International Journal of Public Administration

ISSN: 0190-0692 (Print) 1532-4265 (Online) Journal homepage: https://www.tandfonline.com/loi/lpad20

A Cross-Sectional Qualitative Study of Barriers

to Effective Therapeutic Communication among
Nurses and Patients

Vincent Ekow Arkorful, Anastasia Hammond, Ibrahim Basiru, Jennifer

Boateng, Francis Doku, Sarah Pokuaah, Eric Kwadwo Agyei, Joyce Asamoah
Baoteng & Benjamin Kweku Lugu

To cite this article: Vincent Ekow Arkorful, Anastasia Hammond, Ibrahim Basiru, Jennifer
Boateng, Francis Doku, Sarah Pokuaah, Eric Kwadwo Agyei, Joyce Asamoah Baoteng & Benjamin
Kweku Lugu (2020): A Cross-Sectional Qualitative Study of Barriers to Effective Therapeutic
Communication among Nurses and Patients, International Journal of Public Administration, DOI:
10.1080/01900692.2020.1729797

To link to this article: https://doi.org/10.1080/01900692.2020.1729797

Published online: 28 Feb 2020.

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INTERNATIONAL JOURNAL OF PUBLIC ADMINISTRATION
https://doi.org/10.1080/01900692.2020.1729797

A Cross-Sectional Qualitative Study of Barriers to Effective Therapeutic

Communication among Nurses and Patients
Vincent Ekow Arkorfula, Anastasia Hammondb, Ibrahim Basirua, Jennifer Boatengc, Francis Dokud,
Sarah Pokuaahe, Eric Kwadwo Agyeif, Joyce Asamoah Baotengg, and Benjamin Kweku Luguh
a
School of Public Affairs, University of Science and Technology of China, Hefei, China; bDepartment of Psychology, University of Ghana,
Legon, Ghana; cDepartment of Nursing, University for Development Studies, Tamale, Ghana; dDepartment of General Administration,
Nsawam-Adoagyiri Municipal Health Directorate, Nsawam, Ghana; eMedical and Surgical Department, Cleveland Clinic, Cleveland, Ohio, USA;
f
Department of Administration, Premier Health Insurance, Accra, Ghana; gDepartment of Medicine and Surgery, Qiqihar Medical University,
Qiqihar, Heilongjiang, China; hSchool of Management, University of Science and Technology of China, Hefei, China

ABSTRACT KEYWORDS
Effective communication between patients and nurses is cardinal to health care The study seeks Therapeutic communication;
to explore barriers to effective therapeutic communication between patients and nurses in nurses; patients; health
randomly selected health facilities in the Kumasi metropolis, Ashanti region, Ghana. The study communication; perceived
employed an exploratory study to interview 60 respondents comprising 30 nurses and patients barriers
each, using an unstructured interview guide. In addition to nurses' and patients'perceived barriers,
the study revealed the health environment–related barriers. Patients-related barriers include
individual sociodemographic attributes, patient–nurse relationship, erroneous impression, and lan-
guage barrier. Other identified nurses-related barriers include human resource challenges,
patients' distrust in nurses’ competency, interference from patients’ relations, inadequate knowl-
edge, patient’s dissatisfaction with output, patients’ emotional fluctuations. Health environment–
related barriers also include excessive workload, unconducive environment, and environmental
changes. Given the relevance of therapeutic communication to health service, the study, among
other things recommends that efforts be exerted by sector actors to address the challenges and
help promote quality in health-care service and delivery.

Introduction Communication as a complex and dynamic art with

diverse facets (Sheldon et al., 2006) is regarded as an
Within health-care service delivery and practice, effec-
overarching component of nursing engagement
tive communication between practitioners and patients
(Fleischer, Berg, Zimmermann, Wüste & Behrens,
is touted as cardinal to quality health care (Sheldon,
2009). Because this has been the situation, an appro-
Barrett & Ellington, 2006). In underscoring the perti-
priate nurse–patient relationship would play a key role
nence of communication to health care and service
in the provision of health care (Sheldon et al., 2006).
delivery, Pronovost et al. (2003) assert that, deficiencies
Fleischer et al. (2009), Richard, Gregory, Neeraj &
in communication constitute a major hurdle in health-
Ronald (2009) conceptualize therapeutic communica-
care service delivery around the globe. In his view,
tion as the face-to-face medium of interaction targeted
these nagging challenges have the potential to engender
at fostering the physiological and emotional wellness of
debilitating consequences such as anxiety and wrong
patients. Essentially, this form of communication
diagnosis which could in turn bring about not only
involves both verbal and non-verbal exchanges between
wrong treatment but also a general dissatisfaction
nurses and patients (Sherko, Sotiri & Lika, 2013).
with health service. According to the American
Whereas the verbal aspect employs the use of words,
Nurses Association (2013), nurses constitute the ful-
the non-verbal, on the other hand, involves cues such
crum around which patient advocacy strides revolve.
as eye contact, body language, and other facial expres-
As such, nurses must endeavour to maintain an effec-
sions (Sherko et al., 2013).
tive communication with patients. In doing so, given
Health practitioners’ acquisition of therapeutic com-
the pertinence of communication to dispensing health
munication skills is very essential to not only health-care
care, fostering patient recuperation and healing, nurses
delivery but also health-care quality (Fleischer et al.,
must devise strategies to interact with patients.
2009). Series of studies including Alvarez & Coiera

CONTACT Vincent Ekow Arkorful saintvincentino@gmail.com School of Public Affairs, University of Science and Technology of China, Hefei, China
© 2020 Taylor & Francis Group, LLC
2 V. E. ARKORFUL ET AL.
(2006); Kullberg, Sharp, Johansson & Bergenmar (2015);
McGilton, Robinson, Boscart & Spanjevic (2006);
and Swasey (2013) have confirmed the efficacy of thera-
peutic communication outcomes. Caris-Verhallen,
Kerkstra and Bensing (1999) accentuate that, central to
providing patients emotional and physiological needs is
therapeutic communication, which has the potency to
help in earthing hidden health needs of health seekers.
As such, initiatives geared towards establishing effective
communication should take into cognizance, the needs of
patients (Manongi et al., 2009).
In spite of the inherent strengths in therapeutic
communication such as strengthening patient–nurse
bond, and fostering a germane health-care atmo-
sphere, Fleischer et al. (2009) contends that, commu-
nication is impeded in diverse ways by a concatenation
of factors. In addition to the fact that therapeutic
communication challenges have dominated discus-
sions within the public space in Ghana, Osei-Ntansah
(2014) sheds light on the dearth of therapeutic com-
munication within Ghana’s health-care settings.
Moreover, few seminal studies have been conducted.
For instance, Amoah, Anokye, Boakye & Gyamfi
(2018) conducted a quantitative study on effective
therapeutic communication at the Kumasi South
Hospital. In another study, Amoah et al. (2019) under-
take a study at the Komfo Anokye Teaching Hospital.
These studies have focused on hospital-specific set-
tings, with significant gaps in evidence from a cross-
section of nurses and patients due to lack of evidence
from a much diverse population in various health
facilities. In view of these deficits, studies are required
to be conducted to address the knowledge lacunae that
has arisen.
It is the convergence of these observations that has
provided the motivation for the conduct of this
research. This study would help to identify challenges
from among a diverse population, and where possible,
guide the institution of mechanisms, and the subse-
quent deployment of measures against factors with
the potency to infirm and impair communication,
health care, and service delivery. On this score, in
trying to foster an understanding, and further help
gain insights into the phenomena health-care commu-
nication, the study sets out to tap into perspectives of
service providers and service recipients by conducting
a cross-sectional qualitative study to investigate hurdles
to effective nurse–patient therapeutic communication
in the Kumasi metropolis of the Ashanti Region of
Ghana.
This would help provide pointers for designing pol-
icy guidelines to strengthen health service, while accel-
erating the realization of health-related goals, all within
the broader framework of the global goals—thus, the
Sustainable Development Goals (SDGs).
Methodology
Study site
The study was carried out in some selected health
facilities in the Kumasi metropolis of the Ashanti
Region of Ghana. The Kumasi Metropolis, 1 of the 30
districts in Ashanti Region is located between latitude
6.35° N and 6.40° S and longitude 1.30° W and 1.35°
E. The Metropolis is elevated 250–300 meters above sea
level and shares boundaries to the north with Kwabre
East and Afigya Kwabre districts; Atwima Kwanwoma
and Atwima Nwabiagya districts to the west; Asokore
Mampong and Ejisu-Juaben municipality to the east
and Bosomtwe district to the south. The metropolis
has about 36.2% of the region's populations and lies
270 km north of Accra, the capital city. It has a surface
area of about 241.3 square kilometers. Kumasi
Metropolis has 136 health facilities providing health-
care services to its residents. The biggest of such facility
is the Komfo Anokye Teaching Hospital (KATH)
which is a modern teaching hospital widely used by
residents and others from Ghana and overseas. Out of
the136 health facilities, 115 are privately owned (Ghana
Statistical Service, 2014).
Research approach and design
Study design
The study utilized an exploratory research study approach
premised on a qualitative study to explore nurse–patient
perspectives on barriers to effective therapeutic commu-
nication. Given the suitability of the inductive approach,
and interpretivism for context-dependent studies, Madill,
Jordan & Shirley (2000) geared towards gathering subjec-
tive experiences of participants on a phenomenon
(Bryman & Bell, 2015), the study adopted this approach.
Whereas the epistemological aspect of interpretivism
dwells on the subjectivity of knowledge, the ontological
aspect focuses on the differing nature of experiences and
realities across persons (Creswell, 2013; Creswell, Hanson,
Plano & Morales, 2007; Thomas, Nelson & Silverman,
2018). The qualitative research approach enhances the
understanding of participants' experiences and compre-
hension about a phenomenon (Creswell et al., 2007). The
phenomenological design of the study helps in under-
standing the lived experiences of participants (Zikmund,
Babin, Carr & Griffin, 2013). The study sought to explore
the experiences of nurses and patients regarding barriers
to therapeutic communication. The study therefore

employed a qualitative phenomenological approach,
hinged on interpretivism, and inductive reasoning.
Moreover, the study used thematic content analysis to
present themes captured in interview transcripts regard-
ing the subject matter under investigation. Thematic con-
tent analysis as a method for data analysis is also essential
in gathering insights and knowledge to guide action (Elo
& Kyngäs, 2008). It entails a subjective process of categor-
izing data into categories of similar entities to enhance the
identification of patterns and relationships between vari-
ables within a context (Given, 2008). Content analysis
takes into consideration experiences (Payne & Payne,
2004).
Population and sampling
Participants and sampling
The target group for the study was nurses and patients.
A total of 30 nurses and patients each were interviewed.
The study used a purposive sampling technique to
recruit study participants. In the views of Patton
(2015), the strength of a purposeful sampling technique
largely lies in selecting information-rich respondents
capable of providing rich information for an in-depth
study.
Sampling was maintained until data saturation was
reached. Mack, Woodsong, MacQueen, Guest &
Namey (2005) define saturation as the point at which
new data collected and analyzed does provide no
further and better meaning to the research questions.
In the case of both nurses and patients, at the point of
interviewing the 30th respondents, the researchers rea-
lized the subsequent information resonated with
already provided information, so the interview session
was ended. Selection of respondents was based on their
characteristics and capabilities to provide necessary
information to meet the study objectives. The availabil-
ity and willingness of participants to participate were
also considered. In selecting respondents for the study,
the following inclusion criteria were used:
a. Registered nurses employed full time
b. Registered nurses willing to participate in the
survey
c. Registered nurses who have worked in the med-
ical facility for not less than 5 months
d. Patients on admission (not less than 5 days)
e. Patients aged 18 years and above
f. Patients willing to participate in the survey
On the other hand, the exclusion criteria use included
the following:
INTERNATIONAL JOURNAL OF PUBLIC ADMINISTRATION 3
a. Nurses unwilling to participate
b. Nurses not engaged on full-time basis
c. Student nurses on clinical assignments
d. Nurses who have worked in the medical facility
for less than 5 months
e. Unconscious patients
f. Patients reluctant to participate
g. Patients aged less than 18 years
Data collection
Data for this research were elicited through the use of an
unstructured in-depth interview guide. This was used to
gather in-depth information from respondents. The
open-ended nature of questions helped the research
team in gathering data from participants. This was to
help tap deep into the respective experiences of partici-
pants regarding the subject matter under investigation.
Prior to interview, participants were informed about the
study overview, informed of their liberty to withdraw at
any time, and assured of their anonymity, confidentiality,
and privacy. Selected institutions were also served an
introductory letter seeking for permission to conduct
the study in their institution. Participants were inter-
viewed once. Interviews were guided by the recommen-
dation of McCracken (1988). Long interviews were held
to enable the gathering of detail information and cate-
gorization of responses for thematic analysis. The inter-
view guide was reviewed, approved and had its credibility
established by three researchers and three academics with
expertise in qualitative research. The interview guide was
then subjected to two pilot tests after which the questions
were refined in line with panel suggestions. Interviews
spanned from 30 to 35 min. This allowed participants to
freely express views on meaningful issues (Denzin &
Lincoln, 2011). Data were collected by three research
assistants within a space of 1 week, considering the con-
venience of participants. Data collection instruments
included an audio recorder, pens, and a jotter. To estab-
lish rapport with respondents, participants were initially
engaged in social conversations about specific experi-
ences. This kept the participants and the researchers on
track (McCracken, 1988).
Data analysis
To ensure quality research work, higher research standards
were adhered to. Data analysis was done in agreement with
the recommendations of Graneheim and Lundman (2004).
Initially, interviews were transcribed and carefully read over
several times to foster understanding. The interviews were
then set as an analysis unit after which meanings (identified
from words, phrases, sentences, and paragraphs) with sig-
nificant bearing on content and meanings were identified
4 V. E. ARKORFUL ET AL.
and condensed into units, and further, subsequently labeled
with codes. Going forward, a careful study of the categories
was done. This helped in generating themes. Much efforts
were exerted in ensuring trustworthiness and rigor in data
eliciting and analysis. In this regard, the recommendations
of Lincoln and Guba (1985) were followed to ensure cred-
ibility, thoroughness, honesty, integrity, dependability, and
confirmability. Credibility was maintained by eliciting
accurate data while increasing interaction time with
respondents. Caution was exercised in maintaining trans-
parency, and representation of participants' experiences
rather than a partial interpretation of the researchers.
Stories shared by participants were eliminated. And because
data collection and analysis were done concurrently, tran-
scriptions were validated from participants to ensure that
the study captured true narratives of participants. The
first, second and third authors conducted the interview
analysis. Independent validation of the results was also
conducted by the other authors who were not part of the
interview process. To settle minor discrepancies that char-
acterize interview interpretations, brief meetings were held
with participants. This helped the research team to confirm
the themes to corroborate the responses of participants. For
this reason, the results were reliable, valid (Mason, 2002),
clear (Richards, 2009), fair, and devoid of bias.
Limitations of the study
The study was conducted in some selected health facilities
in the Kumasi metropolis in the Ashanti region of Ghana.
As such, the results of this study cannot be generalized.
This does not in any way invalidate the study results as it
could provide sufficient pointers to future policy making,
in so far as health communication is concerned.
Results
Gathered data were thematically analyzed in line with
the study objectives. The results captured the socio-
demographic characteristics of respondents and emer-
ging themes from the study. The themes were broadly
Table 1. Emerging themes and main findings.
Broader themes
Patients' perceived barriers (subthemes)
Individual sociodemographic attributes
Patient–nurse relationship
Erroneous impression
Language barrier
Lack of empathy from nurses
Negative patient attitude towards nurses
Health environment–related barriers
Excessive workload on nurses
Unconducive environment
Change in environment
classified as follows: (i) nurses-related barriers and (ii)
patients-related barriers. The respective broader themes
had associated subthemes presented in Table 1.
Participants’ sociodemographic characteristics
Table 2 portrays the demographic characteristics of the
study participants. As captured in the table, patient’s
participants distribution composed of 19 females and 11
males. Majority of the study participants in the study fell
within the age range of 29–39 years. Moreover, as cap-
tured in the table, it could be deduced that, 17 of the
participants were married, 11 single, and 2 divorced. With
regards to the educational background of participants, it is
apparent that, whereas 2 patients had elementary educa-
tion, 8 had primary, 10 secondary, 9 tertiary, and 1 had no
formal education. Relative to the nurses, out of the 30
participants comprising 10 males and 20 females, 23 were
diploma degree holders while 6 had bachelor’s degree and
1 had postgraduate master's degree. With regard to
nurses’ years of service, majority of the nurses had worked
for more than 3 years. Nine had worked for less than
1 year and five participants had also worked for 1–2 years.
Key findings
Patients' perceived barriers
Patients' perceived barriers are precisely hurdles ema-
nating from patients that hinder effective therapeutic
communication. In assessing patient-related barriers,
subthemes that emerged included individual sociode-
mographic attributes, patient–nurse relationship, erro-
neous impression, language barrier, lack of empathy
from nurses, nurses’ technical language, and negative
patient attitude towards nurses.
Individual sociodemographic attributes
The interplay of factors such as age, religion, and eth-
nicity was revealed to have a significant impact on
effective therapeutic communication. Actually, in the
Nurses' perceived barriers (subthemes)
Human resource challenges
Patient's distrust in nurse’s competency
Interference from relations
Inadequate knowledge
Patient's dissatisfaction with output
Emotional fluctuation of patients
 INTERNATIONAL JOURNAL OF PUBLIC ADMINISTRATION 5

Table 2. Participants’ sociodemographic characteristics. which falls outside the tenets of their beliefs and prac-
Variables Frequency Percentage tices are regarded as unethical. (Participant 12)
Patient’s distribution
Sex To some patients, the refusal or inability of nurse
Male 11 37 practitioners to demonstrate some religious or cultural
Female 19 63 gestures like bowing, prostrating and knocking before
Age (years)
18–28 10 33 entering wards is an affront to them. Whenever this
29–39 15 50 happens, patients see themselves to have been disre-
40+ 5 17 spected and as such refuse to cooperate. In the end, this
Marital Status
Married 17 57
affects communication. (Participant 1)
Single 11 37
Divorce 2 6 Another nurse also recounted that
Educational Level
Elementary 2 7 For religious and cultural reasons, some patients come
Primary 8 27 with preferences. Whereas most males prefer male
Secondary school 10 33
Tertiary 9 30 nurses to attend to them, females do same. Whenever
No formal education 1 3 these expectations are not met, patients’ cooperation
Employment Status become minimal which takes a toll on communication.
Employed 7 23
Unemployed 9 30 (Participant 2)
Self-employed 14 47
Duration of Admission (days)
5–10 14 47 Patient–nurse relationship
11–15 7 23
≥16 9 30
Cardinal to healthcare service and delivery is patient–
Nurse’s Distribution nurse relationship. The degree of good relationship
Sex
Male 10 33
existing between a patient and a nurse comes with
Female 20 67 overwhelming benefits such as entrenching trust and
Age (years)
18–28 8 27 confidence in the patient. This in turn boosts the con-
29–39 14 46 fidence of nurses to deliver quality services effectively
40+ 8 27
Marital Status and efficiently. Gathering perspectives from patients
Married 12 40 revealed some degree of displeasure. And as much as
Single 14 47
Divorced 4 13 some nurses acknowledged the relevance of communi-
Education Level cation in health care, they also recounted certain lapses
Diploma 23 77
Degree 6 20 characterizing such relationships. A patient participant
Masters 1 3 had this to say
Years of Service
>1 9 30
1–2 5 17 Generally, I think the relationship between we patients
3+ 16 53 and nurses isn’t bad. That however said, I equally think
the conduct of a handful of nurses here leaves much to
be desired. (Participant 1)
views of nurse participants, these factors diversely In shedding more light on the views shed prior,
inform expectations and also influences the world a participant talked about the professional disposition
views of individuals. In illuminating on these factors, of nurses. The following echoes their concern
a participant recounted that
There are question marks about the sense of profes-
Sometimes, age affects communication and comprehen- sional decency and urgency of some nurses. It’s an
sion. The situation is much better for the middle aged institution, so you wouldn’t have all characters equal.
than for those in their twilight years. (Participant 3) (Participant 3)

Another nurse confirmed that

Another also reiterated that
Even for the young and middle-aged folks, they some-
times have difficulty understanding certain things. But
comparatively, I think dealing with the difficulties of
the young is quite better than in the case of the old.
(Participant 17)
Some patients are too difficult to handle. No matter the
level of professionalism displayed, they never get satis-
fied. But we understand the psychology of medication.
And given their ill-health situation, such difficulties are
understandable. (Participant 4)

Others echoed that Erroneous impression

Erroneous impression borders on misconceptions and
Some patients are too stuck to their religious and certain preconceived impressions held by a party about
cultural practices that, anything done in the hospital another. An individual may hold a perception about
6 V. E. ARKORFUL ET AL.
another, which may border on a character trait or
a certain attitude. Our interaction revealed that, health
seekers mostly go to health facilities with some sort of
perceptions about health service personnel. These mis-
conceptions which were revealed to have been largely
held by patients appeared to have the tendency to breed
mistrust between health seekers, their relative care-
givers and health service providers. In sharing views,
a patient disclosed that
Some of us patients come to health facilities with an already
framed up mindset (real or perceived) stereotypes about
nurses. We absorb these deeply, generalize and assume all
nurses are of the same character trait. This prejudice and
malice results into negative attitude towards nurses which
does not foster cooperation and communication between
patients and nurses. (Participant 5)
Another said that
On the back of the much-speculated issue that nurses
are promiscuous, rude and husband snatchers, some
patients come to hospital with their husbands and
prove too protective. (Participant 25)
Some nurses also had this to say
So even when a female nurse is trying to be nice while
in the line of duty, wives and girlfriends of patients
tend to be suspicious and sometimes get furious
because they think, the nurse is trying to woo their
partner. (Participant 8)
It is same with us male nurses. Some gentlemen who
come with their partners suspect us of same. There are
times depressed patients would want to talk to us on
private issues concerning their health situation, with-
out their partners present. Mostly when their partners
are around, they interfere. What most partners fail to
understand is that, it is not everything that could be
shared with them. This is simple. They should all
understand. (Participant 13)
Language barrier
Central to health care communication which takes the
form of an exchange between a sender and a recipient.
The inability of either the sender or recipient to make
meaning from the exchange may hamper the commu-
nication process. And this is not different from commu-
nication between nurses and patients. Our interaction
underscored language barriers between patients and
nurses. In shedding lights on the communication diffi-
culties, some patients had this to say
I am from the northern part of Ghana and not profi-
cient in the Twi Language. So, whenever the nurses
come to ask me about health-related matters and other
things, am unable to express myself. I am worried
because I think this communication challenge may
affect my treatment. (Participant 7)
Some nurses have difficulty explaining issues to lay
men patients to understand. What is the essence of
communication when I don’t understand what the
nurse is saying? They should find simple ways to com-
municate technical issues to patients. (Participant 9)
Another expressed that
When I could barely understand what the nurses com-
municate to me, how could I tell them my condition?
How do we communicate to each other? And sign
language is not enough to facilitate the communica-
tion. communication is a big problem for health care.
(Participant 8)
Other nurses stated that
Sometimes we have patients from neighboring coun-
tries who cannot speak the Akan language which is the
commonest language. This makes it very difficult to
communicate with them. (Participant 19)
There are also occasions we have speech and hearing-
impaired patients. Because this facility has no human
resource with such a communication specialty, it is always
difficult to communicate with them. (Participant 25)
Lack of empathy from nurses
Our interaction with study participants revealed that,
patients’ perceived empathy from nurses could facilitate
communication. However, the dearth of empathy for
patients in pain and anxiety could also pose a barrier to
effective communication between patients and nurses.
In recounting experiences, a patient stated that
When I am in pain, I do expect the nurse to express
concern and urgently attend to me. When they refuse
or fail to demonstrate it, I easily get angry. And when
the pain had subsided and they come close, I naturally
develop a cold attitude towards them. Our communi-
cation gets bad as well. (Participant 12)
In this same regard, another nurse said that
When a patient is in pain, calls for attention and we are
unbale to deliver, patients tend to think we are insen-
sitive and uncaring. But that is not the case. There are
times we have emergencies. For this reason, we may
not be able to sort all patients out at all times. But some
patients wouldn’t understand. And they get angry,
throw tantrums and worst of all, wouldn’t want to
talk to anyone. (Participant 30)
Negative patient attitude towards nurses
Patients’ demonstration of untoward behaviours
towards nurses may occasion a decline in confidence
of nurses. Negative attitudes displayed by patients such
as rudeness and raining insults on nurses invariably
affect nurses’ performance, quality health service, and
communication as well. In exploring how these

attitudes could debilitatingly affect therapeutic commu-
nication, a patient shared the opinion that
Some patients openly insult nurses here as though the
nurses are kids. They don’t show respect to the nurses.
And as professionals, nurses are unable to engage
patients in verbal exchanges. (Participant 17)
Another added that
These bad attitude dips nurses’ confidence. It distracts
them. And this affects the effectiveness of interaction
with patients. (Participant 29)
Other nurses stated that
Some patients verbally abuse us as if we have never
been to school, let alone know what service to render
to patients as professionals. For whatever reason some
patients keep on doing this, I cannot tell. This is the
service I have chosen to render. I have opted to serve
Ghana as a nurse. (Participant 6)
I don’t think it is a crime to be a nurse. But some
patients sometimes make me feel I have chosen the
wrong career path. Well, every work has its hazards.
So, I believe this is one for me as a nurse.
(Participant 13)
Nurses' perceived barriers
Nurses' perceived barrier discourses on nurses-related
factors that pose a challenge to effective therapeutic
communication between patients and nurses. Our
research identified five key subthemes comprising
human resource challenges, patient's distrust in nurse’s
competency, interference from relations, inadequate
knowledge, patient’s dissatisfaction with output, and
emotional fluctuation of patients.
Human resource challenges
In our interaction with nurses, one subtheme that
became more poignant bordered on insufficient
human resources. Essentially, the issue of the dearth
of human resource was an issue that resonated with
almost all participants. In the views of participants, this
situation has made it quite challenging meeting the
needs of patients. Illuminating on the human resource
hurdles, a nurse indicated that
In situations where we have human resource chal-
lenges, few nurses on duty would have to do multiple
works. This stress nurses. As such, nurses are unable to
have ample time communicating and explaining issues
to patients to understand. (Participant 15)
Interaction with patients confirmed the negative
impacts of human resource challenges on health service
and delivery. Gathering perspectives from patients eli-
cited the following responses:
INTERNATIONAL JOURNAL OF PUBLIC ADMINISTRATION 7
Few nurses on duty affects service delivery. The few
have either little or no time for us patients.
Engagements becomes tighter for them especially
when they have more urgent cases at hand.
(Participant 19)
Another said that
Patients spend more time waiting when there are not
enough nurses available. After waiting, it sometimes
happens that, we don’t get to see or meet them at all.
(Participant 14)
Patient distrust in nurse’s competency
The study further revealed patients’ distrust in nurses
as another barrier to communication. The lack of con-
fidence in the competence of nurse practitioners, to
a larger extent, affects not only service delivery but
also the degree of patient–nurse practitioner commu-
nication. Some nurses echoed that
Some of the patients think they know much than the
nurses here. When they come and we offer them pro-
fessional advice on health-related matters, they don’t
listen. They go to their homes and do their own things,
only to report with complications later. (Participant 15)
Some think they know much than we know. So, they
don’t listen to whatever a nurses say. (Participant 7)
Another patient confirmed that
It’s quite interesting how some adult patients behave
childish. Some come to hospital with their thoughts
and expectations about medication and processes.
when such expectations are not met, they assume the
nurse in question isn’t up to the task. Then they start
challenging. This is very bad I think. (Participant 17)
Interference from relations
Relations of patients attempt to interfere with medical
processes and procedures. This was revealed as
a challenge nurses face in dispensing services. In the
views of nurse participants, this attitude militates
against the level of interaction between patients and
nurses. In expressing worries about this phenomenon,
a nurse said that
Some relatives are too recalcitrant. They aren’t ready to
comply with directives. They want to visit at non visit-
ing hours. They would want to see their sick relatives
when they are sleeping. Some even come and wake
patients up from their sleep. And when you tell them
the right thing, they think we are being too authorita-
tive. (Participant 6)
Another accentuated that
Relatives of patients are difficult to deal with. The
patients are not the headache. Because relatives dictate
to patients, they also have no option than complying.
8 V. E. ARKORFUL ET AL.
Some relatives go outside the medication and give
patients concoctions in place of the hospital medica-
tion. This is so annoying. If you know concoctions are
effective, why not take them home or to a spiritualist?
(Participant 13)
Inadequate knowledge
Participants admitted the deficiencies on the part of
nurses relative to sufficient knowledge on effective
communication techniques, which is key to establishing
a strong patient–nurse rapport. The establishment of
such a relationship in the views of patients boosts
patients’ confidence in the nurse. And whenever such
a relationship is established, patients feel free to com-
municate and open up to nurses on medical issues. In
exploring this subtheme, a nurse commented that
Therapeutic communication skill is a powerful weapon
in the hands of every nurse. Having such knowledge
aids the nurse to unlock most secrets from the patients.
The nurse can then capitalize on this to expedite the
treatment and healing process. The lack of knowledge
about it may yield adverse outcomes. (Participant 3)
Another nurse said that
Deploying therapeutic communication skills makes
work quite easy and simple for nurses. In the course
of communication, patients develop trust, they become
more friendly and open up on issues. (Participant 14)
Patient's dissatisfaction with output
Discontentment with the outcome of service(s) ren-
dered may in one way or the other affect communica-
tion. In the series of interaction with patients, it was
apparent that, the level of satisfaction or otherwise of
service posed a barrier. A nurse expressed that
When patients are satisfied with the services received,
you see it all over their faces, in their voices and in
their whole body. You feel their elation. Their coopera-
tion in terms of communication gets better as well.
(Participant 9)
Another patient said that
Sometimes when we patients are satisfied with the
service of a particular nurse, our mood reflects it.
There are even times that when you get satisfied, for
a while you don’t feel the illness and you freely engage
the nurse without reservation. (Participant 8)
Emotional fluctuation of patients
Most nurses reiterated that patients experience fluc-
tuating moods. They further stressed that, the mood
of patients is not stable, but rather subject to fre-
quent changes depending on their ill-health condi-
tion. By inference, the state of illness or disease state
goes to influence their level of communication. In
explaining this, a nurse commented that
Given the unbearable pain patients who have undergone
surgery go through, their communication becomes diffi-
cult. Because of the pain, they find it difficult to talk. Even
sometimes, they don’t have the desire to see people
around them at all, talk less of talking. (Participant 11)
Another confirmed that
In the case of old people with dementia, communica-
tion becomes a challenge. Also, in the case of patients
with special needs like the eye, ear and speech impaired
and the mentally challenged, their communication
becomes difficult under severe ill health situation.
(Participant 1)
Health environment–related barriers
Health environment–related barriers are challenges within
and outside the health working space that hinders effective
therapeutic communication. As part of the study objectives,
in addition to exploring specific patient' and nurse' per-
ceived barriers, we also explored the inherent systemic
hurdles saddling the health system. Our interaction with
participants revealed subthemes such as excess workload,
unconducive environment, and change of environment.
Excessive workload on nurses
After the concatenation of interviews with participants,
it became more obvious that, the workload on nurses
was too overwhelming that it negatively impacted on
effective therapeutic communication. A nurse said that
In times when nurses get sick or have other impromptu
emergencies to attend too, they are unable to come to
work. When that happens, there is pressure on the avail-
able nurses who report to work. And the few nurses are
unable to serve the patients timely. (Participant 7)
Another patient also indicated that
I have made a personal observation that, nurses over
here are hard working. But on days when they are few,
it causes unnecessary delays for we patients and we
have had to spend more hours here. And because of
the pressure on the few, we hardly have enough time to
communicate. (Participant 13)
Unconducive environment
Interaction with participants revealed the relevance of
environmental factors to health communication. It was
confirmed that, the more germane and conducive the
environment, the more enhancing communication
becomes. Participants shared varying, yet insightful views
on how the health environment could impel effective ther-
apeutic communication. A nurse participant had this to say:

Some patients talk on top of their voices when they are
either are on phone or on a one- on-one conversation
with relatives. This creates much noise in the wards.
(Participant 15)
Some patients also stated that
Some of the wards have strange smell such that it is
difficult living here. Am not surprised we have mos-
quitoes here. Generally, the facilities are ok, but for
these things I have mentioned. something needs to be
done because it obstructs patients sleep and relaxation.
(Participant 3)
The room temperature here gets unfriendly. Sometimes,
it gets unbearably cold, hot and warm. It is suffocating.
I think something must be done about the internal tem-
perature. Ventilation issues needs to be addressed as well.
(Participant 12)
Change in environment
A change in environment for some patients could be
challenging for them. While some patients easily adjust
to such changing situations, others too find it uneasy to
readjust. In a way, the change in environment largely
affects the communication of patients. These were the
revelations from study participants. A patient said that
Psychologically, most patients experience a change in
mood the very moment they are admitted. With the
mentality that they are in the hospital, they feel emo-
tionally down. This affects their communication.
(Participant 11)
Another nurse emphasized that
Most patients on admission, especially those who have
been on admission for long think too much. They
think of when they would be discharged. And they
also think much because, they think been on admission
for days implies their condition is not the best. And
this affects their communication. (Participant 7)
Discussion
This research explores barriers to effective communica-
tion among a cross-section of patients and nurses in some
randomly selected health facilities in the Kumasi metro-
polis of the Ashanti region of Ghana. The results revealed
barriers spanning from patients-related, nurses-related,
and health environment context-specific related. Among
some of the nurses-related barriers to communication
revealed by this study include individual sociodemo-
graphic attributes. Key among such attributes include
age. The study revealed that, old age significantly exerts
some amount of negative impacts such as anxiety, weari-
ness, dementia, among others on the individual. The
onset of this cycle affects the psychology, and by exten-
sion, the general communication ability of the individual.
INTERNATIONAL JOURNAL OF PUBLIC ADMINISTRATION 9
And because this has been the case, the sense of estima-
tion, articulation, and understanding of the individual is
substantially impaired. This finding is consistent with
Payne, Kerr, Hawker, Hardey & Powell (2002).
Other sociodemographic characteristics revealed to
impair communication was religion and culture.
Interaction with study participants indicated that, the
inextricable relationship between patients and their
respective cultures and religions defines the individual
and further influences their thinking. Given this con-
text, Anderson, Scrimshaw, Fullilove, Fielding &
Normand (2003), Amoah et al. (2019), and Cioffi
(2003) contend that, differing cultural values and incli-
nations between nurses and patients greatly infirm
communication. Amoah et al. (2019) also posit that,
regardless of the similarities in sociodemographic char-
acteristics of nurses and patients, there may be one
variable to set them apart. As such, nurses’ communi-
cation should take into cognizance caution and the
cultural diversities of patients (Anderson, Scrimshaw,
Fullilove, Fielding, & Normand, 2003).
The research further identified patient–nurse rela-
tionship as a challenge to effective therapeutic commu-
nication. Respondents repeatedly complained about the
insufficient time received from nurses. This in the view
of patients does not only affect health information
seeking behaviors but also communication. The essence
of nurses assigning full undivided attention to patients
is confirmed by Teutsch (2003) who illuminates on the
level of gratification derived from interaction with
nurses by patients, as communication helps to clear
all traces of doubts, fears, and other burdensome
thoughts and ideations.
The findings revealed that, the stereotypical miscon-
ceptions held by patients about nurses’ character traits
in one way or the other militates against communica-
tion. In the view of some patients, nurses are rude and
have bad traits. For this reason, their cooperation and
tolerance of even good gestures is doubted by some
patients. This result is consistent with Amoah et al.
(2019) who identified patients’ misconceptions about
nurses as a barrier to effective therapeutic communica-
tion in a study in Ghana.
The study also identified language as a barrier to
communication. Study participants complained of lan-
guage constraints. Specific complaints by patients
regarded the use of technical language by nurses.
According to some patients, this makes them more
confused and even develop a much-exaggerated sense
of their ailments. In confirmation of these findings,
Desmond and Copeland (2000) assert that, the frequent
use of jargon and technical language by nurses alienates
patients from nurses. So, it becomes pertinent that,
10 V. E. ARKORFUL ET AL.
nurses use simple language in communicating with
patients. This is similarly reported by (Anoosheh,
Zarkhah, Faghihzadeh & Vaismoradi, 2009; Baraz,
Shariati, Alijani & Moein, 2010; Cioffi, 2003; Del
Pino, Soriano & Higginbottom, 2013; Quesada, 1967;
Tay, Ang & Hegney, 2012).
This study reports patients’ perceived dearth of empa-
thy from nurses as a barrier to communication. Patients
feel that, nurses have no sympathy or positive feelings for
their ill-health situation. Given this deep-seated notion,
patients feel neglected and dejected while not given atten-
tion. In reaction to this, nurses also ascribed their inability
to serve patients timely to human resource challenges.
This buttresses the research findings of Anoosheh et al.
(2009) who accentuate that, heavy workload and human
resource shortage constrain communication.
Moreover, the study identified that, negative attitudes
such as insults thrown at nurses by patients dip nurses’
confidence. This eventually dampens communication
between patients and nurses. This study finding is con-
sistent with Amoah et al. (2019). Furthermore, Vida,
Eesa & Fazlollah (2014) in a recent qualitative study on
therapeutic communication in cardiac surgical wards
corroborate our research finding that patients distrust
in nurse’s competency. This suggests that, ensuring
effective therapeutic communication in health establish-
ments is a two-way affair requiring much equal efforts
from both nurses and patients. In underlining the rele-
vance of patients' trusts in nurses, Antipuesto (2015)
states that, the failure or refusal of patients to trust and
have confidence in nurses hinders commitment to treat-
ment procedures.
Besides, this research identified interference from rela-
tions as a hindrance to effective therapeutic communica-
tion. As gathered from our interaction with participants,
the unfortunate situation and malpractice whereby
patients try to influence and alter health outcomes could
be detrimental to health quality. Loghmani, Borhani &
Abbaszadeh (2014) confirm the negative effects of inter-
ference from patients’ relations in medical processes and
clarifies how such interference has precipitated a decline
in communication within global health settings.
The study results markedly revealed that, human
resource challenges were regarded as a barrier to effec-
tive therapeutic communication between nurses and
patients. The study indicated that, the dearth of nurses
results in increased workload on available nurses. Owing
to this reason, patients are unable to interact with nurses.
And nurses on the other hand have insufficient time to
also communicate with patients. These in effect greatly
affect effective therapeutic communication between
nurses and patients. This finding is consistent with
Park and Song (2005).
Another prominent finding of this study was the
general levels of dissatisfaction among patients who in
their responses think they need information and emo-
tional support to keep themselves encouraged. Almost
all patients appeared discontent with the services of
nurses because they felt neglected. This is in line with
the research findings of Rauseo (2016). Quite surpris-
ingly, the study revealed unappealing levels of knowl-
edge on therapeutic communication among nurses.
Whereas most nurses expressed fair knowledge about
therapeutic communication, others also opened up to
have no in-depth knowledge. As such, overcoming this
barrier calls for the institution of measures such as
organizing training sessions to deepen practitioner’s
knowledge of health communication.
Other participants also conceded to the relative
effectiveness of the various forms of therapeutic com-
munication between patients and nurses. In this regard,
a nurse participant reiterated that, in touching and
feeling a patient for instance, its application would be
ineffective when caring for an unconscious patient.
This exposes the complexities and complications in
the application of effective therapeutic communication
measures and strategies. This makes it urgent for
nurses, and other health service providers to adhere to
the subtleties and nuances underpinning therapeutic
communication. Nurses’ inadequate knowledge about
therapeutic communication is succinctly buttressed by
Amoah et al. (2019).
The research further revealed that, as a result of
patients’ anxiety, pain, and discomfort, they undergo
emotional fluctuations that affect effective therapeutic
communication between patients and nurses. This is in
agreement with a study by Aghabarari, Mohammadi &
Varvani-Farahani (2009) who undertook an explora-
tion of barriers to effective therapeutic communication
and concluded that, patients’ pain and discomfort
could impede effective communication as they feel
uneasy to talk. Nayeri, Nazari, Salsali & Ahmadi
(2005) also attest the same.
With regard to health environment–related hurdles to
effective therapeutic communication, change in the envir-
onment emerged key among the themes. From our inter-
action with patients, it became apparent that, patient’s
unfamiliarity with, and newness to the health environ-
ment impairs communication with nurses. In this con-
text, some nurses confirmed communication difficulties
with parents. These challenges, in the views of nurses, set
in at the early days of admission or visit to the hospital. In
a study of therapeutic communication at the Okomfo
Anokye teaching hospital (KATH) in Ghana, Amoah
et al. (2019) emphasize on change in the environment
as a barrier to effective therapeutic communication.

It was also discovered from the study that uncondu-
cive environment was key to some of the health envir-
onment–related barriers that militate against effective
therapeutic communication. This is confirmed by
Bartlett, Blais, Tamblyn, Clermont, & MacGibbon
(2008) who identified unsuitable health environments
as barriers to communication. The study participants
also stated unbearable room temperatures in the hospi-
tal environments especially in the wards as one of the
potential barriers to effective communication. This
study finding is in agreement with Mendes, Trevizan,
Nogueira & Sawada (2009).
Conclusion
After the exploration of the barriers to therapeutic
communication, the study confirms that, at the heart
of the health delivery system and quality healthcare lies
effective therapeutic communication. The study identi-
fied a myriad of factors that could take a toll on health
communication, quality, and general comprehensive
care within health-care facilities. These factors are
themed around patients' perceived barriers, nurse' per-
ceived barriers, and health environment barriers. To
help overcome the challenges, and further help realise
the attainment of health-related SDG‘s, the study
recommends that
● Hospital authorities should as a matter of urgency
create a patient communication department to offer
patients reliable avenue to channel complaints and
grievances regarding service dissatisfaction. This
department among other things should be tasked
with educating patients on the need to cooperate
with nurses and entreat them to eschew all tenden-
cies of displaying negative attitudes which could
cause a decline in nurses’ confidence levels. The
researchers believe that, the institution of such mea-
sures would help strengthen comprehensive health
service delivery, promote quality, and at the same
time, help authorities to put in place measures meant
to propel effective therapeutic communication.
● Health authorities must endeavour to ensure suf-
ficient availability of human resources to help
reduce the workload on nurses and help promote
effective therapeutic communication between
patients and nurses.
● To overcome communication challenges, authori-
ties should regularly organize on the job trainings,
seminars, and workshops for practitioners, espe-
cially nurses, on effective therapeutic communica-
tion. This would also help practitioners update
INTERNATIONAL JOURNAL OF PUBLIC ADMINISTRATION 11
their knowledge on modern trends regarding ther-
apeutic communication measures and strategies.
● Nurses are entreated to communicate in simple
language to the understanding of patients. This
would help simplify issues to laymen. From our
interaction with patients, it became apparent that,
communication in simple language by nurses
would help allay the fears of patients regarding
the gravity of their health situation.
● Hospital authorities must enforce measures to
regulate visiting of patients by relatives. In addi-
tion to this, measures must be instituted to help
promote a conducive atmosphere for both nurses
and patients. This may contribute to promote
quality health service delivery.
● Authorities should entreat nurses to have enough
time to communicate with nurses. This would help
patients inquire about issues bordering their minds.
● In recruiting and assigning nurses, we implore
authorities to take into consideration factors such
as patient–nurse ratio. While we entreat govern-
ment authorities to prioritize posting nurses to
under-resourced areas, we also implore health
authorities to ensure sufficient availability of nurses
in departments in the various health departments.
This would help promote release pressure and allow
for more nurses to have adequate time for patients.
Acknowledgments
The research team would like to extend our gratitude to
participants for their immense cooperation.
Funding
The authors received no financial support for the research,
authorship, and/or publication of this article.
Competing Interest
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Data availability statement
The data described in this article are openly available in the
Open Science Framework at DOI:10.17605/OSF.IO/TPA6U.
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