This research is done in their natural settings and the methodology involves a qualitative thematic analysis followed by in-depth interviews in hospitals and participant observation. This would provide us the insightful views of the participants in the environment without any controlled lifestyle factors around. The questionnaire was kept open-ended in nature, and the answers are gathered through conversation with the patients. It is developed to keep in mind that it could make indigenous sense.
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How was your experience at this hospital?
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Do you think the behavior of nurses was professional or unprofessional?
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Did the nurses make sure that the hospital environment was catering to your inclusive care?
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Do you suggest that a positive hospital environment could help you recover?
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Were your emotional and social needs catered to?
Data Collection and Sampling Location
The sampling of this research as shown in Table 1 was done randomly in two public hospitals, one in Rawalpindi and the other in Islamabad. The total population of these two cities is approximately 4.5 million (33), and have a better healthcare system compared to other cities, i.e., available to the public. During the research, I had to go to those public hospitals to interview people with their consent to gain insight into their experiences at the hospital. Such qualitative exploratory research first involves understanding the hospital culture historically, i.e., evolved from the birth of small clinics to the modern hospital today. The hospitals today are the input of cultural heritage along with the amalgamation of Western and Asian medication (34). As Warner shares, though the patients were provided with enough healthcare in a metropolitan city of the country but were faced with these harsh experiences especially on the end of nurses, due to which they redeemed their treatment from other nonmedicinal sources such as faith healers, homeopaths, they were satisfied with them due to their behavior (35).
Table 1
Patients | Age in years | Gender | Type of Illness | City | Days of Stay |
1 | 1 year | Female | Neurological | Rawalpindi | 3 weeks |
2 | 43 years | Female | Hernia | Rawalpindi | 1 week |
3 | 45 years | Female | Ulcer | Rawalpindi | 2 weeks |
4 | 52 years | Male | Thyroid | Islamabad | 2 weeks |
5 | 32 years | Female | Lungs Infection | Islamabad | 3 weeks |
6 | 50 years | Male | Liver dysfunction | Islamabad | 2 weeks |
7 | 54 years | Female | Stomach Problem | Islamabad | 1 week |
8 | 21 years | Male | Extreme Diarrhea | Islamabad | 4 days |
9 | 20 years | Female | Stomach Problem | Islamabad | 1 week |
10 | 62 years | Male | Blood Cancer | Islamabad | 3 weeks |
Demographics of the Patients
The demographics of patients have been explained below in Table 1. The participants were ten in total, two of them were unable to give interviews due to their weak conditions. Their information was given by the caregivers of the patients who were their attendees.
Analysis and Findings
Thematic analysis was done based on the data retrieved from the interviews. The interview was held in an open-ended discussion which derived the following themes.
Here we would discuss, the parameter of communication and its impact as a part of verbal and nonverbal communication (28). The part of verbal communication is pitch, tone, choice of words, and what language we are speaking, as shown in Table 2.
Table 2
Verbal and Nonverbal Communication
Themes | Sub-Themes |
Verbal Communication | Tone of Voice Pitch of voice Choice of Words |
Non-verbal Communication | Listening Skills Body Language Social Touch |
Verbal Communications Themes
a. Tone of Voice
In the medical profession, the concept of tone frequency matters too much and is not appreciated if the nurse is ignorant of it. Nurses are meant to be empathetic due to the nature of the profession. The patient feels a sense of relief when s/he senses calmness, compassion, and empathy in a caregiver's voice (36). They are there to comfort their patient. The tone of voice also reflects the level of gratitude, humbleness, or respect the communicator has in his way of speaking (37). Nurses soft tone gives the feeling of empathy, care, and warmth but a cold tone of voice can also give a sense, not adherent to the patient's pain. As some patients reported,
They had an aggressive tone of voice during conversation as if they were not willing to provide care to them. (P2)
Nurses spoke in a very ignorant tone of voice. (P4)
The nurses had an aggressive reaction if called more than once or twice for help. (P7)
We don't know what to do, the doctor will come and have a look. (P2)
Their tone displayed a sense of disgust which made the patient feel inferior. The tone of voice affects the feelings of care, ignorance, grief, pain, happiness, joy, etc. It also changes with the change of environment, for example, in a family gathering our tone would be friendly but in a professional environment, it would be calm, composed, and polite. This should be a concern that communication should be inclusive according to the illness scale a patient is on. The tone of voice depicts the sincerity of the healthcare giver. The clarity of importance of one thing over another would be clear to us by assessing the tone of voice of a person (38).
b. Pitch of Voice
In the nursing profession, the sound or pitch of the nurses is advised to be kept low, it causes stress for the patient who is already suffering from an ailment. Sometimes their high-toned voice can be misinterpreted as irrational behavior and cause the patients to suppress their concerns rather than communicate them to the nurse. This type of behavior may impact their ability to communicate their disease and might also camouflage the sick role of their adaptation (39).
A patient tells her story,
The nurses are always shouting even though one ward had many patients who were under post-operative care. (P3)
The patients who were asked to take rest were not able to due to constant sound in the patient's wards. According to one patient whenever asked to keep their voice low the usual response was,
We have many patients to attend to, we cannot keep our voices low. (P5)
Even at night, they were not adherent toward the patients who were sleeping. The patient especially with neurological issues were extremely disturbed due to their behavior. Some of the patients were mentally disturbed after their experience with the hospital and wanted never to come back to this hospital. One of the patients was an older adult who especially complained,
The pitch of voice of nurses was too demanding and abrasive, they did not care that I was an older adult like their father or grandfather. (P10)
The pitch and voice are key components of communication, understanding the concern, sense of worry, patience, and warmth is one annotation that can be attached to it. However, this may vary with gender biases as well. The variations can also be based on the age of the patient and, how much care s/he requires, the inclusive needs also require that in older adults and children specifically lower or higher volume of voice according to their age (40). An older adult would be having a hearing disability with age due to which s/he would need a hearing aid along with high pitch and sound of the voice to be communicated. Similarly, s/he would respond with the same pitch and voice. A child whatsoever will prefer a lower pitch of voice and would prefer a sweet sound with a soft pitch in terms of communication.
c. Choice of Words
The nursing staff's choice of words (terms and terminologies), during communication and understanding with patients also should be considered, specifically, to convey precise meaning. The vocabulary of words opted in communication may be different and have always different meanings (41). In our population, though Urdu is a national language there are several other regional languages spoken with their terminologies and meaning to specific connotations. Thus, keeping in mind also these things public speaking for nursing staff to patients, specifically, should be part of their training and daily routine practice. Using medicinal vocabulary overshadows the patients' knowledge power and s/he might feel illiterate, and this might disrupt his story regarding his illness. Because in this case, the medicinal staff might have an authoritative role rather than a reciprocating role of communication (42).
The nurses were unclear about treatment, upon asking they responded that the doctor knows better. (P2)
This caused uncertainty in the patient's mind due to which he had anxiety about his ailment. Technical language might be used in professional settings, but layman vocabulary should be considered when dealing in a public setting. A patient was confused about what his medicine is for,
The nurses told me I have to take these tablets for my ailment, I don’t know what kind of ailment I have. (P10)
Upon looking at his file, I came to know that she had a stomach problem due to which these medicine for further prevention. Her medicine was according to his age along with some multi-vitamin for weakness due to stomach issues. Now the ambiguity of words hindered them to be a barrier for her to follow. Caregivers should be guided about the patient's disease in the correct manner. A mother of the patient I interviewed responded that,
Nurses were unclear about how to treat the patient but instead were dependent on the doctor’s advice. (P1)
The nursing staff's choice of words, in particular, should be understandable and convey the exact meaning. In this case, social inclusion is also important. The language of words used in communication may differ and have various meanings.
Nonverbal Communication Themes
The insignificant yet significant form of communication is nonverbal communication. According to studies nonverbal communication plays a very more significant role than verbal communication (43). The nonverbal signs of misbehavior included mocking them and not paying attention, holding them like an object, and mistreating them like machines. Often look at them with disgust due to their present condition (44). This conveys that either this is a normal situation in a hospital that has emptied their emotion or insanity has overpowered them. These were a few examples related to how nurse communication both verbal and non-verbal plays an important role in a patient’s understanding of disease and from that their path of recovery (45). The patient’s understanding of that particular disease decides what the parameters of that specific disease are according to their view. Unfortunately, such research has not been carried out earlier in Pakistan due to the continuing malpractice of patient abuse (46). The understanding of non-verbal communication is very limited for the layman of Pakistan staff. Here are a few aspects of non-verbal communication as shown in Table 2 which include listening skills, body language, and the sense of social touch while interacting with the patient.
a. Listening skills
The person along with being a good speaker, should be a good listener as well. Listening to the patient conveys the message that the person is providing care with full sincerity and devotion (47). The nurse should be a good listener as well adhering to the patient’s needs. According to one patient over there,
They did not listen to the symptoms and kept on saying do what we are advising you to do. (P8)
A healthcare provider needs to adhere to the patient's concerns by listening to them with patience that can convey what they feel during the illness can relieve stress and gain trustworthiness for the patient. The mental relief that a patient gets that the staff at the hospital especially nurses are adherent to their point of view and concerns can impact the overall healing process (48). During interviews, I came to know that the patients were more comfortable with nurses who were responding when required to communicate their needs to the doctors,
I asked for that nurse who was listening to me politely, she conveyed my condition to the doctor and treated me patiently. (P9)
A bizarre and ignorant behavior can make the patient feel supported in an alien environment and the willingness to seek treatment and invention regarding the disease decreases. The mental relief that a patient gets from the staff at the hospital eases half of the patient's pain. There was a patient who said,
The patient was ailing in pain, and no one responded to her pain whatsoever. in the morning she was called up for some tests but before that, she had to call some family members to assist. (P2)
According to her the nurses there said they were busy, and it was not their responsibility to take to look at them, they have other patients to attend to. This ensures the patient s/he is in safe hands in the hospital. This will also help increase the repute of the hospital and his willingness to seek help whenever requires. It also helps resolve conflicts of information (49).
b. Body Language
This is mainly divided into two forms: facial gestures and body movement. These two can be strong reflections of a person's emotions. As a nurse, one should display body language that can convey trust and confidence (50). They should convey the embodiment of a stable character providing care in the hospital. Body language also displays how self-aware they are about their job; their attentiveness is clearly shown by their body language. A caring nurse would have a smile on her face, even the slightest sign of worry shown in her body language can convey a strong message that the patient is in secure hands. As a nurse, you should project confident body language. According to a patient,
They had a frown on their face when she was treating me. (P5)
The patient should feel calm and relieved by the body language. Looking down upon them with disgust, with a frown the person feels vulnerable and weak because of that. One patient who had blood cancer was complaining,
While getting his blood job they were looking with so much disgust that, he felt venerable instead of feeling better. (P10)
The body language of nurses as a caregiver was supposed to be comforting for the patient but instead turned out to be ignorant and disgusting. As an observer, a comforting smile or only empathizing with the patient release their discomfort and it initiates a positive response in their body. The least they can do is keep a smile on their face to ensure that all will be well. The proper eye contact which describes a calm and composed person, the accurate distance from the patient, the leaning arm movement, and the right amount of body orientation have been having a significant impact on patient satisfaction (51). This is also the display of mutual respect and understanding between the patient and caregiver (52). Sometimes if the body language is not right the patient may get a false depiction of the message. Body language is very personal to culture as well; the rural or urban culture may be different (53).
c. The social touch
When someone enters your personal space (54), that is referred to as a social touch. The social touch of a caregiver can provide task-oriented contact, touch promoting physical comfort, and touch providing emotional containment. Social touch at first may be alienated feel but this sense develops across over time. The touch which has a comforting impact on the patient can develop a sense of comfort in the patient. This however discriminates with a cross-gender version of social touch (55). In the nursing profession, there are more female nurses than male nurses (56). Female nurses are prioritized when it comes to receiving touch from them. Male nurses due to their basic view of being hard and rough are mostly not considered when it comes to receiving touch. But they are available for carrying people from one ward to another or doing hard tasks (57). Thence females would avoid if male nurses were in that department. A female nurse is considered much more soft-handed, when it comes to performing tasks, such as inserting needles, assisting mobility, or transferring the person from operation theaters, etc. During a discussion of their behavior, one of the patients responded that,
I felt like they were treating me like an object, I politely asked them to hold me softly, but they did not listen. (P9)
Older adults mostly require a soft hand of the notion when touched and they primarily need assistance. Upon questioning the patient responded that,
They held me with hard hands. (P3)
They need to be gentle while injecting them. The patient's perception of vulnerability while ill is affected by this sense of social touch (58). However, in Pakistani culture, cross-gender reservations are there. One response was,
A nurse refused him and asked the male technical staff to deal with him: He quoted they are either harsh or refuse especially to younger people. (P8)
The right amount of pressure, with hand movement, can ease the pain of the patient. here have been many studies showings that touch can reduce high heart rate, decrease the rate of depression (59), and anxiety in a patient, and boost the immunity as a healing response (60). Even a calm pat on the back and a comforting touch can aid in healing the patient. Nurses have to touch patients in their daily practice but fail to recognize that humanizing touch is more important (61). Soft touch is preferred, being rough with the patient can lead to a negative medical treatment. Socially permissible touch is also dependent on culture (62). Cultural appropriation is to be kept foremost in mind during social touch. It is to refrain from crossing boundaries and maintain a healthy patient-nurse relationship. This factor is also dependent on the age, gender, and cultural community of the patient. A child would be dealt with utterly gentle hands, the same goes for an older adult. This aspect is also influenced by the condition of the patient. A patient with mild illness and a patient in post-operative care requires two different levels of social touch in care (63). The nurses are to be trained properly when handling such cases care of the patients.
Overall Experience of the Patients
All these interviews were taken by people who were admitted to those hospitals or had stayed there a very short while ago. All these patients were already stressed due to the behavior of the nursing staff. It is undeniable that they have a load of patients and nurses are short-staffed in our country (64), but this does not justify their treating the patients. The patients were socially looked down upon by the nurses due to their status. A layman suffers the insufferable to maintain their health (65). In medicine, communication is the most evident element in understanding the patient and nurse relationship. The patient's care is entirely dependent on the patient's expressed feelings. Pain, for example, can be physical, mental, or social. The account for the pain that a patient express both verbally and non-verbally. Expression of pain also explicitly explains the adaptation of the patient to a sick role and its treatment (66). This is developed by sound communication of the disease between nurses and patients.