Level of Nurses to Patients Communication and Perceived Barriers in Government Hospitals of Bahir Dar City, Ethiopia, 2020

Background: Communication is the process of exchanging information or messages from one group to the other through mutually understood verbal or non-verbal ways. Communication barrier is anything that prevents receiving and understanding the messages. poor communication between patients and the nurses’ result in an increased length of stay, wastage of the resource, patient dissatisfaction, absence of confi dence, and frustration for both the nurses and the patients. This study will provide basic information on the level of nurses to patients’ communication and perceived barriers in government hospitals of Bahir Dar city.

A communication barrier is anything that prevents from receiving and understanding the messages others use to share their information, ideas, and thoughts. Language barriers occur when people do not speak the same language, or do not have the same level of ability in a language. Such a language difference is causing an inability to exchange information and therefore a potential for misdiagnosis and mistreatment. Even with in the same language, there are vocabulary differences based on regions and professions. The nursing professions have their nomenclature that nonmedical persons may not be able to understand. It also affected by time constraints, cultural differences, lack of knowledge and communication skills, nurse discomfort, and environmental factors which causes poor patient outcomes [4,[6][7][8][9].
The studies in Manchester, England, and Canada indicated that poor communication between patients and the nurses' result in an increased length of stay, wastage of the resource, patient dissatisfaction, absence of con idence and frustration for both the nurses and the patients [1,10]. Failure to recognize the two-way communication capability quite often leads to negative conclusions and attitudes. Moreover, the message sent is not the same as the message received. The decoding of the messages is based on individual factors and subjective perceptions. The receiver interprets the message they heard is not according to what the sender said but according to their code [2]. According to the research center for quality care, 10.8% of patients believed that nurses sometimes or never listened to them carefully, do not explain things clearly, and do not spend enough time with them [11]. patients can be determined by the communication capacity of nurses. So, if the nurses have good communication skills, the patients' communication will be smoothed with their nurses. Even if, the Ethiopian ministry of health has implemented a compassionate respectful caring training program for health care workers including nurses to bring satisfaction to the patients; it might, unfortunately, helps to improve nurses' communication with the patient. However the nurse to patient communication in the health institution not solved which observed as the obstacles of better care and patients suffered for long periods in the health institution without a listener and better care. Poor communication between nurses and patients increase mortality, morbidity, long hospital stay, increasing health care costs, and minimize clients' attraction towards health institutions. Study indings will be used as input for decision-makers and responsible bodies like the federal ministry of health (FMOH), regional health bureaus, academic institutions, and health care professionals which helps to decide what needs to be done to improve nurses to patients' communications. It will be used as baseline data for the researcher who needs to conduct on the area of the nurse to patient communication. Therefore the purpose of this study was to assess the' level of the nurse to patient communication and perceived barriers in government hospitals of Bahir Dar city. In addition to these nurses' experience on the nurse to patient communication barriers was explored.

Study setting
The study was conducted in Bahir dar city which is the capital city of the Amhara region located in 565 kilometers away from Addis Ababa in the NorthWest direction. There are three governmental hospitals in Bahir Dar city administration. These are Tibebe Gihon specialized-teaching hospital (TGSTH), Felege Hiwot comprehensive specialized hospitals (FHCSH), and Addis Alem primary hospital (AAPH). The total numbers of nurses in these three hospitals were 744 from February to March 2020. was used. The source populations were all nurses who work in government hospitals of Bahir Dar city, and nurses on sick leave or annual leave, and some other social problems were excluded. The total samples were 380 nurses for quantitative. First, the three governmental hospitals in Bahir Dar city were selected based on convenience because there are only three governmental hospitals, and private hospitals were not included because of the nurses in the governmental hospital also work at the private. Proportional allocation of samples based on the number of nurses was given for each hospital (Figure 1). Finally, nurses from each hospital were selected by simple random sampling using the lottery method. The sample size for qualitative was considered until data saturation, and 7 nurses were interviewed with data saturation was gained at the fourth participant. Data saturation is a matter of identifying redundancy in the data or relates to the degree to which new data repeat what was expressed in previous data during data collection [17]. The study was conducted from February -March 2020.

Operational defi nition
Good communication: Those nurses' who answered mean and above mean communication questions. That is there are 14 questions prepared to assess communication level with a Likert frequency scale (never, rarely, sometimes, often and always) with the value of 1 to 5. So the summation of the ive Likert responses is 15 then divided by ive which equals 3. Therefore the mean of one question is 3 and 42 is the mean of the 14 questions.

Data collection tool
A questionnaire assessing the level of nurses' to patients' communication and perceived barriers was adapted after a review of different works of literature [4,18,19]. The data collection instrument was prepared in English and translated to Amharic, and again re-translated to English by nurse academician. The pre-test was done in 5% of the calculated sample at Debre Tabor hospital to check whether the questions are simple, clear, and easily understandable. The questionnaire contained three sections. The irst part included demographic part contains 8 questions, the second part was concerned with the perceived barriers of nurses to patients' communication which contains 27 questions which were assessed by ive-point Likert using agreement (strongly disagree=1, disagree=2, neutral=3, agree=4 and strongly agree=5) then which latter recorded or categorized as strongly disagree, and disagree=1, neutral=2, agree and strongly agree=3 for analysis; and the third part is about the level of communication which contains 14 questions with a minimum score of 14 and maximum of 70 scores. The validity of questionnaires' was checked by expert opinion (face validity) [20]. Therefore the questionnaire's validity was checked through face validity by four nurse academicians, one of them is an assistant professor, two lecturers, one assistant professor with a Ph.D. holder, and three clinical Bsc nurses who working at the hospitals. Internal consistency or reliability of the questionnaire was checked by using Cronbach's alpha which was 0.919 for perceived barriers and 0.942 for the level of communication questions. An in-depth interview guide semi-structured questionnaire was used to elicit information concerned perceived communication barriers from the nurses' point of view. Detailed information about nurses' thoughts was explored in-depth which was offered a more complete picture of perceived barriers of the nurse to patient communication.

Data collection procedure
The data collection for a quantitative questionnaire was facilitated by BSc nurses, who had a better experience of data collection skills on clinical, and also training on data collection procedures and instruments were given. The data collectors distributed the self-administered questionnaire to the respondents to ill it. The qualitative data were collected by the principal investigator.

Data quality assurance
Adequate training and supervision were provided for the data collectors and supervisor. Codes were given to the questionnaires. The illed questionnaire was checked for completeness by data collectors and supervisors every day. Problems encountered during the study period were discussed in the study team and were solved. Computer frequencies and data sorting were used to check for missed variables, outliers, or other errors during data entry.

Data processing and analysis
Data were irst checked for completeness and then each completed questionnaire assigned unique code. Subsequently, the data were entered using Epi Data 4.6. The generated data was exported to a statistical package for social sciences (SPSS) version 25. The data was cleaned by visualizing, calculating frequencies, and sorting. The analysis was done with descriptive statistics by using frequency, percentage, mean, median, and mode. Bivariate analysis between dependent and independent variables was performed using binary logistic regression by the enter method. Multicollinearity between independent variables was checked using the correlation coef icient. The correlation coef icients between predictor variables greater than 0.7 is an appropriate indicator for when collinearity begins to severely distort model estimation and subsequent prediction [21] . All explanatory variables which had an association in bivariate analysis with a p-value less than or equal to 0.25 were entered into a multivariable logistic regression model. Hosmer and Lemeshow test were checked for model goodness of it (0.363). During the analyses, 0.05 P-value, and 95% con idence interval (CI) was used. A P-value of less than 0.05 was taken as a signi icant association. Results were presented in text, tables, charts, and graphs. Convergent parallel design (the quantitative and qualitative strands of the research are performed independently, and their results are brought together in the overall interpretation). In both quantitative and qualitative, the data collection and data analysis occur concurrently (QUAN + qual) and independently [22]. For the qualitative study ield note and audio recorded was taken. Each interview was transcribed by cross-checked both the audio record and the ield note. The accuracy of the transcripts was checked by repetitive listen to the audiotape and by reading the transcripts. The analysis was carried out by using deductive approach thematic analysis which involves coming to the data with some preconceived themes that expect to ind re lected there, based on theory or existing knowledge [23]. Based on this data were thematized in four major themes. The themes included; common communication barriers with sub-themes of language difference; nurse related barriers with subthemes of lack of communication skill, shortage of nurses and workload; patient-related barriers with sub-themes pain, and family interferences; environmental/health setting related barriers with sub-themes of lack of medical facilities and lack of continuous training, inappropriate and busy environment.
The integration was taking place in the results point of integration; in which writing down the results of the irst component, the results of the second component are added and integrated [22]. The inal result was triangulated to support the quantitative result.

Ethical clearance
Ethical issues within the study were taken into consideration when carried out the study. Ethical clearance was obtained from the institutional review board of Bahir Dar University, college of medicine, and health sciences with protocol number 0044/2020. A formal letter was submitted to Addis Alem primary hospital, Felege Hiwot hospital, and Tibebe Gihon hospital. For both the quantitative and qualitative study, at the initial stage of data collection and interview, informed consent was obtained from respondents and assured that their participation will be recorded anonymously, and con identiality of response was maintained throughout the study.

Socio-demographic characteristics of the participants
A total of 380 samples were included in the study, and 370 participated with a response rate of 97.4%. The participants' age ranged from 23 to 58 years, with a median age of 29 years. Among a total of participants, 189 (51.1%) were female ( Table 1).

Level of communication
Nurse to patient communication is the exchange of information or message between nurses and patients.  score lies between a minimum of 14 to a maximum of 70. The mean used for dichotomous the data as poor and good communication was pre-determined ( Table 2).

Distribution of socio-demographic and perceived barrier variables and the level of communication
Those nurses quali ied as degree and above 107 (79.2%) were had poor communication. Nurses less than 2 years of experience 48(35.5%) were had poor communication (Table  3a,b).

Perceived nurse to patient communication barriers
Perceived communication barriers include sociodemographic characteristics nurses, common-related or perceived barriers on both sides, nurse-related, patientrelated, and environment-related communication barriers.

Common-related pe rceived communication barriers reported by nurses
Barriers that are common between nurses and patients inhibited the communication of nurses with the patients.
Language difference was the highest perceived commonrelated communication barrier with a-mean score of 2.27, and 60.5% of nurses at 95% CI (49.7%, 70.4%) were agreed as a perceived common-related communication barrier with (median=3, mode=3), whereas religion difference was the least perceived barrier with a mean score of 1.795. But nurses disagreed with gender, culture, religion, and age differences (median=1, mode=1) ( Table 4).

Nurses related communication barriers reported by nurses
Nurse related communication barriers are barriers to communication which make patients not having a good relationship with nurses.
The workload was the highest perceived nurse related communication barrier with a mean score of 2.66, and 80.8% participants at 95% CI (70.4%, 91.5%) were agreed as a barrier of communication, while unfamiliarity of the nurse with dialect was the least perceived communication barrier with a mean score of 2.01. About 74.6% of nurses also agreed that a shortage of nurses as a perceived communication barrier with 95% CI (65%, 83.9%). Workload, shortage of nurses, lack of time, lack of communication skills, problems outside the working area, nurses' unwillingness to communicate, and low salary were the perceived communication barriers (median=3, mode=3). The nurses were tending to neutral or agree about the place of working, nurses' unpleasant experiences, and unfamiliarity with dialect (median=2, mode=3) ( Table 5). You inform patients of the results when taking their vital signs (blood pressure, temperature, heart rate) 1 2 3 4 5 3 You give the patient information on any diagnostic tests(namely the type of test, its purpose, preparation and what will happen during the test) You inform the patient about the medication-taking during hospitalization(kind, dose, side eff ects) You keep patients informed on the condition of their health 1 2 3 4 5 3 You inform the family about the health conditions of critical patients and children 1 2 3 4 5 3 You try to include/inform them about the decisions related to their therapy 1 2 3 4 5 3 You provide information to the patients when they ask you 1 2 3 4 5 3 You are polite and friendly towards your patients(manner of speaking, protection of privacy, respect in diversity) 1 2 3 4 5 3 You immediately respond to their call for help(notifi cation button, sign) 1 2 3 4 5 3 You inform the patients on how to take care of themselves at home after being released from the hospital 1 2 3 4 5 3 You inform the patients about positions which help to alleviate pain 1 2 3 4 5 3 You dedicate adequate time to communicate with patients 1 2 3 4 5 3 You respond to the patients' concerns and complaints during their stay at the hospital 1 2 3 4 5 3 Overall mean score 42 36.5% 63.5% Poor communication

Bivariate and multivariable logistic regression
From the total of eight socio-demographic and 27 perceived variables, 16 independent variables were associated with the outcome variables during bivariate analysis. Variables with a P value less than or equal to 0.25 were entered into multivariable logistic regression. But two variables which were age and culture difference (age with experience=0.747, culture with religion difference= 0.873) were dropped or not entered into multivariable regression because of multicollinearity. Finally, four variables were associated with the dependent variable. These were educational level, experience, the unwillingness of nurses for communication, and lack of communication skills. Those nurses who quali ied degree and above were 6.14 times more likely with 95% CI 6.14(2.741, 13.764) to have good communication than diploma nurses. Those nurses who had work experience of 6-10 years were 3.5 times more likely with 95% CI (1.585, 7.748), and those who had greater than 10 years of experience were 12.85 times more likely with 95% CI (4.747, 34.762) to had good communication than those nurses who had less than two years of work experience. Nurses who agreed that unwillingness of nurses to communicate is a perceived communication barrier were 60.5% times less likely to have good communication than those who disagree (Table 8).

Socio-demographic characteristics of nurses
A total of seven nurses have participated in the qualitative interviews, while 5(71.4%) of them were male. The age of the participants ranged from 38-50 with a mean age of 43.86 years.

Common communication barriers
Common barriers are those barriers that could arise from both sides of the nurse and patients which can decrease the nurses to patients' communication. The barrier included under this was language difference.

Language diff erences
Persons without having common language cannot communicate effectively or properly to express their feeling as those who have a common language.  One of the participants said that the differences in language affect communication with the patients. The patients give other meanings as we told positive things for them. In this condition, I may no longer interest to communicate with such kind of patients (Participant 5).
The other nurse continued and he said we have face dif iculty of communication with those patients who speak other than Amharic like "Awigna and Afan Oromo" language speakers cannot understand us whatever we talk good thing for them (Participant 6).
The 50 years old nurses spoken that language difference with the patients also affect our communication for example; we cannot easily communicate with those patients who speak "Agewigna" (Participant 1).

Nurse-related barriers
These are barriers that arise from the nurses, which can inhibit the nurse-patient communication. The barriers included under these were workload, shortage of nurses, and lack of communication skills.

Workload
The presence of workload from the nurses is the potential threat of better care. When nurses carry out activities more than their capacity they became burnout and unable to satisfy the patients' care needs. There is a shortage of nurses as a result we serve the patients more than our capacity and we feel fatigued, exhausted, and burnout. This damages our communication with the patients (Participant 3). The other participant also continued we face physical fatigue when we did more than our capacity; this leads to the obstacles of communication (Participant 6). I cannot give adequate time to communicate with the patients rather I prefer to do the routine activities because of workloads (Participant 7).

Shortage of nurses
The presence of inadequate nurses in the hospitals or few nurses during their shift can damage communication with their patients because of unable to address all demands of the patient very well.
"Especially at night shift nurse to patient ratio is one to ten up to twelve." (Participant 5).
A 38 years old nurse said that there are a limited number of nurses compared to the low of the patients. So during this time, we prefer to do our routine activities like medication administration, doing the nursing process without listening to the patient idea. As a result, our communication with patients is affected (Participant 4). The other nurse continued "we serve more than twenty patients especially during duty time" (Participant 6).

Lack of communication skill
Communication skill for nurses is very essential to communicate effectively with their patients. Nurses without good communication skill they cannot provide better care for the patients.
One nurse reported that "some nurses have natural behavior which may not shape with training" (Participant 2). The other nurse continued we most nurses have lacked the skill to communicate with the patient like the place we select for communication, how to start communication, and are patients understand me or not...is not considered (Participant 4). Some nurses cannot fully explain what things are going to do for their patients about care or treatments (Participant 6).
The other nurse said that I know one nurse she was assigned to work with me together in the pediatric ward. She was having an ethical problem. She made con lict most of the time with the patients. The entire mother knows her ethical problem and they always complained that we are not voluntary if our children's medication is given by this red nurse. So this was the great barrier of communication with the patients (Participant 7).

Patient-related barriers
Patient-related barriers are these obstacles arise directly from the patients that inhibit nurse to patient communication.
The barriers included under these were pain and family interference.

Presence of pain
Pain is a general term that describes uncomfortable sensations in the body. It can change the behavior of the patients from stable to irritable mood and results in refuses to make contact with their caregiver.
One nurse revealed that the presence of pain decreases the communication between nurses and patients. If the patients are in the good condition they have a good facial expression for nurses greeting but, if they are with the pain they cannot respond to our greeting (Participant 1).
The other participant also said that as the patients suffered by the pain, they are not voluntary to communicate with us (Participant 4). One of the participants also continued if the patients get pain they are not voluntary to communicate with the nurses (Participant 5). The 47 years old nurse said that patients with severe pain cause to disrupt our communication. Those patients are not voluntarily given accurate data to us unless we give anti-pain and got relive from pain (Participant 7).

Family interference
Con lict in the caring environment is common between care providers, and the patients' attendants either intentionally or unintentionally. This is because of the unnecessary interferences of family or attendant with the caring process.
One of the nurses told that during we give care for the patients the family interferes with our activities. This makes angry for the nurses and leads to con lict with them and inally, communication with the patients inhibited. For example, one day the patient medication was discontinued in around session then the attendant comes and complained that why not you give the medication. The nurse responds for the attendant as it was discontinued, inally the attendant ight with the nurse why you discontinued it as it is already prescribed by the physician (Participant 5). The other nurse continued that at one time one college student come to us because of illness. During this time we were trying to help her but, her friends come and disturb us. They said this is not the disease rather she attacks by an evil eye person so, this cannot be treated by modern medicine, and they also try to hit one of the nurses with us (Participant 7).

Environmental-related barriers
These barriers are arising directly from the health care setting which caused the barrier of the nurse to patient communication. The barriers included under these were lack of continuous training, lack of medical facilities for the patients, Inappropriate and busy environment. https://doi.org/10.29328/journal.cjncp.1001023

Lack of continuous training on communication
If nurses do not get continuous training regularly, they cannot update themselves and they may easily subject to tradition as well as lacked basic caring skills.
To increase our communication with the patients we need to have continuous training. But there is no training to enhance the nurse capacity especially on communication skills (Participant 4). The other nurse said that we need to have training on communications skill to enhance our communication with the patients (Participant 5). Lack of training on communication is the major barrier to communication with the patients. Short training needs to enhance the nurse to patient communication (Participant 7).

Lack of medical facilities
If the hospitals cannot provide the necessary medical equipment or materials for the patients; the patients complained goes to their immediate caregiver or nurses. This is the main cause of the communication barrier.
All participants said that a lack of medical facilities was a barrier to communication. One female nurse said the hospitals cannot provide all necessary medical facilities for the patients like a drug. For example, most societies in this surrounding area used health insurance. We prescribe drugs to the patients but they cannot get the drug inside the hospital rather they pushed to buy out of the hospital or in the private pharmacy. Then the patients complain to us as they cannot afford to buy the drug. We told the truth as it is not our responsibility and if hospitals can list out the non-available drug and post to the working unit we cannot prescribe it. They did not listen to us. This leads to con lict between nurses and patients and decreases communication (Participant 1). The other nurse continued that the health institution related issues are affecting our communication. For example, we send the patient to buy the drug out of the hospital then the patient made con lict with us. This is happening because the hospital cannot provide an adequate supply of drugs. This alters our communication with the patients (Participant 2).
The health insurance is another challenge for communication. The hospital cannot ful ill all the necessary drugs and the patients bought it out of the hospital. After that, they ask us to audit the cost of the drug. We respond to them our duties is to prescribe the drugs not auditing cost. This affects the communication we have with the patients (Participant 3). One male nurse also stated that "patient comes to the hospital with their health insurance, and drugs are not available adequately. During this time the patient is not interested to listen to us whatever we talk. This challenges our co mmunication with the patients (Participant 4). The patients come with their health insurance, and they expect everything inside the hospital. If they did not get the services as they expected they shout towards us. In this condition, our communication with the patients is affected (Participant 5). Almost all persons use health insurance and the hospital cannot provide all the patient medical facilities like drug supply. If they cannot afford to buy the drug out of the hospitals their treatment may discontinue and they complain to us why the treatment discontinued. In this time we lead to an unnecessary verbal ight with the patients (Participant 6). Patients come with health insurance for free services but the hospital cannot provide all the services like drug supply; when they ordered to buy out of the hospital the make con lict with us (Participant 7).

Inappropriate environment
Unsafe caring environments are among the obstacles of the nurse to patient communication. Unattractive health care environments can hinder the interaction between nurses and patients.
Participants reported that poor sanitation of the room also affects the communication between nurses and patients (Participant 4&7).
Busy environment: Busy environment or the crowdedness of the health care environment is can inhibit nurse to patient communication.
One of the nurses said that the place of the hospital as it is nearing to the road the sound of the cars also affects us (Participant 5).
The other nurse also continued his idea for example when I enter the ward to care for my patient I saw the persons who make crowded rooms at that time I prefer to leave the room; because the environment was not suitable for me to communicate with my patient (Participant 7).

Discussion
The main purpose of this study was to assess the level of the nurse to patient communication and perceived barriers in governmental hospitals of Bahir Dar city. Perceived communication barriers included common communication barriers; nurse-related, patient-related, and environmentalrelated barriers were assessed and explored in both quantitatively and qualitatively. The study participants were nurses working in governmental hospitals of Bahir -Dar city.
From the total of participants (N=370), 36.5% of nurses were had poor communication.
In this study, the proportion of poor communication is found to be high. This showed how much the communication level of nurses' lies in dif icult conditions and indicates that nurses did not get adequate communication skills in their training period at the college or university level. This result is higher than a study done in João Pessoa, Brazil showed that In this inding, diploma nurses are more likely to have poor communication than a degree and above-quali ied nurses. This is obvious that being advanced from lower to higher-level education is expected to have better skill and knowledge because the required competencies seated in the curriculum bring this difference which is consistent with the evidence in British journal of nursing supports that degree nurses were showed genuine differences in clinical practice than diploma nurses [24]. In this study nurse who had less than two years of work experience were more likely to have poor communication than those who had work experience of 6-10 and greater than10 years of work experience; which is consistent with the study done in China, found that as the nurses became experienced their communication level gets improved. Those who experienced two to three years were lacked communication skills with their patients [25]. Evidence in Saudi Arabia also showed that nurses with shorter experience perceived more barriers to communication than nurses with longer experience [4]. This is because while nurses get more experienced, they might be acquired different communication skills or techniques that how they can approach and communicate with their patients than the less experienced or newly employed nurses.
Language difference was perceived common-related communication barrier reported by nurses. As the qualitative inding also supported that language difference affect nurse to patient communication. This because of the presence of multilingual people in Ethiopia including the study area can be the barrier of communication. This result is consistent with the studies done in Saudi Arabia in which nurses were reported that they faced dif iculty in dealing with patients because of language differences [26]. Another study in Saudi Arabia also supported this inding in which some of the communication practices rely on non-verbal methods due to a lack of a common language which often results in misinterpreted in the meaning of the communication [27].
In this study, nurses agreed that workload was the barrier of the nurse to patient communication which is also supported in the qualitative result of this study. Because when nurses working beyond their capacity they become exhausted and burnout as a result they cannot easily interact or communicate with their patients. This result is in line with a study conducted in Ghana; in which nurses were agreed that overwork as the barrier of communication [15]. This inding also supported by the studies done in two different areas of Iran indicated that workload was the barrier of communication between nurses and patients [28,29]. It also supported by a study in Saudi Arabia in which nurses were agreed that heavy workload as a barrier of the nurse to patient communication [4].
Nurses agreed that the shortage of nurses was barrier communication as participants in qualitative interviewees also strengthen this idea. The main reason is in this area the nurse to patient ratio reaches to one to twenty or more compared to in the state of California the maximum nurse to patient ratio is one to six [30]. This inding is similar to a study done in Ghana in which nurses agreed that shortage of nurses as barrier communication [15]. Other Studies in two different areas of Nigeria also supports that inadequate or shortage of nurses was affect the nurse to patient communication [31,32].
Lack of time also another communication barrier reported by nurses. This is because, if the nurses carry a high burden of activities, they do not have adequate time to communicate with the patients. This result is aligned with the study done Egypt, and in two different areas of Nigeria, and Ghana showed that lack of time was the barrier communication between nurses and patients [15,[31][32][33].
Nurses agreed that Problems outside the working area were a barrier of communication, but a study done in Saudi Arabia showed that there was disagreement about problems outside work as a barrier to communication [4]. The difference is due to the work experience of nurses in Saudi -Arabia was from 1-24 months and since most of the nurses were freshmen for the working area, they might not be encountered problems out of working area compared to these study participants.
Nurses' unwillingness to communicate found to be the barrier of the nurse to patient communication. This is due to the presence of a lack of communication skills in the nurses. This is supported by studies done in Singapore and Ghana showed that nurses were more reluctant or lack of interest to engaged in communication which caused communication barrier between nurses and patient [18,34].
In this study low salary paid for nurses was the barrier of communication. The reason is that if the nurses cannot be paid based on the task performing, they will not get satis ied with their work and result in a decrease in engaging in communication with patients. This is aligned with a study done in Saudi Arabia nurses were agreed that low salary was one of the perceived communication barriers [4].
More than seventy percent of nurses agreed that the presence of pain was a barrier of communication which also supported by the qualitative results. The main reason that patients seek to visit health institutions is because of pain. If pain cannot manage properly, the patients do not have the interest to communicate with their caregiver. This study is consistent with a study done in Ghana indicated that Pain was the major patient-related barriers to communication which accounts for eighty percent of respondents [15].
The inding indicates that the presence of contagious disease was one of the perceived communication barriers. This is because nurses afraid acquiring of communicable or contagious disease from the patients, they prefer to away from the patient and lead to a decrease in the nurses' interaction with their patients. This result is similar to the studies done in Iran that showed that the obstacle of communication was the in luence of contagious diseases [28,35]. It also supported by a study done in Saudi Arabia [4].
In this study family interference is the other barrier of the nurse to patient communication both in quantitative and qualitative results. It is due to the interference of family members in the patient caring process unnecessarily, the nurse preferred to leave the patient. This is aligned with the study done in Saudi Arabia, and a qualitative study in Ghana indicated that family interference was the barrier of Communication [4,18].
Nurses agreed that distrust nurse competency is the main communication barrier. This is happening because patients and their attendants do not give enough credit for the work of nurses. This inding is supported by a study done in Singapore which showed that nursing has a low occupational prestige; as a result, communication was greatly inhibited as patients see nurses similar to foreign domestic workers [34].
In this study, nurses agreed that the lack of continuous training on communication skills was the major barrier of communication, and participants' in-depth interviewees also supported this inding. This because nurses without adequate continuous training on communication skills can easily vulnerable to poor communication. This result is similar to the study done in Saudi Arabia indicated that there was general agreement among the nurses that lack of continued training in communication skills was seen as a communication barrier between nurses and patients [4].
Both quantitative and qualitative inding shows lack of medical facilities is the barrier of the nurse to patient communication. Because patients come to the hospitals to get adequate services, if not this, patients make con lict with the frontline caregiver or nurses. This result is similar to the study done in Egypt showed that there were inadequate facilities that affect patients' communication with nurses [33]. It also supported by the study done in Saudi Arabia nurses were showed their agreement as a barrier of communication [4].
In this study, both quantitative and qualitative indings show that a busy environment is one of the environmentalrelated communication barriers. Unsafe environments make boredom relationships between nurses and patients as a result they cannot create comfortable conversations on both sides. It aligned with studies done in Isfahan Iran, Ghana, and Egypt showed that busy or crowded rooms were the main environment-related communication barrier [15,33,35].
In this study unfamiliar environment was the barrier of communication as reported by nurses. When the patients are new to the health institution or hospitals, they faced different challenges like anxious interaction with caregivers and unable to ind different service rooms in the hospital. This result is similar to the studies done in two different areas of Ghana indicated that nurse to patient communication was affected when patients new to the hospitals [15,18].
Generally, the inding revealed that nurses have found to be at a poor level of communication. There are perceived communication barriers including socio-demographics, common related, nurse related, patient-related, and environmental or hospital-related barriers which affect nurse to patient communication. There was the correspondence of results in both quantitative and qualitative methods or the indings in qualitative in-depth interviewees used to support the quantitative results. The result of this study has multidimensional implications. It can be used for the nurses to deal with and overcome the communication barriers. Dealing with the communication barriers mean also dealing with the problems of the patients so that the patients can get better care from their caregiver. As the barrier going to be minimizing or decreasing, the hospitals can be attractive for patients, safe for healing, increasing patient satisfaction, decrease hospital stay, and helps to minimize health care costs. Finally, this inding can be used as a baseline for further research.

Strength of the study
The study employed a mixed-methods design which helps to triangulate the quantitative indings by the qualitative indings.

Limitations of the study
This study was focused on nurses' perception only; perceptions of patients on the communication barrier were not assessed and explored. As the response of the questionnaires was prepared by a Likert scale; there might be social desirability bias. https://doi.org/10.29328/journal.cjncp.1001023

Conclusion
In this stud y, the communication of nurses to patients is found to low. Nurse to patient communication can be achieved by investing in continuous education as a way to enlighten professionals on the purpose of communication. Nurses, patients, and the environments are the main perceived communication barriers as indicated in both quantitative and qualitative methods. Lack of medical facilities or access is the main barrier of the nurse to patient communication which needs great attention of the stakeholders. Nurse professionals need to have good communication skills to solve or overcome the problem of patients; and must communicate effectively to perform their roles as educators, managers, decision-makers, client advocators, problem solvers, and caregivers. To enhance communication with the patients; nurses and other stakeholders like the Ministry of health, health bureau, and hospital authorities need to recognize the communication barriers. Giving awareness on the communication barriers for the nurses helps to minimize the barriers and improve the nurses to patients' communication.