and child's pain. Conclusion: There are certain causes which hinder therapeutic communication between pediatric nurses and mothers of hospitalized children. Recommendation: Maintain adequate children patient-nurse ratio to reduce nursing workload in order to facilitate effective therapeutic communication.

1. Introduction

Communication is a multidimensional, complex and dynamic process. ¹ Also, it has been defined by many as the exchange of information, feelings and thoughts among people. ² Employing effective therapeutic communication skills is a valuable tool to assess patients’ needs and provide them with the appropriate physical care, emotional support, knowledge transfer and exchange of information. ¹ On the other hand, failure to communicate effectively is a major potential obstacle in the provision of standard services in caring settings. This can result in anxiety, misunderstanding, misdiagnosis, possible maltreatment, exposure to complications, and increased length of hospital stay and waste of resources as well. ¹

Effective therapeutic communication is a core skill for all healthcare professionals and nursing staff in particular, since nurses spend more time with patients and their relatives than any other healthcare professional. ³ When nurses communicate effectively with interest, listen actively and demonstrate compassion, patients may be more likely to report their experiences as positive, even at times of distress and ill health. Nurses have an important role in the care of patients and their loved ones in a variety of healthcare settings. ³

Health providers in pediatric hospitals face unique challenges when they try to make practical improvements in their therapeutic communication with children and their family members. Effective communication is more crucial and often more complicated than it is with adult patients; leading to unique situations that necessitate increased abilities. ^{4, 5}

Pediatric nurses spend more time with children patients and their caregivers than other health care providers. They have multiple opportunities to interact and communicate with them. Moreover, children report being more comfortable when communicating with nurses than their physicians. ⁶ So, Pediatric nurses with effective therapeutic communication skills play a critical role in minimizing the stress associated with hospitalization for both pediatric patients and their families. ^{6, 7} It is very important to communicate effectively with the family, the caregivers -especially the mothers of children- and the patients despite the pediatric age, in order to obtain a full compliance regarding the treatment, and therefore improve the patients’ outcome. ^{8, 9}

In this care environment, parents rely on pediatric nurse to provide information and other forms of support. Pediatric nurse is in a powerful position to influence parents’ ability to cope with stressors and to parent effectively. Good support for the family from pediatric nurse has been found to be associated with less parents' stress. ¹⁰ Further, the quality of pediatric nursing care is strengthened through effective communication with children and their parents. ¹¹

Effective therapeutic communication is considered as the primary tool used for exchanging information and negotiating care between the pediatric nurses and pediatric patients and their families. Unfortunately, there are many barriers could hinder these communications. One of these barriers regarding the pediatric nurses as: high workload, lack of time, lack of support, nurses’ fatigue, staff conflict and not having the skills to cope with difficult mothers reactions. ^{5, 6, 12}

Other barriers are related to the mothers of pediatric patients as: language, lack of privacy, mothers’ health illiteracy, and poor educational levels of the mothers. Unfortunately, these barriers are not rare in our country, where many people still live in poor conditions and many of them do not go to school. Pediatric nurse must learn to overpass these borders and to make sure that she communicates with a manner that every pediatric patient and his mother understand in order to obtain the expected clinical outcome. ^{8, 13}

Yet research concerning both pediatric nurses’ and children mothers' perceptions of therapeutic communication in this setting is limited. ¹⁰ As a result of effective communication is critical to the successful delivery of health care services. ^{6, 14} This study was aimed to assess perceived barriers to effective therapeutic communication between pediatric nurses and mothers of hospitalized children in pediatric hospital.

Aim of the study is to assess perceived barriers to effective therapeutic communication between pediatric nurses and mothers of hospitalized children in pediatric hospital.

What are the perceived barriers hindering effective therapeutic communication between pediatric nurses and mothers of hospitalized children?

2. Materials and Methods

A descriptive research design was utilized to accomplish this study.

The study was carried out at Alexandria University Children Hospital at Alexandria governorate (Egypt).

The present study subjects comprised of 330 of nurses and mothers at the medical departments who were willing to participate in the study; 165 nurses and 165 mothers. The sample size was determined by using EPI Info 7 program using the following information: The admission flow rate ranged from 7-10 patients per day, expected frequency =50%, acceptable error= 10%, confidence coefficient = 95%, which revealed a simple size = 165 mothers. Accordingly, sample size of nurses was 165 nurses. The study subjects were randomly selected using simple random sampling.

Therapeutic Communication Barriers Questionnaires were developed by the researchers after a thorough review of related literature. ^{1, 7}

Tool I: Therapeutic Communication Barriers Questionnaire related to nurses. It included the socio-demographic characteristics of the nurses, nurse-related barriers and health system related barriers (nurses' view). It included 26 statements.

Tool II: Therapeutic Communication Barriers Questionnaire related to mothers. It included the socio-demographic characteristics of the mothers, mothers -related barriers and health system related barriers (mothers' view). It included 16 statements.

A five point Likert Sacle was used ranging from strongly agree to strongly disagree where : strongly disagree = 1 Disagree= 2 Don’t know = 3 Agree= 4 and strongly agree=5.

1. An official permission to carry out the study was obtained from the responsible authorities in Alexandria University Children Hospital after explanation of the aim of the study.

2. The purpose of the study was explained clearly to the nurses and the mothers to get their acceptance and co-operation in data collection.

3. The study tools were developed by the researchers after reviewing the recent related literature. They were validated by five experts in the fields of nursing education and pediatric nursing. Their suggestions and recommendations were taken into consideration.

4. Pilot study was carried out on 10% of the total sample (10% of mothers, 10% of nurses) who were excluded from the study population, in order to ascertain the relevance, clarity and applicability of the tools and test wording of the questions.

5. Cronbach Alpha Coefficient was used to ascertain the reliability of the tools: tool I (r=0.813), tool II (r=0.976).

6. Before the questionnaire was administered, the subjects were thoroughly briefed about the purpose of the study and the data collection process. They were also assured of their anonymity and the confidentiality of their responses.

7. The questionnaire was distributed by the researchers at Alexandria University Children Hospital to nurses (n =165) during morning and evening shifts. Each questionnaire took approximately from 10 to 15 minutes/nurse.

8. Data collected from the mothers (n =165) using interview questionnaire by the researchers during morning and evening shifts. Each questionnaire took approximately from 10 to 15 minutes/mother

9. The data was collected over a period of three months (January, February and March) 2019

Informed written consents were obtained from all nurses and mothers who participated in the study after brief explanation of the purpose of the research.

The anonymity and confidentiality of responses, voluntary participation and the right to refuse to participate or withdraw without penalties at any time were emphasized and guaranteed.

The collected data was organized, coded, tabulated and statistically analyzed using IBM SPSS software package version 20.0. (Armonk, NY: IBM Corp). Qualitative data was described using number and percent. Quantitative data was described using mean, standard deviation. Significance of the obtained results was judged at the 5% level.

The used tests were:

1- Student t-test

For normally distributed quantitative variables, to compare between two studied groups

2- F-test (ANOVA)

For normally distributed quantitative variables, to compare between more than two groups

3. Results

Table 1: Illustrates the distribution of the studied nurses according to their socio-demographic characteristics. It was found that (45.5%) of the nurses were 25-35 years old, only (7.3%) of them were more than 45 years old with mean age of 32.27 ± 8.47. All the nurses were working at medical department. Level of education for the majority of them was diploma qualifications (96.4%). Regarding the years of experiences (43.0%) of them have from 5 to less than 15 years of experience. The majority of the nurses (91.5%) have previous work experience in medical department. No one has attended any workshop about communication skills.

Table 2: Distribution of the studied nurses according to nurses related barriers. The table shows that all of them revealed that the highest barriers for communication were being overworked, shortage of nurses and fatigue (100 %). The majority of them (98.2%) reported that lack of enough time was the barrier. Approximately half of them (53.9%) mentioned that negative attitude of the mothers was the barrier. Meanwhile, insufficient knowledge, nurses’ inability to answer mothers' questions and poor relationship with colleagues were mentioned as barriers by 37%, 27.3%, and26.1% respectively. While the lowest barrier for communication was nurses unpleasant experiences (3.0%). On the other hand, no one of them considers cultural preferences and beliefs, reluctance to communicate, lack of empathy from nurses, lack of communication skills as barriers for communication (0.0%).

Table 3: Presents distribution of the studied nurses according to health system-related barriers. It was found that the highest barriers for communication were workload and busy environment of the ward; noise and traffic (100.0%). Followed by unsuitable environmental, shortage of staff and nursing becoming task-oriented instead of patient-centered (98.8%). Stress related issues mentioned by 97.6%, while lack of support by other staff was the barrier for (89.1%). Less than half of them mentioned poor communication between nurses and physicians as a barrier. On the other hand, the lowest barriers for communication was unfamiliar environment of the hospital for the mothers (9.1%).

Table 4: Shows the descriptive analysis of the studied nurses according to health system and nurses-related barriers. It was clear that the mean percent score for nurses-related barriers was 37.66 ± 9.84. While, the mean percent score for health system- related barriers from nurses' view was 52.26 ± 7.58.

Table 5: Regarding the relation between the overall health system and nurses- related barriers (nurses' view) with nurses' socio-demographic characteristics. It was found that there is statistically significant difference between the nurses' age and the overall health system and nurses' related barriers p<0.001^*. Also, there are statistically significant difference between the years of experience and the overall health system and nurses- related barriers p=0.004^*.

Table 6: Displays the socio-demographic characteristics of the studied mothers and their children. The table reflects that most of the mothers were 22-35 years old (63.6%), only (17.6%) of them were less than 25 years old with mean age of 29.12 ±5.47. More than half of them were educated either for primary or preparatory level of education, only (10.3%) of them were illiterate. The majority of the mothers were from rural (92.2%). The mean no. of children was 3.74 ± 1.35. More than half of the hospitalized children were female (62.4%). Approximately one quarter of the hospitalized children were the first or second child (25.5%, 23.6%) respectively. The majority of the mothers (84.2%) had previous experience of hospitalization with their children.

Table 7: Portrays the distribution of the studied mothers according to mothers- related barriers. The table reveals that the highest barrier for communication was reluctance to communicate (81.2%), followed by language barrier (78.8%). Child's pain and physical discomfort, negative attitude of the nurse, misinterpretation of communication by nurse reported by (77%) of mothers. More than three quarters of the mothers (76.4%) reported that mothers’ health illiteracy and use of technical terms by nurse were barriers for communications. While lack of privacy and child's non-compliance to treatment were barrier for 75.8 % and 74.5% respectively. No assurance of confidentiality and no confidence in nurses reported by 73.9%, 71.5% consequently. On the other hand, the lowest barrier for communication was lack of trust (70.3%).

Table 8: Distribution of the studied mothers according to health system- related barriers. The table demonstrates that highest barriers for communication were noisy environment (81.2%), followed by unsuitable environment (80.6%), nursing workload (80.0%), and unfamiliar environment (77.6%).

Table 9: Shows the descriptive analysis of the studied mothers according to health system and mothers-related barriers. It was clear that the mean percent score for mothers- related barriers was 80.96 ± 30.73. While, the mean percent score for health system-related barriers from mothers’ view was 83.56 ± 31.05.

Table 10: Regarding the relation between the overall health system and mothers-related barriers (mothers' view) with mother's demographic data. It was found that there is statistically significant difference between the mothers' age and the overall health system and mothers-related barriers p=0.001. Also, there is statistically significant difference between the mother level of education and the overall health system and mothers-related barriers p<0.001^*.

4. Discussion

Pediatric nurses with effective communication skills play a critical role for both children patients and their families. Effective communication has become increasingly reported as a key component in effective health care outcomes. In pediatrics, proper communication skills are essential because the manner in which the pediatric nurse informs the family about their child’s disease and its management has a decisive impact on further nurse–patient and nurse–care-givers relationships. Moreover, successful communication provide high quality healthcare, promote patient's satisfaction and patient's adherence with treatment. Therefore, pediatric nurses should perceive and understand the individual differences between children patients, their mothers, and practice strategies to reduce the associated communication barriers. ⁷ The aim of this study was to assess perceived barriers to effective therapeutic communication between pediatric nurses and mothers of hospitalized children in pediatric hospital.

The present study revealed that about half of the nurses were 25-35 years old and had from 5 to less than 15 years of experience. Moreover, the majority of nurses had diploma qualifications in addition to previous work experience in medical department. No one has attended any workshop about communication skills. As regarding mothers of children patients, it was found that approximately two thirds of the mothers were 25-35 years old. More than half of them were educated either for primary or preparatory level of education. The majority of them was from rural and had previous experience of hospitalization with their children. More than half of the hospitalized children were female.

The present study findings illustrated that all of nurses agreed that the main barriers which hindered therapeutic communication were being overworked, shortage of nurses and fatigue. Also the majority of the nurses reported that lack of enough time was another barrier. This may be due to the disturbed nurse- patient ratio in clinical placement, and the increased patients' numbers in relation to nurses' numbers. Shortage of nurses increases work load, and therefore, there is not enough time to establish a good therapeutic relationship and communication with the children's mothers. This is consistent with what Amoah et al (2018) found in their study, that workload and shortage of nurses were the main perceived barriers to therapeutic communication. ¹ Similarly Loghmani et al (2014) and Abagawi and Jones (2017) found that shortage of nurses increases work load, and therefore, there is not enough time to establish a good therapeutic relationship. ^{7, 15}

According to health system-related barriers, the current study discovered a general agreement between the majority of the nurses for becoming task-oriented instead of patient-centered. This finding can be explained by lack of nurses' knowledge about the importance of caring for children and their mothers within health services in which care is planned around the whole family not just the individual child. Furthermore, they ignore that assessing the mothers' needs through communication is an important component to apply and improve the quality of children's care. In this concern, Sharkey et al (2014) reported that there is a need to review routine policies and practices in the ward to create an environment that values communication and encourages child-centered care by all staff. ¹⁶

As regarding mothers' related barriers, the study revealed that there was a general agreement among three quarters of mothers on presence of barriers such as language barrier, negative attitude of the nurse, misinterpretation of mother's communication by nurse as well as health illiteracy and use of technical terms by nurse. Unfortunately, such barriers may be attributed to the lack of pediatric nurses' preparation prior to working at hospitals about the skills of the effective communication with children patients and their mothers. This points to the need for better preparation of the nurses prior to working in hospitals and the importance of in- services continuance training and workshops about effective communication skills especially with pediatric patients and their mothers. These findings are congruent with study done by Shirazi et al (2015) who stressed the role of common language and recognition of different cultural levels of the families in making effective communication between nurses and families. ¹⁷ In the same line, Jungner et al (2018) reported that communication over language barriers and the use of interpreters in healthcare is a challenge for effective communication. ¹⁸

These findings also revealed that child's pain, and his physical discomforts as well as reluctance to communicate were the main mothers' related barriers to therapeutic communication. Therefore, it can be deduced that mothers do not feel comfortable to communicate even with the responsible pediatric nurses when their children suffer from pain. These findings are congruent with Bridges et al (2013) as they found that physical pain, discomfort, anxiety and lack of attention were among the factors that can serve as barriers of communication. ¹⁹ Also Shirazi et al (2015) urged that the obstacles against nurse-family communication were: neonate’s clinical conditions, parents’ emotional situation and interactions between different professions and parents. ¹⁷

Furthermore, about three quarters of mothers reported other barriers for communication as lack of privacy, child's non-compliance to treatment, no assurance of confidentiality and no confidence in nurses. This can be due to the nature of infrastructure of the hospital which does not support privacy for every child and his mother. Moreover, increased number of children's patients sometimes leads to have two children on the same bed with full disclosure between children patients. This is supported by Shafipour et al (2012) who reported that lack of respect for the privacy of the two sides of the relationship was one of the factors which hinder effective communication. ²⁰ These findings are congruent with a study conducted at University of Medical Sciences in Iran (2015) which revealed that parents need to trust nurses in both caring for their child and recognizing parental needs. ¹⁷ Moreover, a study conducted at the Kumasi South Hospital in Ghana (2018) found that lack of privacy, loss of confidence in the nurse's competence and worrying about information confidentiality were barriers of communication. ¹

Concerning to barriers generated by health system, the study revealed that majority of the mothers agreed that nursing workload, unsuitable and noisy environment were the main barriers for therapeutic communication. This can be due to shortage number of nurses and increasing their work load, not giving the mother a chance to communicate freely with the nurse. On the other hand, noisy environment in the ward is not considered safe or suitable for communication. These findings consistent with Norouzinia et al (2016), who confirmed that the hectic environment of the hospital and unsuitable environmental conditions are considered the main barriers for communication regarding both nurses and mothers. ²¹ Similarly, Shafipour et al (2012) in their study confirmed that factors which disturbing the communication process were improper temperature, excessive noise and poor ventilation. ²⁰ Thus, providing a safe and comfortable environment leads to psychological and physical comfort of the nurse, child and his mother which facilitates using communication skills and establishing an effective communication.

As regarding perceived communication barriers and socio-demographic characteristics of the mothers, there was statistically significant difference between the mothers' age with the overall health system and mothers-related barriers. This indicates that older mothers can communicate better than younger because of having more experience and more patience during communication. In addition, they may be keen to know more about their children conditions. On the other hand, Amoah et al (2018) were incongruent with this result as they stressed that there was no significant difference in perceived barriers among the different age group of respondents. ¹

In relation to level of education of the mothers, it was observed that there was a statistically significant difference between the mother level of education with the overall health system and mothers-related barriers. Perhaps educated mothers understood and learned how to communicate with others. Moreover, available access to the internet allows them to know more about the disease and ask for more explanations about it. This was in line with a study conducted by Kounenou et al (2011), they reported that educational background and continuing education could be considered as important factors influencing the integration of communications skills. ²²

As regarding the relation between the overall health system and nurse's related barriers with socio-demographic characteristics of the nurses, it was found that there was statistically significant difference between the nurses' age with the overall health system and nurses' related barriers. Moreover, there was a statistical significant difference between the nurses, years of experience with the overall health system and nurses related barrier. This is due to that the older nurse has more experience and can communicate better than the younger one and able to be more familiar with effective communication skills. This is not a surprising finding as more experience on the job training results in a wise and effective communication and thereby reduce the barriers. Refer to literature; factors that were recognized to increase the effectiveness of communication with patients were in fact the nurses’ prior training and experience in their jobs. ²³ These finding are congruent with Abagawi and Jones (2017) who found that there was a statistical significant difference between the participants’ years of experience and their communication skills towards patients in a Saudi Arabian context. ⁷ While, Amoah et al (2018) were incongruent with these findings as mentioned before. ¹

5. Conclusion

From the current study it can be concluded that mainly perceived barriers to effective therapeutic communication mentioned by nurses were work overload, shortage of nurses, fatigue, lack of enough time and being task-oriented instead of patient-centered. While, the common perceived barriers to effective therapeutic communication reported by the mothers were reluctance to communicate and language barrier. Other perceived barriers were pain, and physical discomfort of the child, negative attitude of the nurse, misinterpretation of mother's communication by nurse as well as health illiteracy and use of technical terms by nurse. The most common perceived barriers regarding health system as indicated by both nurses and mothers were unsuitable and noisy environment. Moreover, there was statistically significant difference between the nurses' age and the overall health system and nurses' related barriers. Also, there was a statistical significant difference between the years of nurse' experience and the overall health system and nurses- related barrier.

6. Recommendations

The hospital authorities should provide proper children patient- nurse ratio to ensure that nursing workload is reduced in order to facilitate effective therapeutic communication. Maintain adequate resources and proper infrastructure to ensure that there is a safe and comfortable atmosphere for effective communication with patients. Hospital management should provide nurses with ongoing in-service training on effective therapeutic communication skills. Additionally, support the implementation of family-centered care approach especially by pediatric nurses which depends mainly on, empathetic communication between parents and pediatric nurse. Furthermore, all newly hired nurses must be trained practically on communication skills.

Acknowledgments

We are grateful to all the mothers and the nurses who participated in this study.

References