Pediatric nurse-patient communication practices at Pentecost Hospital,Madina: A qualitative study

Evns Osei Appih ,Stell Appih ,Smuel Kontoh ,Srh Mensh ,Dorothy Bffour Awuh ,Awue Menlh ,Michel Bidoo

a School of Nursing and Midwifery,Valley View University,Ghana

b Pentecost Hospital,Madina,Accra,Ghana

c Purdue University,West Lafayette,USA

Keywords:Attitude Communication Ghana Nursing staff Pediatric nurses Parents

ABSTRACT Purpose: Delivering quality health care requires effective communication between health care providers and their patients.Nurse-patient effective communication remains a challenge in Ghana,despite criticism and concern expressed by the public.The study,therefore,aims to assess the effective nurse caregivers’ communication practices among pediatric nurses at Pentecost Hospital,Madina.Methods:A qualitative exploratory and purposive sampling technique were used.Participants were engaged in Focus group discussions or face-to-face interviews.In all,4 focus group discussions were conducted with 7 participants in each group and 15 face-face in-depth interviews,with a total sample size of 43.The data was content analyzed.Interviews were taped recorded and transcribed verbatim.Results:The data analysis yielded 3 themes and 11 subthemes.The main themes were: effective communication practices,factors influencing effective communication,and attitudes towards effective communication.The study revealed how the participants communicated with patients who are deafmute,anxious,and those who refused treatment.In addition,participants reported how they used techniques such as silence,listening,and leading cues in communicating with patients and their relatives.Conclusion:Effective communication between pediatric nurses,patients,and their parents is ascertained to be a key tool in the delivery of quality health care.However,several factors are found to hinder this therapeutic communication.Hence,further studies are needed to improve effective communication skills among pediatric nurses and their patients to enhance health care for children.

What is known?

· Effective communication between health care providers and patients is very important for delivering quality health care.

· Excessive workload and shortages of nursing staff negatively impact nurses’ ability to interact effectively with patients.

What is new?

· This study explored the ways in which pediatric nurses can communicate with clients with difficulties in communication.

· Pediatric nurses’ methods of reporting patient complaints for timely feedback were presented.

1.Introduction

Delivering quality health care requires effective communication between health care providers and their patients [1].Patients are protected from potential harm when there is effective nursepatient communication [2].Effective communication makes it easier for the patients to reach a clear understanding of whatever information is being relayed during care [3].Effective healthcare communication such as pre-discharge family meetings is key in empowering patients and families to participate fully in the care of their relatives thereby improving patients’health and adherence to treatment[4].On the other hand,poor communication can lead to patient misunderstandings,failure to follow treatment protocols,and medical errors [5].Healthcare costs and negative patient outcomes increase when there is poor communication in healthcare delivery [6].Nurses are the primary link of communication in the health care team [7].The important communication links are the nurse-patient/family,nurse-nurse,and nurse-physician.

According to a study,ineffective communication among patients and perioperative nurses could negatively impact patient care and outcome[8].In Germany,a study among 6,105 adult patients of 18 years found that few (12%) of the participants reported an understanding of written and oral health information by health care providers [9].In Brazil,it was indicated that communication problems occur in up to 70%of reported cases of adverse events in hospitals [10].It was further indicated in the same study that communication failures are responsible for 32% of errors in the Intensive Care Unit (ICU).A systematic review of articles of literature found that because of language challenges some health professionals relied on non-verbal communication which according to them led to misinterpretation and dissatisfaction [11].

In Africa,the use of structured communication is gradually being introduced and implemented in the health care system.For example,in South Africa,a health facility adopted Situation-Background-Assessment-Recommendation (SBAR) and this showed significant improvement in communication among health professionals and improved safety of patient care[12].In Nigeria,it was reported in a study that patients were satisfied with the nursing care communication in terms of administration of prescribed drugs [13].

Nevertheless,a study in selected sub-Saharan African countries including Cameroon,Benin,Ethiopia,Ghana,and,Nigeria among nurses found that excessive workload and shortages of nursing negatively impact nurses’ ability to interact effectively with patients [14].Nurse-patient effective communication remains a challenge in Ghana,despite criticism and concern expressed by the public[15].Hence,some authors stated that hospital management should conduct regular evaluations of patients’experiences as well as nurses’ experiences to address deficiencies in communication and nurse-patient interactions in Ghana [16].Some of the factors identified by some researchers in Ghana to hinder effective nurse/midwife-patient communication include a shortage of nurses,lack of empathy from nurses toward patients,language barrier,lack of time,and cultural preferences [17,18].Moreover,literature on pediatric nurse-patient communication in Ghana was scarce.It was therefore imperative that this current study explore pediatric nurse-patient communication practices at Pentecost Hospital.

2.Methods

2.1.Design and ethical consideration

A qualitative exploratory-descriptive design was used to explore effective nurse-caregivers communication among nurses.Research design was explained by some researchers as a procedure applied to collect and analyze data[19].Qualitative design involves the use of interviews and observations without formal measurements and expands understanding in exploring research questions [20].This study was approved by the Dodowa Health Research Centre Institutional Review Board(DHRCIRB)with a protocol number DHRCIRB 087/08/2.

2.2.Setting,inclusion and exclusion criteria

A population is a group of individuals from which a statistical sample is drawn for a study.Therefore,the study population refers to all individuals participating in the study.The population for this study was pediatric nurses at Pentecost Hospital,Madina.Participants for the study were pediatric nurses at Pentecost Hospital,Madina who had more than two years of working experience and were ready to give their consent to participate in the study.Nurses who were not psychologically sound and not willing to take part in the study will not be included in the study.

2.3.Recruitment and data collection

Sampling refers to the process where individuals are selected from the entire population [21].Participants of this study were purposely selected.Purposive sampling was done by choosing elements for the sample according to the judgment of the researcher.The sample size will be determined by saturation [22].Data saturation refers to the stage in the data collection process in research when no new information is discovered[23].The researcher would continue to conduct individual interviews until no new ideas were gotten from the participants.The sample size for this study reached 43.

An introductory letter with the ethical clearance was sent to Pentecost Hospital,Madina to seek permission from the hospital administration to be able to carry out the study.A visit was paid to the hospital where the researchers introduced themselves to the authorities to enlighten them on the purpose of the research.The purpose and procedure of the research were explained to the nurses who met the inclusion.They were informed to understand that they had their free will to decide whether or not to participate in the study.After their consent was sought verbally,an informed consent form was provided for the participants to fill out.The participants were engaged in face-to-face in-depth interviews and focused group discussions which were conducted by all the authors.In all,4 focus group discussions(FGDs)were conducted with 7 participants in each group and 15 face-face interviews were performed.The FGDs lasted for 60-80 min whilst the face-to-face interviews lasted for 40-60 min.The collection of data was within 2 months,September and October 2021.The data collection was done by all the authors.

A semi-structured interview guide was used as the main tool for the data collection for the study.The design of the interview was guided by the objectives of the study as well as the demographic characteristics of the participants.The interview contains openended questions with probes which will provide the opportunity for the researchers and the participants to express deeply the subject of the study.The first section of the tool for this qualitative study elicited information on the biographic data of respondents(age,sex,ranks,years of experience,etc.).The other sections were based on the objectives which were: practices of effective communication,factors influencing effective communication,and attitudes towards effective communication.The tool was pretested among two nurses at Valley View University Hospital.No ambiguities were detected during the pretesting and hence no modifications were done to the questions formulated.

2.4.Data analysis

Some researchers defined content analysis as the systematic way of transforming a large amount of text into a highly organized and concise summary of key results [24].The data analysis was done by all the authors of this study.Following the analysis,all the recorded data was produced verbatim by typing all the recorded information unto a word document and indicated with R1-R7 for the focus group discussions and P1-P15 for the face-to-face indepth interviews to ensure anonymity of the participants.

Data analysis is the analysis of the raw data from verbatim transcribed interviews to form categories or themes.It involves familiarization,condensation,coding,categorization,and development of themes.The authors familiarized themselves with the transcribed data by reading the transcriptions severally to gain insight into the transcripts.

Condensation is the process of shortening text while preserving its meaning.This was done by assigning a few words to the responses making sure the meaning was retained.Coding involves labeling and organizing of data to identify different themes and the relationships between them.Categorization is done by grouping together codes that are related to each other in their context.Development of themes involves the expression of data into their underlying meaning.This study used content analysis for data analysis.Hence data were condensed by shortening the text by preserving its meaning,coded,categorized by grouping together codes related to each other,and interpreted into themes and subthemes.The Consolidated Criteria for Reporting Qualitative Studies (COREQ) was used as a guide to reporting the qualitative study.

2.5.Trustworthiness

The trustworthiness is painstakingly followed by adhering to the four dimensions of rigor which are credibility,transferability,dependability,and confirmability [25].The principles were maintained by doing the research systematically,reviewing current literature related to the study,carefully stating the aim,describing the study design,sampling technique,sample size,data analysis and finally supporting themes and subthemes with verbatim quotes of the participants.All researchers were nurses and nurse tutors,however,the authors did not allow this to influence the results of the study,since the results have been presented verbatim as narrated by the respondents.

3.Results

3.1.Participants’ characteristics

Participants were engaged in FGDs or face-to-face interviews.In all,4 FGDs were conducted with 7 participants in each group making it 28 participants for the FGDs.Fifteen face-face in-depth interviews were also done.The language used for the interview was English.The total number of participants was 43.The participants’sociodemographic characteristics can be found in Table 1.

3.2.Themes and subthemes

Three main themes and 11 subthemes generated from the study analysis are shown in Table 2.

Table 1Socio-demographic characteristics of participants (n=43).

Table 2Themes and sub-themes.

3.2.1.Effective communication practices

3.2.1.1.Communicating with the hearing impaired.One of the challenges faced by nurses during communication is communicating with the hearing impaired.In order to communicate effectively with the hearing impaired,nurses are expected to be patient,avoid shouting and maintain eye contact.The majority of the individuals who took part in this interview identified that sign language was largely used to communicate with the hearing impaired.

“If the child is deaf-mute,you need time and concentration to be able to communicate effectively,and to gain their attention youneed to touch them first to alert and then give eye-to-eye contact before the hand come up making sure the hand stays up and not down.This helps gain the patient’s attention.” (R7,FGDs 4)

“With mothers and children who have this problem,facial expression also count when communicating,as much as you communicate with the hand.For instance,when the hand is communicating with sign of happiness you need to show it on your face same applies to sadness and it gives a better understanding to them,making communication effective.”(R1,FGDs 1)

Others also suggested the role of the hospital to aid in communicating with the hearing impaired as follows.

“We use sign when communicating with the patients who are deafmute in this hospital,some staff are experts in using sign language,they are one phone call away so they are called when we encounter patients with these challenges.The hospital management help organize workshops for such nurses to render these services effectively.” (R4,FGDs 2)

3.2.1.2.Communicating with an anxious patient.Anxiety is a normal reaction to uncertainty and the unknown.This is mostly experienced by patients due to their diagnosis or the new environment they find themselves in.When communicating withpatients who are anxious,nurses are expected to explain things clearly,taking time to listen and allowing time for questioning with clarification.Approximately half of the participants 23(53%)shared their thought on pediatric nurse patient communication with an anxious patient.

“As nurses,we reassure them,talk to them calmly make them understand the reason why they are on admission,give them information on their child’s condition and treatment regime,we involve them in everything concerning the child and allow parents to ask questions and we give feedback.This makes them relaxed and cooperative.” (R5,FGDs 3)

Few of the participants gave a scenario where they had challenges relieving the anxieties of their patients.

“Interacting with a patient’s grandmother in view of calming her down did not help at all,she kept on shouting;‘you people should leave me alone because I am thinking of what to tell my son the patient’s father when he calls.’ She was so tensed,the child ninemonth-old accidentally fell into a pot of palm nut soup and had sustained a second-degree burn,at a point,my in charge and I had to allow her to be as she requested but kept an eye on her and visited her the next day when he was calm to communicate with her.” (P8)

“A mother with a six-month-old female who was crying uncontrollably because her child was newly diagnosed with sickle cell diseases and also had to be referred to Kole-Bu Teaching Hospital.She was very worried and anxious because she has lost her first child with that same disease so couldn’t control herself but she assumed this child was also going to die.Reassuring and explaining things on a lighter side that the child will receive the best care at the referring side did not help but we kept on till they finally agreed.”(P15)

3.2.1.3.Use of silence.Silence is a powerful form of effective communication.Ironically,fewer words can result in clearer and stronger message that is being put across.Silence can enhance the therapeutic relationship between nurses and patients.Since it communicates that the nurse is paying attention.These were recounted by less than half of the participants 20 (47%) in relation to the use of silence.

“So,with the kids normally,when you are performing a procedure on them,and they are uncooperative,we normally put a serious facial expression which deters them from what they are doing and to gain their corporation.” (R7,FGDs 2)

“Parents sometimes appreciate nurses who talk less,since they are able to feel comfortable and pour out their concerns without interruptions unlike when they are interrupted while expressing themselves.” (P11)

“We use intentional silence by nodding at times,it’s useful to not speak at all in order to support the patient and relatives acknowledge the process and reflect on changes in their health.We nurses do not break the silence,they do to appreciate the good work nurses do.” (R1,FGDs 4)

3.2.1.4.Disclosing poor prognosis of patient’s condition.Veracity is all about being truthful or accurate in disclosing the poor prognosis of a patient’s condition.It is every patient’s right to be informed by a healthcare provider about their diagnosis,prognosis,and treatment of a condition.This is done for respect and ethical reason,but if giving out the prognosis can in any way harm the patient then sometimes the truth of disclosure may be withheld.Below are what some participants said about disclosing poor prognosis.

“So,since we have a pediatrician around,who normally breaks bad news when we get situations like that,we call upon her to break the news for us.” (P2)

“Sometimes we the nurses break the bad news to patient mothers especially when the doctors are not around,or sometimes doctors just certify the death and leave so you have no option than to break the news to prevent confusion on the ward.” (P14)

How the message is conveyed also keeps relatives calm one participant expressed.

“Sometimes it is not easy,breaking such information,for example,a child who has cancer,how do you inform the parents,but since they have the right to information,we find a way of providing privacy and breaking the news and stay with them after to provide emotional support.” (R2,FGDs 3)

3.2.1.5.Reporting patient complaints.Complaints in healthcare are key in helping healthcare providers know patient concerns,help them undo their and provide quality care.Hence,nurses should not take offense at them but accept all complaints in good faith.Some participants (30/43,70%) shared some situations and ways they reported patients’ complaints and a few of the quotes have been presented as follows.

“We give them the opportunity to make complaints,then calm them down.We then forward the complaints to the doctors and superiors that same day and ensure they get feedback.”(R6,FGDs 1)

“When patients make complaints,I first confront the staff involved to help resolve it but when it is beyond me,I contact the in charge.”(P3)

Few gave instances patients made complaints to them and the action was taken after.

“For instance,there was a time a parent made a complaint that they were feeling hot because the fans were not enough,so I informed the in charge and also put it into writing.Within two weeks new fans were installed because I kept following up.” (R7,FGDs 3)

“ A parent made a complaint about a nurse she inform about her daughter’s IV[Intravenous infusion]line which was not flowing but according to her,she saw the nurse leaving without attending to her so I had to call that particular nurse,who accepted her mistake that it skipped her.She did well by rendering an apology the following day.” (P5)

3.2.1.6.Dealing with nurse’s un-therapeutic communication.Communication plays a vital role in professional disciplines to promote effective communication skills with patients but its untherapeutic ways also damage its effectiveness.A few of the nurses (15/43，35%) gave instances where some pediatric nurses’communication was un-therapeutic.

“There was a time a nurse referred to a patient on the ward as a diabetic patient on bed two instead of mentioning the patient’s name,so I had to come in and correct the nurse.” (P11)

“Some nurses sit at the nurse’s station to discuss patient condition whilst other people are around,I think this is un-therapeutic and should be stopped,I always tell my junior nurses not to do that.”(P17)

“On one afternoon shift I met a nurse in a heated argument with patient’s relative concerning bills to be paid which is not covered by the national insurance scheme,I had to go in to separate them and take the nurse aside reminding her not to argue with patients’relatives on financial issues but rather leave it for the accounting staff.” (R5,FGDs 4)

The respondents listed several communication practices pediatric nurses used including communicating with the hearing impaired and anxious patients,using of silence during therapeutic communication,disclosing poor prognosis of patient’s condition,reporting patient’s complaints and dealing with nurse’s untherapeutic communication.

3.2.2.Factors influencing effective communication

3.2.2.1.Active listening and leading cues.Active listening is a pattern of communication that keeps one engaged in communication.Active listening is complete when one adds a leading cue,such as nodding,or brief verbal affirmations like “I see,” “go on”“ok” and “I understand” since it communicates to the patient that one is really paying attention.This was recounted by most of the participants(36/43,84%)with a few of the responses listed below.

“As nurses,when we are taking information or history from parents of our patients,we pay attention,give the parents or relatives undivided attention and we acknowledge information we receive.By doing that we get the right complaints to aid us give a good nursing diagnosis for an effective care process.” (R3,FGDs 3)

“Sometimes when we are communicating with parents of our we show that we are listening by showing somebody language with nodding and providing feedback on the question they ask,this makes them talk more.” (R5,FGDs 2)

Even though active listening was reported by participants as essential in promoting effective communication,few narrated that they face challenges in implementing this skill.

“Taking care of the sick child is really demanding when you have many sick children to take care of,it becomes difficult because you cannot spend time listening to all of the parents at the same time and hence you have to spend less time with each of them.” (P5)

3.2.2.2.Human factors.The way some health professionals behave toward their patients may affect communication positively or negatively.Some of these factors include being rude,easily angered,showing gratitude and being outgoing.The following are some responses on positive human factors to promote effective communication as listed by some participants (22/43,51%).

“Some of us nurses are naturally nice,we have a way of making our patients comfortable and putting smiles on their faces even if they are sad.How we will introduce ourselves will make them feel at home.” (P5)

“As nurses,we show gratitude to mothers who adhere strictly to the instruction given to them and take good care of their children.This serves as a motivation to other mothers who are uncooperative.”(R2,FGD 1)

“The zeal and passion some of us attach to our nursing duties make some parents and patients appreciate us and this makes communication effective.The way I spend a lot of time with the mother and the child throughout the whole process,the mother couldn’t stop saying thank you to me.” (P9)

However,some participants reported that some nurses are rude and disrespectful to their patients which may negatively affect the care.

“I have observed some nurses who are very rude and extend it to their patients,I think this does not promote effective communication.It sometimes makes the patient uncooperative and involve in conflict with some of the nurses.” (P1)

3.2.2.3.Negative attitude of relatives.Negative attitudes of patients’relatives also emerged from participants’ responses.Some participants mentioned that parents show the negative feeling of anger,disposition,disappointment and envy concerning inappropriate care their wards received.This makes them put up a negative attitude and sometimes exchange words with healthcare providers as declaimed by less than half of the participants (17/43,40%).Participants recounted the following to illustrate the above information.

“Some parents will not appreciate you no matter the care you give to them and their children,they will rather insult you and make negative comments but that is the job we have chosen,therefore we have to cope.” (P15).

“There was an instance we had to take care of a patient because it was an emergency,but after the child had recovered and the mother was asked to pay the bills,she started fighting the nurses on the ward and even absconded with the baby without paying.”(R3,FGDs 4)

Although this theme talked about patient’s negative attitude participant also recounted nurses putting up negative attitudes.

“Some nurses have a bad attitude which they even show to their own colleagues at work.They speak harshly to both patients and other colleagues whilst people are around.There was an instance where one nurse was even exchanging words with a patient whilst on duty which I think is very unprofessional.” (P7)

Some nurses gave such instances and how they controlled it“There are several instances I have observed patient relatives speaking on top of their voices disturbing other patients’ peace.When this happens,I quickly go to them and calm them down;sometimes I have to take them to a private place for them to express their worries so that it can be addressed.” (P11)

“There are times parents will decide to take their children home against medical advice.And I realized that this happens when they do not have sufficient information about the condition or they have run out of funds to pay for the service.Either way,I educate them on the condition or introduce them to social welfare personally to assist them with the payment.This makes them very cooperative after.” (P3)

According the study participants,there are varied factors that hinder promotion of effective pediatric nurse-patient communication and these include active listening/leading cues,human factors and negative attitudes of patients’ relatives.

3.2.3.Attitudes towards effective communication

3.2.3.1.Reaction towards patient’ s refusal of treatment.The rights of patients and relatives are to be respected but sometimes when they refuse treatment,nurses need to explore the reason behind the refusal,educate parents,and make patients and relatives understand the essence of adhering to the treatment prescribed.Nearly half of the participants(22/43,51%)recounted the issue and some responses are listed below.

“A parent once decided not to come close to her daughter because the girl was having autism,so we had to scold her to make her accept to cater for her child which she did.” (P10)

“We had parents who refuse their baby boy to be circumcised but after educating them on the need and importance for the minor surgery to be done because the skin can trap dirt and can cause infection which can harm the child,they agreed and permitted their son to undergo the circumcision.” (R6,FGDs 2)

A few participants 4 (9%) narrated how sometime because of legal issues nurses allow the parent to make their own decisions.

“Because patients or parents legally have the right to refuse treatment,I the nurse can only advice,suggest,and urge parents to comply,and if the patient and relative do not comply I document and inform the doctor on duty for them to take the necessary action.” (P13)

“There could be a reason,people don’t just refuse treatment for no reason,so I get closer to have a conversation with both parent and child,I try to gain their trust to get information as to the reason of the refusal,and I explain to them that the treatment is for their good by telling them the nature of the treatment.” (R6,FGDs 2)

3.2.3.2.Responding to patient needs.Some patients will verbalize their needs whilst others keep those to themselves.Therefore,listening attentively and paying attention to their needs,responding in a timely manner and providing feedback are some of the facts some participants (28/43,65%) mentioned.Participants had these to say below.

“Mothers will always prompt the nurses when their child is in need,especially when the IV line is not patent or when the site is swelling.Nurses are to respond quickly to avoid complications and malpractice.” (P8)

A few participants use their nursing experience to pick up clues about patients’ and parents’ needs and respond as follows.

“Hmmm,with the experience in nursing that I have,I can assess the patient parents’ body language and know they need something I then respond in a timely manner to make sure their needs are met since it enhances recovery.” (P7)

“When a parent brings a concern on something I was to do but time had passed,I admit my fault and avoid placing blame by quickly apologizing,and attending to it as soon as possible.” (P12)

Participants recounted some attitudes exhibited by pediatric nurses during communication which could be positive and others negative.The attitudes of pediatric nurses unveiled in this study during communication included reaction toward patient’s refusal of treatment and responding to patient needs.

4.Discussion

Hearing-impaired patients are the ones who are unable to perceive verbal communication however these people need the same health care delivery as people with normal hearing,especially during communication.The main barrier to communication for people who are hearing impaired stated by some authors was inadequate communication with their health care providers [26].The current study also found that sign language was frequently used in communicating with hearing-impaired patients.Sign language is very essential with regard to communication with the hearing impaired hence it must be signed properly in order to communicate effectively with patients and prevent miscommunication.This is necessary since other authors found that literature on sign language using deaf populations is scarce,less attention is paid to them and such patients are often dissatisfied with communication [27].Hence,nurses should ensure that facial expression corresponds to what they actually want to communicate with patients to prevent miscommunication.Policies should be formulated as well as conducting further research works in these areas.

Anxiety alters the psychological well-being of patients which may,in turn,affect their overall health therefore,relieving anxiety in patients through communication is very essential in nursing care.It is also one of the cheapest since it does not involve any cost and hence it should be encouraged always.From the current study,participants indicated using a calm approach and spending sufficient time chatting with patients to alleviate anxiety.In congruent to the recent study findings,the results of a previous study presented that emergency nurses used techniques such as eye contact,quick response to patient needs,and treating patients with care to relieve patients’ anxieties [28].Good communication between nurses and patients is relevant for patients going through anxiety.Patients may have some level of anxiety due to unknown outcomes of their condition.Having time for patients in their anxious state and speaking with them has an effect by calming them and improving their health.

The outcome of the present study revealed that participants used silence during communication.Some indicated the use of silence is effective as words since it makes children refrain from some bad behaviors they are doing.Other participants also indicated maintenance of silence encourages mothers freely express themselves.Silence is a great form of communication.Depending on the situation sometimes silence might portray a more meaningful communication than the use of words.Therefore,it is sometimes good for nurses to communicate in silence in order to encourage patients to talk more.Similarly,a study established that the use of intentional silence by nurses was imperative in relieving anxiety and promoting nurse-patient relationship [29].

Participants stated that disclosure of poor prognoses is mostly done by pediatricians in their unit.However,they indicated that they sometimes disclose poor prognoses to patients when the doctors are busy or not available.Disclosure of poor prognoses has been one of the ethical dilemmas among health professionals.It is seen that sometimes,health professionals hold on to information about poor prognoses if they fear that may cause harm to the patient.Others try to deliver the prognoses in a systematic order in order to prevent neurological shock.To achieve a successful disclosure of poor prognoses to a patient,there should be a detailed assessment to identify the right time and place for disclosure and the patient’s strength to contain the prognoses.The outcome of the study is in agreement with another study which revealed that breaking bad news requires skills and expertise and should be systematic in order to reduce anxieties [30].On the contrary,a study conducted among cancer patients on disclosure of poor prognoses presented that 71%of the participants wanted to be told of their prognoses regardless of how it is [31].

The participants of this study revealed that they permitted the mothers and their wards to freely voice out their concerns which were then communicated to the ward in charge and the doctors accordingly.Most importantly,they ensure participants get timely feedback on their complaints.This is because patient complaints can provide important and additional information to healthcare delivery on how to improve patient safety and comfort,hence should be given the appropriate response in order to make them comfortable.This is in agreement with a study conducted in the United Kingdom among 446 nurses where participants indicated that they reported patients’ complaints about prompt feedback[32].In reporting patients’ complaints,nurses indicated that the right procedure should be followed in order to prevent conflict between patients and the staff involved.Evidence suggests that presenting patients’ complaints in the right way to authorities enhances immediate response hence the right direction should be followed when reporting such complaints [33].Hence,protocols and policies should be formulated regarding the right way to report patient complaints since this can go a long way to improving patient satisfaction.

Un-therapeutic communication involves various words,phrases,actions,and tones that make a patient feel uncomfortable and worsen their overall mental and physical well-being.It was stated by some participants that some nurses addressed some patients with their conditions,exchange words with patients over their bills,and discuss patients’ conditions openly which according to them was un-therapeutic.Contrary to the findings of this study,an author established in a study that to improve communication,patients should be called by their accepted names [34].Using a person’s name in conversation creates a culture of respect,recognition,and consideration for the discussion.Some measures should therefore be put in place as a form of punishment for those who engage in un-therapeutic communication to deter others from engaging in such.

Active listening is a special communication skill and a great way of ensuring effective communication.The participants of this study cited paying rap attention to patients during the conversation.In support of the current study findings,some authors elaborated that active listening is key to effective communication[35].They added that it requires listening to the content,which communicates empathy among nursing students.Additionally,some participants of this current study indicated that some techniques such as nodding and giving feedback to the questions patients ask during communication facilitate effective communication.This is a good practice as it informs the patients that the nurse is listening to them during communication.In addition,some researchers stipulated that an active listener help managers be successful since it conveys trust [36].

The personality of an individual may affect his or her communication with others.Hence,participants unveiled that nurses with bad personality behaviors like being rude,disrespectful,and easily angered may impair therapeutic communication.On the other hand,some characteristics of nurses such as being open,outgoing,and showing gratitude were found to promote effective communication among nurses and patients.This is in agreement with a study which indicated that good relationships(rapport),hard work,and empathy of healthcare providers to patients made patients happy and improved communication between them [37].When nurses have good relationships and a passion for care,it makes patients comfortable and appreciative and paves way for effective communication.It is therefore the need for nurses to be passionate about the provision of care to patients.This finding is in agreement to a study in Kenya where it was indicated that the most common challenges that affected effective nurse-patient communication were the lack of information about care,the inability of tending to their emotional needs and lack of respect [38].

Some participants mentioned that some relatives never showed appreciation towards the care provided by the nurses and this is likely to demotivate some nurses from providing quality and standard of care to patients.However,nurses should be ready to render their services no matter the reactions of patients since it is their core duty to render selfless care.This result is consistent with a study in low-middle-income countries where it was found that participants showed negative attitudes towards nurses by making negative comments about healthcare providers [39].Other participants added that some mothers began to fight nurses when they were informed about the payment of their bills.This may happen because sometimes,the cost of health is just mentioned to patients to pay without a detailed explanation for the cost incurred.Therefore,to prevent this negative response from patients,nurses should take time and explain the cost that has to be paid by patients in order for them to understand.This is in contrast to a study in Germany where it indicated that patients were satisfied with the explanation of health care given to patients [40].

Patients sometimes refuse treatment prescribed for them by healthcare professionals.From the current study,participants indicated that some patients refused treatment for their children.It was indicated that some Muslim parents refused the circumcision of their children but education by the nurses about the need for circumcision made them accept it later.Even though the rights of patients are to be respected,sometimes when they refuse treatment,nurses are expected to explore the reason for the refusal and educate them to understand the treatment for them to voluntarily accept treatment.On the contrary,a study revealed that most parents accepted oxygen therapy and nasogastric tube for their children[41].The finding disagrees with a study which stated that it is unethical for professional healthcare providers to mistreat patients by disrespectful acts such as shouting and scolding no matter their decision made towards care by giving an example of when a patient was scolded because she had incontinence [42].

The current study revealed that nurses responded quickly to patient needs.Participants indicated that they responded quickly to patient needs,especially whenever they called upon them for help.This was a good practice by nurses since it conveys to patients how nurses care about them by responding to their needs quickly.Similarly,some authors stated that patients are not to be overlooked by nurses for it is one key thing that enhances satisfaction with health care [43].Therefore the need of patients should be considered very important and be treated accordingly provision of care in care by nurses.However,other participants indicated that when a parent brought concern about something they were to do but had forgotten about,they admitted their fault,quickly apologized and attended to it as soon as possible.

Limitations.The current study was limited to only one health facility in the country.Also,the researchers could have considered the mixed method approach to get detailed and varied responses from a large number of people however the FGDs and face-face interviews used ensured that varied responses were retrieved.

5.Conclusion

Effective communication between pediatric nurses,patients,and their parents is ascertained to be a key tool in the delivery of quality health care.The nurses in this study listed some communication practices that are essential in therapeutic communication such as use of silence,responding to patient needs,and reporting patient complaints.However,several factors are found to hinder this therapeutic communication.Some of these factors were human-related (nurses’ attitude and behavior),patient-associated factors and factors related to patients’ relatives.Hence,further studies are needed to improve effective communication skills among pediatric nurses and their patients to enhance health care for children.

CRediT authorship contribution statement

Evans Osei Appiah: Conceptualization,Methodology,Validation,Formal analysis,Investigation,Data curation,Writing -original draft,Writing-review&editing,Project administration.Stella Apiah: Methodology,Validation,Formal analysis,Investigation,Resources,Writing -review &editing.Samuel Kontoh: Methodology,Validation,Formal analysis,Investigation,Resources,Writing-review &editing.Sarah Mensah: Conceptualization,Methodology,Validation,Formal analysis,Investigation,Resources,Writingreview &editing.Dorothy Baffour Awuah: Conceptualization,Methodology,Validation,Formal analysis,Investigation,Resources,Writing -review &editing.Awube Menlah: Methodology,Validation,Formal analysis,Writing -review &editing.Michael Baidoo: Methodology,Validation,Formal analysis,Funding acquisition,Writing -review&editing,Project administration.

Funding

Nothing to declare.

Data availability statement

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments

On behalf of the researchers,we express our gratitude to all the authors whose work were cited,the administration of Pentecost hospital and finally all the nurses who participated in this study.

Appendix A.Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.ijnss.2022.09.009.