Journal of Public Health Research 2021; volume 10:2225

Exploring the relationship between nurses’ communication satisfaction
and patient safety culture
Linda Wieke Noviyanti, Ahsan Ahsan, Tita Sefti Sudartya
School of Nursing, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia

Abstract
Background: Patient safety culture is associated with the val-

ues, attitudes, competencies and behaviors that support the safe
conduct of individual or group activities in hospitals and other
health organizations. Safety culture is influenced by various fac-
tors, one of which is communication, which plays a significant
role in health services. Therefore, this study aims to analyze the
relationship between nurse communication satisfaction and the
quality of patient safety culture in hospitals.

Design and Methods: This is a cross-sectional design with the
proportional random sampling method used to data from 51 nurs-
es, which was analyzed using the Spearman rank test. The major-
ity of the nurses were female, between 20-30 years old, with 1-5
years working experience.

Results: The results showed a significant relationship between
nurse communication satisfaction and the quality of patient safety
culture. Furthermore, the higher the nurses’ level of communica-
tion satisfaction, the better the applied quality of patient safety
culture (r = 0.338).

Conclusions: Nurse communication satisfaction affects the
provision of effective health care, with the ability to create good
cooperative relationships and foster trust between professions in
order to improve the quality of service delivery and patient safety.

Introduction
Effective communication between nurses and doctors is a two-

way process that involves sending appropriate and understandable
messages accepted and understood by others, thereby enabling a
supportive working environment and patient safety.1 The Joint
Commission stated that poor communication accounts for two-
thirds of sentinel incidents in health care. Furthermore, inadequate
communication between nurses and doctors leads to dissatisfac-
tion and a lack of autonomy among nurses.2 Doctors are easily
frustrated when orders are not placed on time, and communication
vagueness also contributes to their job dissatisfaction.3 This tends
to affect the quality of care and patient safety adversely. Donchin
et al.4 stated that 37% of all health sectors’ errors are caused by the
low communication quality between doctors and nurses in the

Intensive Care Unit. The authors further stated that some of these
errors are preventable events. Communication satisfaction com-
prises eight dimensions, namely the organization’s general per-
spective, organizational integration, personal feedback, relation-
ships with superiors, horizontal and informal communication,
media quality, communication climate, and employee relations.4
The research results regarding the communication satisfaction of
nurses in the Intensive Care Unit room found that women had
lower scores on the dimensions of the general perspective of the
organization and media quality.5 Nurses with master’s degrees
scored lower on the dimensions of media quality and communica-
tion climate compared to graduate and undergraduate graduates.6

An important factor affecting the quality of health care is
applying a patient safety culture, with positive perceptions associ-
ated with lower rates of adverse events.7 Patient safety is the act
of avoiding, preventing or correcting a bad outcome or injury in
the hospital treatment process. This area is important in health
care due to the increase in adverse events that endanger patients’
lives.8,9 The 2013 Joint Commission International report stated
that the adverse events associated with the health care industry in
the United Kingdom and Australia were approximately 10% and
16.6%, respectively.10 Based on the types of incidents that
occurred, near-miss was 47.6%, while the negative event was
approximately 46.2%. The National Committee of patient safety
recorded a total of 137 incidents from January 2010 to April 2011.
Out of the measured 11 provinces in Indonesia, East Java had the
highest number at 27%. Furthermore, out of the 137 patient safety
incidents, adverse events, near miss, and other incidents were in
percentages of 55.47%, 40.15% and 4.38%, respectively.11 There
was an increase in the incidence of adverse events from 2007 to
2011, which prompted nurses and other health workers to reduce
these incidents. Nurses play an essential role in improving patient
safety because they are most often in direct contact with them.12

Therefore, hospital staff are used to determine and assess the level
of patient safety in the hospital.

Patient safety culture comprises of seven sub-cultural factors,
namely leadership, teamwork, evidence-based, communication,
learning, accuracy, patient focus.13 Communication is a determin-
ing factor in providing quality services in a hospital and plays an
essential role in various areas of life. In an organization, commu-
nication coordinates various activities to achieve set goals and
develops an attitude of mutual understanding towards organiza-

Article

Significance for public health

Inadequate communication between nurses and other health workers causes sentinel incidents in health services. This also contributes to job dissatisfaction,
which tends to affect the quality of care and patient safety. One of the important factors affecting the quality of health services is by applying a patient safety
culture. For instance, positive perceptions were associated with a lower incidence of adverse events in patients. It is important to analyze the determinants of
patient safety culture is applicable in all health care settings. Therefore, this study describes the relationship between nurse communication satisfaction and
patient safety culture.

[Journal of Public Health Research 2021; 10:2225] [page 317]

tional members. Similarly, effective communication among health
workers is a key feature of safe and reliable patient care.

Internal communication is an important factor in the successful
achievement of organizational goals because it affects perform-
ance, satisfaction and employee involvement. Similarly, effective
communication between nurses and doctors positively affects the
quality of patient outcomes such as satisfaction, short length of
stay, and reduces adverse events.14-16

A preliminary study carried out in the inpatient room of Wava
Husada Hospital stated that 57.4% of the patients were not satis-
fied with communication in each team’s work unit. These patients
were unhappy with the slow response to information delivery by
some of the staff using WhatsApp. The team coordinator stated
that sometimes staff fail to carry out orders immediately because
they were still working on other jobs. Sometimes, after completing
these jobs, they forget to carry out the previously assigned orders.
Interviews with nursing staff found that 4 out of 5 or 80%
expressed dissatisfaction with communication, especially in terms
of openness with supervisor and limitations in conveying ideas and
opinions. Therefore, this study examines the relationship between
communication satisfaction and patient safety culture.

Design and Methods
This is a cross-sectional research with the non-experimental

design process used to identify the relationship between communi-
cation satisfaction and safety culture. The proportional random
sampling method was used to obtain data from nurses employed at
four medical/surgical units in a hospital located in the Malang
region and 248-beds in March 2019. The units were selected based
on a set of criteria, which included those that have worked in an
inpatient unit for at least 2 months, performed nursing care directly
to patients, and those that work more than 7.5 hours per week.
Furthermore, data were obtained using the Communication
Satisfaction Questionnaire (CSQ), which was tested for reliability
with a value of r=0.990 and the Hospital Survey on Patient Safety
Culture by AHRQ to measure safety culture. In addition, the
Spearman Rank statistical test and SPSS for Windows version 16
statistical analysis were used to determine the correlation between
the two variables with a significance limit of p<0.05.

Results and Discussions
Table 1 shows that out of the total number of nurses used in the

research, 42 (82.4%) aged 20-30 years. Based on gender, the char-
acteristics of respondents showed that 76.5% (39 nurses) were
female. Meanwhile, the number of those that worked in hospitals
for 1-5 years is 26 (51.0%). Table 2 shows the distribution frequen-
cy of patient safety culture. The Spearman rank correlation statis-
tical test results also indicated a significant relationship between
nurse communication satisfaction and the quality of patient safety
culture. Therefore, the higher the level of nurse’s communication
satisfaction, the better the patient safety culture (p=0.015; α=0.05;
r=0.338).

The satisfaction research on communication carried out on 51
nurses showed that most were in the high category. In the question-
naire item regarding communication satisfaction, “the extent to
which my supervisor listens and pays attention to me” and “the dis-
closure of financial status by superiors” had the highest and lowest
values, respectively. This is in accordance with the dimensions of

communication satisfaction, known as openness, which tends to
affect the environment when not properly fulfilled. However, it is
inversely proportional to another study whereby 110 respondents
(70.5%) based on supervision and direction stated that nurse
organizations’ communication satisfaction in hospital inpatient
rooms shows that organizational communication satisfaction is
weak.17 The result showed that this occurs when the communicator
has less experience and knowledge in conveying messages.

The highest communication satisfaction is shown at the age of
20-30 years because the majority of respondents come from that
age. Furthermore, age is also related to the length of work in the
hospital. This is in accordance with another finding which stated
that job satisfaction is influenced by communication satisfaction in
an organization, which continues to increase in more professional
staff along with rise in age.18 The length of time a person has
worked in a hospital and certain units indicates their ability to pos-
sess more experience working as nurses. Experience influences
communication satisfaction, which supports the quality of speech.
Therefore, people with good knowledge need adequate communi-
cation qualities to increase the enthusiasm of the interlocutor and
enable them to understand the information provided. Therefore,
good coordination has the ability to increase communication satis-
faction among nurses and other health workers.19

Nurses need proper communication to carry out activities and
achieve set goals in the care unit. When the communication
sources are sufficient, job-related information’s availability and
adequacy enable nurses to feel satisfied. Communication satisfac-

Article

Table 1. Demographic characteristics of respondents.

Characteristics n %

Age
20-30 years 42 82.4
>30 years 9 17.6
Sex
Male 12 23.6
Female 39 76.5
Hospital units
Inpatient 34 66.7
Intensive care 11 21.6
Hemodialysis 6 11.7
Length of work
<1 year 4 7.8
1-5 years 26 51.0
6-10 years 18 35.3
11-15 years 3 5.9

Table 2. Frequency distribution on perceptions of patient safety
culture.

Characteristics % positive
response rate

Expectations and activities of supervisors / 65.19
managers that support Safety
Organizational learning – continuous improvement 96.73
Teamwork in the hospital unit 81.86
Openness of communication 62.74
Feedback and communication about error 83.01
Response not punish to error 40.52
Staffing 41.18
Hospital management support for patient safety 68.63

[page 318] [Journal of Public Health Research 2021; 10:2225]

tion refers to the extent to which nurses feel satisfied with the
information provided in their environment.6 The existing literature
shows that when employees are satisfied with their communication
rate, effective working relationships are established between
supervisors, subordinates and peers. The research results on the
quality of patient safety culture carried out on 51 nurses showed
that the majority had a good quality of safety culture. In the ques-
tionnaire for the quality of patient safety culture, the highest score
was on the item “our unit works together as a team to complete a
job” this is shown by good coordination between team members in
the unit when receiving patients and when communicating with
doctors regarding the patient’s condition. While the lowest score
on the item was “Our unit has enough staff to handle the excessive
workload”, therefore this item has a major effect on the quality of
patient safety culture that is not good. This is in accordance with
the research carried out by Pujilestari et al. at the inpatient instal-
lation center. The research showed that out of a total of 75 nurses,
38 (50.7%) had a good safety culture quality, while 37 (49.3%)
were in the poor category.20 This is evidenced by the high level of
awareness of nurses in ensuring patient safety. This study shows
that the longer a person works in a certain unit, the better the
patient safety culture’s quality. Therefore, the length of work is
directly related to nurses’ performance because the longer a person
works, the higher the productivity. Hence it can be concluded that
nurses with longer work experience in a unit are able to implement
a safety culture properly.21

In addition, there is a significant relationship between nurse
communication satisfaction and the quality of patient safety cul-
ture. The higher the level of nurses’ communication satisfaction,
the more significant the quality of the patient safety culture that is
implemented. This study’s results are in accordance with the state-
ments that safety culture is enhanced through programs, such as
unit-based interventions, the participation of organizational leader-
ship in setting patient safety as a priority, education in hospitals,
increasing collaboration between disciplines and increasing open-
ness of communication within and between units.19,22,23

Organizational climate is influenced by the way members
behave and communicate. When the organizational climate in an
organization is built positively or well developed, it increases pos-
itive behavior or attitudes, job satisfaction, and communication
satisfaction among members.23,24 An open communication climate
is needed in hospital services because it is multidisciplinary and
has the potential for conflict due to efficiency. In health care, 70-
80% of the errors that occur are caused by poor communication
and understanding within the team. Therefore, teamwork helps to
reduce the problem of patient safety. Furthermore, interprofession-
al collaboration is needed to enhance the quality of outcomes in
health service delivery. Collaborative communication is an impor-
tant factor in nursing care, capable of improving patient safety.22

The American Nurses Association stated that effective communi-
cation is used as a standard for professional nursing practice. Most
nurses’ communication satisfaction is good due to their freedom to
express their opinions on ideas and input to other health workers.
A good work environment can increase nurses’ confidence in
expressing opinions, thereby raising their ability to apply a positive
attitude towards implementing patient safety procedures.25

The role of managers in determining the level of satisfaction of
staff communication is very large. Managers have interpersonal
roles that lead to achieving organizational goals, which is signifi-
cantly dependent on their communication method. The nursing unit
manager shows learning through supervision, encouragement or
motivation, and the provision of information to improve staff work
abilities and increase the nursing unit team’s effectiveness through
the communication process.23 When the nursing unit team’s effec-

tiveness increases, their performance in implementing a patient safe-
ty culture rises, thereby maximizing the services provided. The man-
ager role in evaluating structured work shifts provides open commu-
nication opportunities for the health team. It simultaneously fosters
a collaborative work environment and a positive atmosphere for staff
regarding freedom of speech regarding emotional events, teamwork,
roles and organizational aspects predetermined model. This can help
team members increase their understanding of their roles and
responsibilities. Also, it can be used to solve collaborative problems
among teams, thereby increasing communication. Nurses need to
implement effective professional communication because it is relat-
ed to the provision of effective health.26 Effective, responsible and
respectful communication between nurses, doctors and other health
workers enhances cooperative relations and increases trusting rela-
tionships between related professions.2 Effective communication is
needed in a nursing unit in a hospital to improve service quality and
patient safety.

Conclusions
In conclusion, the majority of nurses’ communication satisfac-

tion in health care centers is high. However, hospitals need to
implement effective communication between units and individual
nurses, managers and other health workers to achieve professional
services. This acts as the basis for the organization to build a safety
culture that starts with communication.

[Journal of Public Health Research 2021; 10:2225] [page 319]

Article

Correspondence: Linda Wieke Noviyanti, School of Nursing,
Faculty of Medicine, Universitas Brawijaya, Jl. Puncak Dieng, Kunci,
Kalisongo, Kec. Dau, Malang, East Java 65151, Indonesia.
Tel.+62.341569117 – Fax: +62.341564755.
E-mail: [email protected]

Acknowledgments: The authors are grateful to all those that con-
tributed to this research, particularly students of the bachelor program
in School of Nursing, Faculty of Medicine, Universitas Brawijaya,
Malang, Indonesia.

Key words: Patient safety culture; communication satisfaction; nurses.

Contribution: All authors contributed equally to this article. LWN
served as a supervisor in verifying the method and design of the study;
TSS carried out the research, performed the statistical analysis and
interpretation of data. Furthermore, all authors discussed the results
and contributed to the final manuscript.

Conflict of interest: The authors declare no potential conflict of interest.

Funding: This work was supported by the Nursing Department Grant,
funded by the Faculty of Medicine, Universitas Brawijaya, Malang,
Indonesia (No: 91A/UN10.F08.12/KS/2018),

Ethics approval: The study was approved by the Health Research
Ethics Commission of the Faculty of Medicine, Universitas
Brawijaya, Malang, Indonesia (ethical clearance letter no.
186/EC/KEPK/ 06/2019).

Conference presentation: Part of this study was presented at the 1st

International Nursing and Health Sciences Symposium, November
13th to 15th 2020, Brawijaya University, Malang, Indonesia.

Received for publication: 16 January 2021.
Accepted for publication: 15 March 2021.

©Copyright: the Author(s), 2021
Licensee PAGEPress, Italy
Journal of Public Health Research 2021;10:2225
doi:10.4081/jphr.2021.2225

[page 320] [Journal of Public Health Research 2021; 10:2225]

References
1. Brady AM, Byrne G, Quirke MB, et al. Barriers to effective,

safe communication and workflow between nurses and non-
consultant hospital doctors during out-of-hours. Int J Qual
Heal Care 2017;29:929–34.

2. Wang YY, Wan QQ, Lin F, et al. Interventions to improve com-
munication between nurses and physicians in the intensive care
unit: An integrative literature review. Int J Nurs Sci 2018;5:81–
8.

3. Rosenstein AH. Nurse-physician relationships: Impact on
nurse satisfaction and retention. Am J Nurs 2002;102:26–34.

4. Donchin Y, Gopher D, Olin M, et al. A look into the nature and
causes of human errors in the intensive care unit. Crit Care
Med 1995;23:294-300.

5. Down CW, Hazen MD. A factor analytic study of communica-
tion satisfaction. J Bus Commun 1990;14:63–73.

6. Vermeir P, Blot S, Degroote SV, et al. Communication satisfac-
tion and job satisfaction among critical care nurses and their
impact on burnout and intention to leave: A questionnaire
study. Intensive Crit Care Nurs 2018;48:21–7.

7. Huang CH, Wu HH, Lee YC. The perceptions of patient safety
culture: A difference between physicians and nurses in Taiwan.
Appl Nurs Res 2018;40:39–44.

8. Soop M, Fryksmark U, Köster M, et al. The incidence of
adverse events in Swedish hospitals: A retrospective medical
record review study. Int J Qual Heal Care 2009;21:285–91.

9. Vlayen A, Hellings J, Claes N, et al. A nationwide hospital sur-
vey on patient safety culture in Belgian hospitals: Setting pri-
orities at the launch of a 5-year patient safety plan. BMJ Qual
Saf 2012;21:760–7.

10. Irawan A, Yulia S, Mulyadi M. [Hubungan Supervisi Dengan
Penerapan Budaya Keselamatan Pasien Di Ruang Rawat Inap
Rumah Sakit XX (The relationship between supervision and
the implementation of patient safety culture in inpatient rooms
at XX hospital)].[Article in Indonesian]. Maskermedika
2018;5:241-54.

11. Hospital Patient Safety Committee. [Patient safety incident
report].[in Indonesian]. Jakarta; Hospital Patient Safety
Committee; 2011.

12. Maeda S, Kamishiraki E, Starkey J. Patient safety education at
Japanese medical schools: Results of a nationwide survey.
BMC Res Notes 2012;5:226.

13. Sammer CE, Lykens K, Singh KP, et al. What is patient safety
culture? A review of the literature. J Nurs Scholarsh
2010;42:156–65.

14. Larrabee JH, Ostrow CL, Withrow ML, et al. Predictors of
patient satisfaction with inpatient hospital nursing care. Res

Nurs Heal 2004;27:254–68.
15. Tschannen D, Kalisch BJ. The impact of nurse/physician col-

laboration on patient length of stay. J Nurs Manag
2009;17:796–803.

16. Riga M, Vozikis A, Pollalis Y, et al. MERIS (Medical Error
Reporting Information System) as an innovative patient safety
intervention: A health policy perspective. Health Policy (New
York) 2015;119:539–48.

17. Rudianti Y, Handiyani H, Sabri L. [Peningkatan Kinerja
Perawat Pelaksana Melalui Komunikasi Organisasi di Ruang
Rawat Inap Rumah Sakit (Improving the performance of
implementing nurses through organizational communication in
hospital inpatient rooms)].[Article in Indonesian]. J
Keperawatan Indones 2013;16:25–32.

18. Doo EY, Kim M. Effects of hospital nurses’ internalized dom-
inant values, organizational silence, horizontal violence, and
organizational communication on patient safety. Res Nurs Heal
2020;43:499–510.

19. Yoo J, Chung SE, Oh J. Safety climate and organizational com-
munication satisfaction among Korean perianesthesia care unit
nurses. J Perianesthesia Nurs 2021;36:24-29.

20. Pujilestari A, Maidin A, Anggraeni R. [Budaya Keselamatan
Pasien di Instalasi Rawat Inap RSUP Dr. Wahidin
Sudirohusodo Kota Makassar (Patient safety culture in Dr.
Wahidin Sudirohusodo hospital, Makassar City].[Article in
Indonesian]. J MKMI 2014;10:57–64.

21. Kim SH, Weng SJ. Incorporating work experience of medical
staff into patient safety climate management: A multi-group
analysis. BMC Health Serv Res 2018;18:919.

22. Liu W, Gerdtz M, Manias E. Creating opportunities for inter-
disciplinary collaboration and patient-centred care: how nurs-
es, doctors, pharmacists and patients use communication
strategies when managing medications in an acute hospital set-
ting. J Clin Nurs 2016;25:2943–57.

23. Silla I, Navajas J, Koves GK. Organizational culture and a
safety-conscious work environment: The mediating role of
employee communication satisfaction. J Safety Res
2017;61:121–7.

24. Kim Y, Jang SJ. Nurses’ organizational communication satis-
faction, emotional labor, and prosocial service behavior: A
cross-sectional study. Nurs Health Sci 2019;21:223–30.

25. Doo EY, Choi S. Effects of horizontal violence among nurses
on patient safety: Mediation of organisational communication
satisfaction and moderated mediation of organisational silence.
J Nurs Manag 2020. Online ahead of print.

26. Norouzinia R, Aghabarari M, Shiri M, et al. Communication
barriers perceived by nurses and patients. Glob J Health Sci
2015;8:65–74.

Article

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Received: 17 August 2018 | Revised: 25 March 2019 | Accepted: 30 March 2019

DOI: 10.1111/ppc.12381

OR I G I NA L AR T I C L E

Relationship between communication skills and care
behaviors of nurses

Nurcan Kirca PhD, RN1 | Kerime Bademli PhD, RN2

1Department of Obstetrics & Gynecological

Nursing, Faculty of Nursing, Akdeniz

University, Antalya, Turkey

2Department of Psychiatric Nursing, Faculty

of Nursing, Akdeniz University, Antalya,

Turkey

Correspondence

Nurcan Kirca, PhD, RN, Department of

Obstetrics & Gynecological Nursing, Faculty of

Nursing, Akdeniz University, Dumlupinar Blvd,

07058 Antalya, Turkey.

Email: [email protected]

Abstract

Purpose: In this study, we aimed to determine the relationship between commu-

nication competence and patient care behaviors of nurses.

Design and Methods: The study was designed as a descriptive relational study and

conducted in Akdeniz University Hospital between March 2018 and May 2018. Data

of this study were collected from clinical nurses working in Akdeniz University

Hospital. The study was carried out with 262 nurses who accepted to agreed

participate in the study.

Findings: Of all nurses, 97% were college graduates, 63% were married, and 35% had

working experience between 5 and 9 years. There was a moderate positive

correlation between communicative competence and care behaviors of nurses

(r = 0.5, P < 0.01).

Practice Implications: More training can be implemented to educate nurses about

communication barriers to equip them with effective communication skills and

strategies. The nursing process is a scientific method of exercising and implementing

of nursing care, this is only achieved through dialogue, interpersonal environment,

and specific verbal and nonverbal communication skills. In service training of nurses

on effective communicative techniques will inevitably have a positive impact rather

than reflection on patient care.

K E YWORD S

care, care behaviors, communication, communication competence, nurses

1 | INTRODUCTION

The primary duty of nurses is to know and meet physical,

psychological, and social needs of individuals.1 Efficient communica-

tion is considered as one of the primary duties of a nurse.2

Communication is an essential component of nursing and has critical

importance in nursing practice.3 Efficient communication is an

inseparable part of quality care.4,5 Effective communication increases

the satisfaction of patients. In a study on this subject, it was stated

that patients expected nurses to have empathy, ability and good

communication skills.6 In another study carried out with nurses,

participants reported that they could increase care quality by using

communication skills.7 In a systematic review regarding the percep-

tion of nurses about care quality, it was revealed that patients

perceived communicative competence of nurses as a dimension of

care.8

Good communication between nurses and patients is essential for

the successful outcome of individualized nursing care of each patient.

To achieve this, however, nurses must understand and help their

patients and demonstrate courtesy, kindness, and sincerity. They

should also devote time to the patient to communicate in necessary

confidentiality, and they should not forget that this communication

includes the people who surround the sick person, therefore, the

language of communication should be understood by all those

Perspect Psychiatr Care. 2019;55:624-631.wileyonlinelibrary.com/journal/ppc624 | © 2019 Wiley Periodicals, Inc.

involved in it. Good communication is also based on education and

experience.9 Communication is an indicator of health care quality.8

Effective communication is an important component to be included in

patient care.10 In this case, the communicative competence of nurses

influences care behavior. Nurses should take into account the

expectations of patients, and deliver care in a manner that will meet

these expectations. Effective communication strategies together with

care environment are important determinants of positive nurse‐
patient relationships.11

Communication intervention of nurses usually includes asking

open‐end questions, intervening with patients, determining expecta-

tions and fears of patients and responding to these, and controlling to

facilitating patients’ understanding of diagnosis and treatment

recommendations. Although such patient‐nurse relationship is

designed for increasing the quality of knowledge exchange, it also

produces richer interpersonal interactions. Any intervention de-

signed to improve communication will enhance the quality of

interpersonal relationship and quality of care delivered to the

patient.12 Determination of nurses’ communicative competence and

the relationship between communicative competence and care

behaviors will guide communication training to be given to nurses.

The development of communicative skills of nurses will also provide

increased quality of patient care. In this context, this study aimed to

determine the relationship between communicative competence and

patient care behavior of nurses.

2 | PARTICIPANTS AND METHODS

2.1 | Design

This study was designed as a descriptive relational study.

2.2 | Sampling and setting

This study was conducted between March 2018 and May 2018 in

Antalya province located on the Mediterranean coast of Turkey.

Nurses working at internal medicine clinics, surgical clinics,

intensive care units, and pediatric units of Akdeniz University

Hospital were included in the study. The data were collected by

face‐to‐face interview technique. A total of 300 questionnaires were

delivered to nurses for determining the final sample size. Two

hundred sixty‐two nurses returned their questionnaires, which is a

response rate of 87.6%. Nine nurses did not fully complete their

questionnaires. Thus, the study was carried out with a sample size of

262. Filling of the personal information form, Communicative

Competence Scale (CCS) and Care Behaviors Inventory (CBI) lasted

for 10 to 15minutes.

2.3 | Measures

2.3.1 | The personal information form

Personal Information Form consisted of eight questions related to

sociodemographic data and three questions related to communica-

tion. Questions about sociodemographic features included age,

educational status, type of family, status of having children, year of

working, unit of working, and status of preferring this profession

willingly. Questions on communication were as follows: Have you

received any training on communication? If the answer is “Yes,”

please specify the content of the training you have received and in

which cases do you have difficulty in communication with your

patient? (When receiving history/data, when giving bad, sad or hard

news, when caring, when informing the patient, when performing the

physical examination, and when conducting the introductory

interview).

2.3.2 | Communicative Competence Scale

CCS scale developed by Wiemann13 consists of 30 items and 5

subdimensions. These subdimensions include General Communica-

tion Competence (seven items), Empathy (seven items), Affiliation/

Support (six items), Behavioral Flexibility (five items), and Social

Relaxation (five items). Validity and reliability of the CCS was studied

by Koca and Erigüç.14 Internal consistency coefficient of the scale

was found as 0.87. In this study, the Cronbach’s α reliability

coefficient of the CCS was 0.86.

2.3.3 | Care Behaviors Inventory

This scale was developed by Wu et al15 and is the short form of

Caring Behaviors Inventory‐42, which was a 42‐item scale

developed by Wolf et al,16 and allows for bidirectional measure-

ment by patients and nurses. The scale was designed to assess the

nursing care process. CBI‐24 is used to compare the self‐
assessment of nurses and patients’ perceptions. In addition, the

scale can also be used to evaluate nursing care (care behaviors

involving listening, education, and including the patient in

decision making) delivered in the preoperative and postoperative

periods. The scale consists of 24 items and four subdimensions.

These four subdimensions include assurance (eight items),

knowledge and skill (five items), respectful deference to others

(six items) and connectedness (five items). Turkish validity and

reliability study of the Care Behaviors Scale‐24 (CBS‐24) was

performed by Kurşun and Kanan.17 Cronbach’s α was found as

0.96 for the total scale and between 0.81 and 0.94 for the

subdimensions. In this study, the Cronbach’s α reliability

coefficient of the CBI was 0.96.

2.4 | Ethical considerations

Ethics committee approval was received for this study from the

ethics committee of Akdeniz University (decision number:

70904504/83). The participants were verbally informed about the

study before giving the forms. They had the right to withdraw from

the study at any time. Nurses assured that they voluntarily agreed to

participate in the study.

KIRCA AND BADEMLI | 625

2.5 | Data analysis

Statistical analyses were conducted using the IBM SPSS Statistics for

Windows (SPSS Statistics Base v23; IBM). In the case of normally

distributed data, independent samples t test was used to compare

sociodemographic data and scales, and Pearson’s correlation analysis

was used in the evaluation of correlation between the scales. In

addition, data were expressed with mean, standard deviation and

percentage. Cronbach’s coefficients (for internal consistency of the

scale items) were used to assess the data. The level of statistical

significance was P < 0.05.

3 | RESULTS

3.1 | Characteristics of the participants

Of the participant nurses, 97% were college graduates, 63% were

married, and 35% had a working experience between 5 and 9 years.

Of the nurses, 72.1% reported that they willingly chose this

profession, 63% stated that they had not been trained on commu-

nication, and 78.4% had difficulty in communication when they

conveyed bad or sad news to a patient or healthy person (Table 1).

3.2 | The mean scores of CCS, CBI, and
subdimensions

When the mean scores of nurses in CCS and CBI were examined, the

mean score of CCS was the highest in personal aspects subdimension

(23.95 ± 2.62). Although mean scores of the CBI were close to each

other, the highest mean score was found in the assurance

subdimension (39.42 ± 5.55) (Table 2).

3.3 | Sociodemographic characteristics of nurses
and CCS and CBI mean scores

When nurse’s sociodemographic characteristics of nurses and CCS

and CBI mean scores were examined, while CCS social behavior

TABLE 1 Sociodemographic characteristics of partici-
pants (n = 262)

Demographic features n %

Education

High School 8 3.1

University 254 96.9

Marital status

Married 164 62.6

Single 98 37.4

Family type

Nuclear 257 98.1

Extended 5 1.9

Years of work, y

<5 83 31.7

5‐9 92 35.1

10‐14 47 17.9

15‐19 40 15.3

Having children

Yes 127 48.5

No 135 51.5

Willingness to select this occupation

Yes 189 72.1

No 73 27.9

Having communication training

Yes 98 37.5

No 163 62.5

Communication difficulty

When introducing

Yes 68 32.2

No 143 67.8

When informing

Yes 73 34.9

No 136 65.1

When caring

Yes 84 37.7

No 139 62.3

When giving bad, sad news

Yes 192 78.4

No 53 21.6

TABLE 2 Distribution of the mean scores that participants received from the scales (n = 262)

Variables Min‐max Mean ± SD

Communicative Competence Scale

Social Relaxation 3.794‐4.023 15.60 ± 2.170

General Communication Competence 3.992‐4.137 23.95 ± 2.624

Empathy Competence 3.973‐4.111 16.19 ± 1.926

Behavioral Flexibility 4.049‐4.198 12.47 ± 1.400

Affiliation/Support 3.901‐4.103 12.01 ± 1.669

Care Behaviors Scale

Reassurance 4.756‐5.103 39.42 ± 5.556

Knowledge‐Skills 4.973‐5.141 25.26 ± 3.604

Respect 4.748‐4.962 28.90 ± 4.276

Connectedness 4.725‐4.847 23.82 ± 35.77

626 | KIRCA AND BADEMLI

adequacy subdimension showed a statistically significant difference

according to marital status, willing choice of profession, and receiving

communication training (P < 0.05), there was no significant difference

in the subdimensions of CBI (P > 0.05). Furthermore,a significant

difference was found according to marital status having children in

the compliance adequacy subdimension of CCS (P < 0.05), there was

no significant difference in the subdimensions of CBI (P > 0.05)

(Table 3).

3.4 | Nurses’ difficulty with communication and the
mean CCS and CBI scores

When the mean CCS and CBI subdimension scores were evaluated

according to the nurses’ having or no difficulty with communica-

tion, behavioral flexibility subdimension showed a significant

difference in nurses who had no difficulty when introducing

themselves (P < 0.05). The subdimensions of the CBI scale showed

a significant difference in nurses who had no difficulty when

introducing themselves (P < 0.05). CCS behavioral flexibility sub-

dimension and CBI subdimensions were statistically significant in

nurses who had no difficulty when giving information and care

(P < 0.05). The behavioral flexibility subdimension of the CCS was

statistically significant in nurses who had no difficulty when giving

bad, sad news (P < 0.05), while CBI subdimensions were not

statistically significant (P > 0.05) (Table 4).

3.5 | The correlation between communicative
competence and care behaviors of nurses

When the correlation between communicative competence and care

behaviors of nurses was examined, there was a moderate positive

correlation between communicative competence and care behaviors

of nurses (r = 0.5, P < 0.01) (Table 5).18

4 | DISCUSSION

Communication is an essential component of nursing and has a

critical importance in nursing practice.3 Communication between

nurses and patients is of importance to deliver a quality care.

Communication with patients and families is an essential compo-

nent of high‐quality care in serious illness. Nurses and patients

stated that they had experienced apprehension and disappoint-

ment when communication was not sufficient.19 Communication

skills are needed to allow the person’s voice to be heard and to

maintain the persons’ dignity.20 Although the importance of

communication in nursing profession is known, more than half of

the participant nurses had not received any training on commu-

nication. This indicates the need for supporting nurses with in

service training on communication. In a study carried out by Bays

et al,21 communicative skills training given to the nurses provided

positive behavioral changes in healthcare professionals. The

difficulty healthcare professionals experienced when giving bad

or sad news was significantly decreased and empathic response

skills were increased in healthcare personnel who received

communicative skills training.21 This indicates that communicative

skills training that will be given to nurses can both increase the

quality of care and prevent difficulties that they will have with

communication.

Another finding of the present study is that the majority of nurses

(78.4%) had communication difficulty when giving bad, sad news to

patients or healthy persons. Giving bad news to patients or their

families is one of the most difficult duties that should be performed

by health care professionals. Nurses may play an important role in

informing patients or their relatives, and therefore they should be

trained for clinical and communication skills necessary for perform-

ing this duty.22 Similarly, studies have demonstrated that commu-

nicative skills training is effective in coping with difficulties in giving

bad or sad news.23–25 Within this context, evidence‐based commu-

nication skills interventions for nurses are urgently needed.

According to the results of this study, personal characteristics

highly affect communication competence of nurses (23.95 ± 2.624).

Effective communication skills of healthcare professionals have

positive effect on the health and recovery rate of patient’s. Nurses

should take into account the expectations of patients about this

nurse‐patient relationship and should arrange their own behaviors to

meet patients’ expectations. Nurses should be aware of their own

personal communication skills. Effective communication strategies

together with care environment are important determinants of

positive nurse‐patient relationships.11 Establishing a trusting rela-

tionship is identified as central to the patient‐centered care

independent of the professional group.26 Effective nursing is based

on relationships and the ability of the nurse to establish a relation-

ship with the patient. The evidence demonstrated that patients judge

the quality of the relationship through the alignment of the explicit

and implicit values demonstrated around caring behaviors and

attitudes displayed by the nurse. Effective communication strategies

together with the context or care environment were also important

determinants of positive nurse‐patient relationships.11 Most patient

complaints in developed health care systems result from ineffective

communication, including inadequate information provision, no

feeling of being listened, failure to value patients concerns, and

patients not feeling involved in care decisions.27 Effective inter-

personal and communication skills between health care providers

and patients are among the most significant factors for improving

patients’ satisfaction, compliance, and overall health outcome.

It was found that nurses without communication difficulty when

delivering care had no problem in all subdimension of care behaviors.

When the correlation between mean scores of communication

competences and care behaviors of nurses was examined, a

moderate positive correlation was found between communication

competences and care behaviors. These results can be interpreted as

establishing sufficient communication positively affects care beha-

vior. Communication has effects in all areas of nursing, and all

interventions such as protection, treatment, rehabilitation, education,

and health development. Effective communication is the key for

KIRCA AND BADEMLI | 627

T
A
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628 | KIRCA AND BADEMLI

delivering sufficient care for the needs of patients.9 Lack of

establishing a professional communication leads to failure in care.28

Jones, Hamilton, and Murray29 stated that in their study, there is

insufficient communication between the nurse and patient due to

insufficient number of nurse and too much number of the patient.

The results of our study and the other studies indicate that

effective communication influences patient care outcomes. In

conclusion, effective communication skill of nurses is a precondition

for the ability to provide care to meet the needs of patients.

4.1 | Limitations

The study was conducted only in a single center. No comparison was

made with other hospitals. Therefore, the results of this study may be

limited only to the center of the study and should not be generalized.

5 | CONCLUSION

Communication is not only an ability differing from person to

person, but also it is a skill that can be obtained with necessary

training and experience. Communication training in nursing is an

important component to deliver more beneficial care for the needs

of patients. As it is shown in this study, good communication in

nursing increases the quality of care. In addition, this is an

inevitable precondition for establishing a real and meaningful

communication among patients, nurses, and other health care

professionals. Providing nurses with education, and continuous in

service training will enable them to sufficiently meet the

expectations of patients.

5.1 | Implications for nursing practice

More training can be implemented to educate nurses about

communication barriers to equip them with effective communica-

tion skills and strategies. Communication is important in health

care to encounter with patients, in particular, to understand each

patient’s needs and to support health and well‐being. This goal can
be achieved by shortening the working hours and workload by

recruiting more nurses or practical nurses, this will reduce stress

and allow for more time to thoughtfully communicate more

professionally. More training can be implemented to educate

nurses about communication barriers to equip them with effective

communication skills and strategies. Communication is important

TABLE 4 Communication challenge by mean scores of CCS and CBI scales (n = 262)

Communication Competence Scale Care Behaviors Inventory

Communication
difficulty

Social
relaxation

General

communication
competence

Empathy
competence

Behavioral
flexibility

Affiliation/
support Reassurance

Knowledge‐
skills Respect Adherence

When introducing

Yes 3.8 ± 0.43 3.9 ± 0.50 4.0 ± 0.45 3.9 ± 0.50 3.9 ± 0.61 4.8 ± 0.67 4.8 ± 0.69 4.5 ± 0.67 4.5 ± 0.69

No 3.8 ± 0.61 4.0 ± 0.43 4.0 ± 0.49 4.2 ± 0.44 3.9 ± 0.52 5.0 ± 0.71 5.1 ± 0.71 4.9 ± 0.70 4.8 ± 0.72

Test value −0.046 −1.323 −0.313 −3.885 −1.079 −3.804 −2.015 −3.429 −3.629

P value 0.964 0.187 0.755 0.000 0.282 0.001 0.045 0.001 0.000

When informing

Yes 3.8 ± 0.47 3.9 ± 0.47 4.0 ± 0.46 3.9 ± 0.48 3.9 ± 0.58 4.7 ± 0.70 4.8 ± 0.70 4.5 ± 0.63 4.5 ± 0.67

No 3.8 ± 0.60 3.9 ± 0.44 4.0 ± 0.49 4.2 ± 0.43 3.9 ± 0.54 3.9 ± 0.38 5.0 ± 0.69 5.1 ± 0.72 4.9 ± 0.71

Test value −0.208 −0.361 −1.212 −5.090 −0.516 −4.210 −2.851 −3.730 −4.640

P value 0.835 0.718 0.227 0.000 0.607 0.000 0.005 0.000 0.000

When caring

Yes 3.8 ± 0.54 4.0 ± 0.46 3.9 ± 0.48 3.9 ± 0.47 4.0 ± 0.60 4.7 ± 0.71 4.7 ± 0.67 4.5 ± 0.68 4.5 ± 0.69

No 3.8 ± 0.55 3.9 ± 0.43 4.0 ± 0.49 4.2 ± 0.43 3.9 ± 0.53 5.0 ± 0.67 5.2 ± 0.71 4.9 ± 0.70 4.8 ± 0.71

Test value 0.136 0.848 −1.5 7 −3.9 53 0.543 −3.443 −4.718 −3.994 −3. 476

P value 0.892 0.397 0.117 0.000 0.587 0.001 0.000 0.000 0.001

When giving bad news

Yes 3.9 ± 0.55 4.0 ± 0.44 4.0 ± 0.46 4.1 ± 0.46 4.0 ± 0.55 4.9 ± 0.69 5.0 ± 0.71 4.7 ± 0.69 4.7 ± 0.71

No 3.8 ± 0.48 3.9 ± 0.44 4.0 ± 0.48 4.2 ± 0.47 3.9 ± 0.54 4.8 ± 0.70 5.0 ± 0.76 4.8 ± 0.73 4.7 ± 0.73

Test value 0.745 0.595 0.631 −2.203 0.341 0.871 −0.315 −0.956 −0.411

P value 0.457 0.552 0.529 0.029 0.734 0.385 0.753 0.340 0.682

TABLE 5 Correlation between communicative competence and
care behavior scales of nurses (n = 262)

Communicative
Competence Scale

Care Behaviors
Inventory

Communicative

Competence Scale

1.00 1.00

Care Behaviors

Inventory

r = 0.5

P < 0.01

KIRCA AND BADEMLI | 629

in health care to encounter with patients, in particular, to

understand each patient’s needs and to support health and well‐
being. Development of an effective relationship is important for

patient‐centered care. Nurses should know the importance of

communicative skills for a quality nursing care. Nurses should take

into account the expectations of patients about caring needs.

Nurses should improve their communicative skills to determine

patients’ needs correctly. Nurses should understand the effects of

their communicative styles and skills on patients’ care. There are

mutual interactions between the nurses and patients. Nurses are

affected by the patient and vice versa, thus nurses should assess

the effects of their behaviors on patients. This would improve the

patient‐nurse relationship, thus providing a quality care which

focuses on patients’ needs. Communication between nurses and

patients is highly important to deliver quality care. If nurses are

trained for effective communication through in service training, its

positive reflections on care quality will be inevitable. It is

important to appropriately update training of nurses about

communication according to recent conditions. Regular commu-

nicative skills training for nurses can be organized in hospitals.

Although health professionals and students both warrant continu-

ing education in communication, the opportunity to correct this

problem lies within early education efforts.

CONFLICT OF INTERESTS

The authors declare that there are no conflict of interests.

ORCID

Kerime Bademli http://orcid.org/0000-0002-3969-9010

REFERENCES

1. Özcan A. Nurse‐Patient Relationship and Communication. 2nd ed.

Ankara: System Publishing; 2006.

2. Naish J. The route to effective nurse–patient communication. Nurs

Times. 1996;92:27‐30.
3. McCabe C. Nurse–patient communication: an exploration of patients’

experiences. J Clin Nurs. 2004;13:41‐49.
4. McGilton K, Robinson HI, Boscart V, Spanjevic L. Communication

enhancement: nurse and patient satisfaction outcomes in a complex

continuing care facility. J Adv Nurs. 2006;54:35‐44.
5. Anoosheh M, Zarkhah S, Faghihzadeh S, Vaismoradi M. Nurse–patient

communication barriers in Iranian nursing. Int Nurs Rev. 2009;56:243‐
249. https://doi.org/10.1111/j.1466‐7657.2008.00697.x

6. Staniszewska S, Ahmed L. The concepts of expectation and satisfac-

tion: do they capture the way patient sevaluate their care? J Adv Nurs.

1999;29:364‐372.
7. Ross H, Tod AM, Clarke A. Understanding and achieving person‐

centred care: the nurse perspective. J Clin Nurs. 2015;24:1223‐1233.
https://doi.org/10.1111/jocn.12662

8. Mohammed K, Nolan MB, Rajjo T, et al. Creating a patient‐centered
healthcare delivery system: a systematic review of health care quality

from the patient perspective. Am J Med Qual. 2016;31:12‐21. https://
doi.org/10.1177/1062860614545124

9. Kourkouta L, Papathanasiou IV. Communication in nursing practice.

Mater Sociomed. 2014;26:65‐67. https://doi.org/10.5455/msm.2014.

26.65‐67
10. Tobiano G, Bucknall T, Marshall A, Guinane J, Chaboyer W. Nurses’

views of patient participation in nursing care. J Adv Nurs.

2015;71:2741‐2752. https://doi.org/10.1111/jan.12740
11. Wiechula R, Conroy T, Kitson AL, Marshall RJ, Whitaker N,

Rasmussen P. Umbrella review of the evidence: what factors

influence the caring relationship between a nurse and patient? J

Adv Nurs. 2016;72:723‐734. https://doi.org/10.1111/jan.12862
12. Kelley JM, Kraft‐Todd G, Schapira L, Kossowsky J, Riess H. The

influence of the patient‐clinician relationship on health care out-

comes: a systematic reviewand meta‐analysis of randomized con-

trolled trials. PLOS One. 2014;9:e94207. https://doi.org/10.1371/

journal.pone.0094207

13. Wiemann JM. Explication and test of a model of communicative

competence. Hum Commun Res. 1977;3:195‐213. https://doi.org/10.
1111/j.1468‐2958.1977.tb00518.x

14. Koca, GŞ, Erigüç, G. Validity and reliability of communicatıon

competence scale. Int. Journal of Management Economics and Business,

2017;13:789‐799. http://dx.doi.org/10.17130/ijmeb.2017433408

(in Turkish).

15. Wu Y, Larrabee JH, Putman HP. Caring behaviors inventory: a

reduction of the 42‐item instrument. Nurs Res. 2006;55:18‐25.
16. Wolf ZR, Giardino ER, Osborne PA, Ambrose MS. Dimensions of

nurse caring. J Nurs Scholarsh. 1994;26:107‐112. https://doi.org/10.
1111/j.1547‐5069.1994.tb00927.x

17. Kurşun Ş, Kanan N. Validity and reliability study of the Turkish

version of caring behaviors inventory‐24. J Anatolia Nurs Health Sci.

2012;15:229‐235.
18. Mukaka MM. A guide to appropriate use of correlation coefficient in

medical research. Malawi Med J. 2012;24:69‐71.
19. Finke EH, Light J, Kitko L. A systematic review of the effectiveness of

nurse communication with patients with complex communication

needs with a focus on the use of augmentative and alternative

communication. J Clin Nurs. 2008;17:2102‐2115. https://doi.org/10.
1111/j.1365‐2702.2008.02373.x

20. Lindberg E, Hörberg U, Persson E, Ekebergh M. “It made me feel

human”—a phenomenological study of older patients’ experiences of

participating in a team meeting. Int J Qual Stud Health Well‐Being.
2013;8:20714. https://doi.org/10.3402/qhw.v8i0.20714

21. Bays AM, Engelberg RA, Back AL, et al. Interprofessional commu-

nication skills training for serious illness: evaluation of a small‐group,
simulated patient intervention. J Palliat Med. 2014;17:159‐166.
https://doi.org/10.1089/jpm.2013.0318

22. Abbaszadeh A, Ehsani SR, Begjani J, et al. Nurses’ perspectives on

breaking bad news to patients and their families: a qualitative

content analysis. J Med Ethics Hist Med. 2014;718:1‐7.
23. Arnold RM, Back AL, Barnato AE, et al. The critical care communica-

tion project: improving fellows’ communication skills. J Crit Care.

2015;30:250‐254. https://doi.org/10.1016/j.jcrc.2014.11.016
24. Grudzen CR, Emlet LL, Kuntz J, et al. EM Talk: communication skills

training for emergency medicine patients with serious illness. BMJ

Support Palliat Care. 2016;6:219‐224. https://doi.org/10.1136/

bmjspcare‐2015‐000993
25. Moore PM, Rivera S, Bravo‐Soto GA, Olivares C, Lawrie TA. Commu-

nication skills training for healthcare professionals working with people

who have cancer. Cochrane Database Syst Rev. 2018;7:CD003751.

https://doi.org/10.1002/14651858.CD003751.pub4

26. Kitson A, Marshall A, Bassett K, Zeitz K. What are the core elements

of patient‐centred care? A narrative review and synthesis of the

literature from health policy, medicine and nursing. J Adv Nurs.

2013;69:4‐15. https://doi.org/10.1111/j.1365‐2648.2012.06064.x
27. Coad J, Smith J, Pontin D, Gibson F. Consult, negotiate, and involve:

evaluation of an advanced communication skills program for health

630 | KIRCA AND BADEMLI

care professionals. J Pediatr Oncol Nurs. 2018;35:296‐307. https://doi.
org/10.1177/1043454218765136

28. Blackman I, Henderson J, Willis E, et al. Factors influencing why

nursing care is missed. J Clin Nurs. 2015;24:47‐56. https://doi.org/10.
1111/jocn.12688

29. Jones TL, Hamilton P, Murry N. Unfinished nursing care, missed care, and

implicitly rationed care: state of the science review. Int J Nurs Stud.

2015;52:1121‐1137. https://doi.org/10.1016/j.ijnurstu.2015.02.012

How to cite this article: Kirca N, Bademli K. Relationship

between communication skills and care behaviors of nurses.

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RESEARCH ARTICLE Open Access

Health care professional’s communication
through an interpreter where language
barriers exist in neonatal care: a national study
Katarina Patriksson1,2,4* , Helena Wigert1,3, Marie Berg1 and Stefan Nilsson1

Abstract

Background: A number of parents in neonatal care are foreign-born and do not speak the local language, which
makes communication between healthcare professionals and parents more difficult. Interpreters can be used when
language barriers exist – parent interactions, medical communication and communication about the care of the
child. The aim in this study was to examine healthcare professionals’ use of interpreters and awareness of local
guidelines for interpreted communication in neonatal care.

Method: A survey was distributed to all 2109 employees at all 38 neonatal units in Sweden, thus to all physicians,
registered nurses and nurse assistants in active service. Data were analysed with descriptive statistics and
dichotomized so the professionals were compared in groups of two using the Mantel-Haenszel Chi Square test and
Fisher’s Non Parametric Permutation test.

Results: The survey was answered by 41% (n = 858) representing all neonatal units. The study showed a difference
between the professional groups in awareness of guidelines, availability of interpreters, and individual resources to
communicate through an interpreter. Nurse assistants significantly lesser than registered nurses (p < .0001) were aware
of guidelines concerning the use of interpreters. In emergency communications nurse assistants used authorized
interpreters to a significantly lesser extent than physicians (p < .0001) and registered nurses (p < .0001). Physicians used
authorized interpreters to a significantly higher extent than registered nurses (p 0.006) and non-authorized interpreters
to a significantly lesser extent than registered nurses (p 0.013). In planned communications, nurse assistants used
authorized interpreters to a significantly lesser extent than physicians (p < .0001) and registered nurses (p < .0001).
Nurse assistants rated their ability to communicate with parents through an interpreter to a significantly lesser extent
than physicians (p 0.0058) and registered nurses (p 0.0026). No other significant differences were found.

Conclusion: The results of the study show insufficient awareness of guidelines in all neonatal units in Sweden. Clinical
implications might be to provide healthcare professionals with guidelines and training clinical skills in using interpreters
and increasing the availability of interpreters by having interpreters employed by the hospital.

Keywords: Healthcare professional, Interpreter, Neonatal, Quantitative, Survey

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

* Correspondence: [email protected]
1Institute of Health and Care Sciences, Sahlgrenska Academy, University of
Gothenburg, Arvid Wallgrens Backe, Box 457, S-405 30 Gothenburg, Sweden
2Division of Paediatrics, NÄL Hospital, S-461 85 Trollhättan, Sweden
Full list of author information is available at the end of the article

Patriksson et al. BMC Health Services Research (2019) 19:586
https://doi.org/10.1186/s12913-019-4428-z

Background
In Sweden, all people have access to health care regardless
of geographical area and socioeconomic or educational level.
Health care is free of charge for all newborn infants. When
an infant requires neonatal care it is common for the in-
fant’s parents to stay at the hospital [1]. Daily communica-
tion occurs between health care professionals and the
parents of a newborn infant who is being treated in the neo-
natal care unit [2]. In neonatal care, parents are supported
in learning about their baby’s behaviour and how to respond
to the baby’s cues through supported involvement and par-
ticipation in care-giving activities [3]. In the case of parents
who are foreign-born and do not speak Swedish, the success
of the communication between health care professional and
non-Swedish-speaking parents depends on the health care
professionals being aware of and having access to the guide-
lines on communication using an interpreter and, further,
on health care professional tapping into their own personal
resources, such as their own language skills [4]. With global
migration an increasing number of people are residing in
countries where another language is spoken. Of these, 70%
are between 20 and 65 years of age, which means that a
large number of immigrants are of childbearing age [5]. In
2017 in Sweden, out of a 10 million population, 1.6 million
were foreign-born and 25,600 of these were asylum seekers
[6]. According to the Swedish Health and Medical Service
Act the healthcare professional can use interpreters when
needed without economic aspects [1], interpreters should be
used to ensure the patients’ rights. Interpreters are used in
consultations between health care professionals and foreign-
born parents about the infant’s care and treatment in the
neonatal care unit. There is no current understanding of the
extent to which physicians, registered nurses and nurse as-
sistants in neonatal care are aware of the guidelines applic-
able to interpreted communications, and the extent to
which interpreters are used is unknown [4].
According to the Swedish Health and Medical Service

Act [1], the healthcare professionals have different roles.
Nurse assistants are responsible for the basic care, regis-
tered nurses are responsible for the advance care and
physicians are responsible for the medical care. Health
care professionals are responsible for ensuring that par-
ents are afforded the opportunity to be present during
and involved in their child’s care. When health care is
provided to children, the best interests of the child must
be taken into account and the child’s guardians, in most
cases the parents, must be kept informed about their
child’s care and treatment.
According to the Swedish health care law, all health care

should be individualized regardless of the individual’s eth-
nicity and cultural background [1]. Verbal communication
affects people’s understanding of their situation [7], and in
health care this often involves giving and receiving infor-
mation. Studies show that non-verbal communication

must be combined with verbal communication, where ne-
cessary using community interpreters in communication
to avoid any misunderstanding [8], as there is a risk, due
to language barriers, that important information may be
missed in meetings with parents of foreign origin [9]. Earl-
ier studies also show that health care professionals may
have difficulty talking through an interpreter because they
lack practical experience [10], which may explain why
some health care professionals prefer not to use inter-
preters or care for patient groups with language barriers
[11]. In one study investigating patient preferences, face-
to-face interpretation was the preferred method of inter-
pretation in health care because this way the patients were
able to see the interpreter’s verbal as well as non-verbal
language. In uncomplicated care situations, telephone in-
terpretation was the desirable method. Telephone inter-
pretation is more anonymous for the participants and
sometimes easier to access in emergencies [12].
Another study has shown that it takes nearly twice as

long to talk via an interpreter and time is often limited in
health care [12]. Training in interpreted communication
can help registered nurses work more effectively through
interpreting, while guidelines can support them in com-
munication with families [11]. In recent years, there has
been an increase in the use of state-certified interpreters.
This has been ascribed to the increase in use of telephone
interpreters [13]. There are benefits to be gained from
good planning before starting an interpreted communica-
tion, including the ability to select an interpreter based on
the situation and to use an interpreter with training in
medical interpreting [14]. An overview concerning access
in health care to support for foreign languages (i.e. non-
Swedish communication) showed that there is a shortage
of interpreters and especially of qualified, trained inter-
preters. As well, there is no clear definition of who is
allowed to call themselves an interpreter and a lack of co-
ordination between county councils and regions concern-
ing interpreting issues [15]. In this study, “authorized
interpreter” refers to an employed interpreter hired
through an interpreter service. A guideline is a regulatory
for when, where and how, in this case, conversations via
an interpreter should be offered to the parents when lan-
guage barriers are present.

Aim
The aim of this study was to examine health care profes-
sionals’ use of interpreters and awareness of local guide-
lines for interpreted communication in neonatal care.

Method
Participants and setting
The study was a cross-sectional study including a written
survey to examine awareness of guidelines and use of in-
terpreters by health care professionals at the national level

Patriksson et al. BMC Health Services Research (2019) 19:586 Page 2 of 8

(Additional file 1). All 38 neonatal units in Sweden were
divided into levels I-III, where level I was basic neonatal
care, level II was specialist neonatal care and level III was
neonatal intensive care [16]. The professionals at all neo-
natal units included physicians, registered nurses and
nurse assistants. The number of surveys distributed was
equal to the number of employees in each neonatal unit: a
total of 2109 professionally active physicians, registered
nurses, and nurse assistants. The health care professionals
in the neonatal units used telephone and face-to-face
interpreting.

Data collection
Development of survey
The contents of the survey are purely developed for this
study and were validated through a focus group led by
the first author (K.P.), which included the professional
categories participating in the survey study. For the
focus group, one physician, one registered nurse and one
nurse assistant were selected from one neonatal unit in
west Sweden. All questions in the survey were read
through and discussed using the think-aloud method
[17]. The discussion lasted 48min and was transcribed
to text. The survey was revised based on the results from
the focus group discussion to prevent subsequent misin-
terpretation of the questions. The survey consisted of
several parts including: a section containing sociodemo-
graphic items, as well as sections asking about commu-
nication, emergency care/planned care, interpreting
(face-to-face/telephonic), guidelines for interpreted com-
munication at their unit, and the respondents’ self-
assessed own ability to speak through an interpreter.
The questions were answered on a Likert scale (always/
often/not so often/never) or a dichotomized (yes/no)
scale. The participants were also given the opportunity
to motivate their answers in their own words.

Distribution of the survey
A paper survey regarding the use of interpreters was sent
to the department heads of all neonatal departments in
Sweden registered in the National Quality Registry for
Neonatal Care by mail [18]. On receipt of the paper sur-
vey, the head of each unit then distributed the survey to
all employees. Data collection took place during the
period of March to October 2016. After about a month,
respondents were reminded by telephone and after further
2 weeks’ personal visits were made to four neonatal de-
partments to ensure that responses were obtained from all
neonatal departments in Sweden.

Data analysis
Demographic data and descriptive statistics were analysed
in SPSS Statistics for Windows, version 24 [19]. In the ana-
lysis of the survey questions, interpreted communication

that concerned the infants’ medical and nursing care needs
was reported by physicians, registered nurses and nurse as-
sistants in their responses to the survey. The answers were
first dichotomized, and the dichotomized answers were
then compared between the health care professionals. For
comparison between groups, the Mantel-Haenszel chi-
square test and Fisher’s non-parametric permutation test
were used for ordered categorical variables using SAS ver-
sion 9.3 [20]. The significance level was p < 0.05.

Ethical considerations
The head of each department gave their oral and written
consent, and they informed the health care professionals’
group that participation in the study was voluntary and
that the aim was to examine health care professionals’
attitudes to communicating with parents in neonatal
care in Sweden. Respondents gave their consent by com-
pleting the survey, choosing which questions to answer
and every survey was coded to ensure that the same per-
son could not answer the survey twice. The respondents
were informed that the results of the study would be
analysed at the group level; that no individual would be
able to be identified; and that data would be used for re-
search purposes only [21]. No ethical approval was
sought for this study. The study complies with Swedish
law concerning ethical review of research involving
humans [22] and the World Medical Association and
Declaration of Helsinki’s principles for medical research
involving human subjects, whose purpose is to protect
individuals and ensure respect for human dignity [23].

Results
Sample characteristics
The survey was distributed to physicians, registered
nurses and nurse assistants in neonatal care and was an-
swered by 858/2109 (41%) (Tables 1 and 2).
The proportion of each professional category repre-

sents the distribution of professional categories working
in the neonatal departments in Sweden at the time the
data were collected.
Distribution of answers to the survey on the use of in-

terpreters by physicians, registered nurses and nurse as-
sistants in neonatal departments in Sweden.

Sociodemographic information
Pairwise comparisons between level I and level III, and
level II and level III showed a significance difference in
sex between levels II and III. No other significant differ-
ences were found (Table 1).
Pairwise comparisons between nurse assistants and reg-

istered nurses showed a significant difference in age with
nurse assistants being older by 3.8 years. A significant dif-
ference was also found in sex between nurse assistants

Patriksson et al. BMC Health Services Research (2019) 19:586 Page 3 of 8

and physicians (p < 0.0001), and between registered nurses
and physicians (p < 0.0001). Additionally, a significant dif-
ference was found between nurse assistants and physicians
(p < 0.0001), and registered nurses and physicians (p <
0.0001), in ability to speak a third language. Differences
were also seen in years in the profession between nurse as-
sistants and registered nurses (p < 0.0001) and between
nurse assistants and physicians (p 0.0003). No other differ-
ences were found (Table 2).

Awareness of guidelines
Many health care professionals reported little or no
awareness of the existence of guidelines for the use of
interpreters in communications at the neonatal unit.
There was a significant difference between the profes-
sional groups as regards their awareness of guidelines (p
0.0001) (Table 3). Pairwise comparisons showed that,
compared with the registered nurses, nurse assistants
had significantly lower awareness of guidelines concern-
ing the use of interpreters (p < 0.0001). No other signifi-
cant differences were found.

Availability of authorized interpreters
All health care professionals used authorized interpreters
largely for emergency communications. There was a sig-
nificant difference between the professional groups as
regards their access to authorized interpreters (p <
0.0001) (Table 3).
Pairwise comparisons showed that in emergency situa-

tions, nurse assistants used authorized interpreters to a
significantly lesser extent than did physicians (p <
0.0001) and registered nurses (p < 0.0001). Physicians
used authorized interpreters to a significantly higher ex-
tent compared with registered nurses (p 0.006). No other
differences were found.

In planned communications, nurse assistants used au-
thorized interpreters to a significantly lesser extent than
did physicians (p < 0.0001) and registered nurses (p <
0.0001). No other significant differences were found.

Availability of unauthorized interpreters
There was not a significant difference between the pro-
fessional groups as regards their use of unauthorized
interpreters in emergency situations. Regarding com-
munications in an emergency, it appeared that physi-
cians rarely used unauthorized interpreters to talk to
parents. However, there was a significant difference be-
tween the professional groups in use of unauthorized
interpreters for planned communications (Table 3) (p
0.0013). The health care professionals in the neonatal
units used telephone and face-to-face interpreting.
Pairwise comparisons showed that in emergency situa-

tions, physicians used unauthorized interpreters to a sig-
nificantly lesser extent compared with registered nurses
(p 0.013). No other significant differences were found.
In planned communication, nurse assistants used

unauthorized interpreters to a significantly higher extent
than did physicians (p 0.013) and registered nurses (p
0.015). No other significant differences were found.

Individual resources for communicating through an
interpreter
Respondents rated their ability to communicate with
parents through an interpreter, revealing a significant
difference between the professional groups (p 0.0003)
(Table 3).
Pairwise comparisons showed that nurse assistants rated

their ability to communicate with parents through an in-
terpreter significantly lower compared with physicians (p

Table 1 Characteristics of healthcare professionals by level

Test between groups
p-value

Variable Level I Level II Level III Level I vs Level II Level I vs Level III Level II vs Level III

Respondents, n = 858 204 486 168

Percentage based on total response frequency 23.8 56.6 19.6

Age, m (range) SD 42.5
(18.8; 66.7)
11.8

42.1
(20.3; 65.9)
12.0

41.7
(21.3; 64.9)
11.8

0.66 0.50 0.72

Missing 7 9 1

Distribution men/level, m (%) 11 (5.5%) 14 (2.9%) 16 (9.5%) 0.16 0.20 0.0018*

Missing 4 4 0

Spoke a third language/level, m (%) 36 (17.8%) 88 (18.2%) 42 (25.0%) 0.84 0.11 0.088

Missing 2 2 0

Years in profession, m (SD) 15.2 (12.4) 15.4 (12.0) 14.9 (12.3) 0.86 0.83 0.68

Missing 17 32 12

*p < 0.05

Patriksson et al. BMC Health Services Research (2019) 19:586 Page 4 of 8

0.0058) and registered nurses (p 0.0026). No other signifi-
cant differences were found.

Discussion
The results showed that there was a difference between
professional categories concerning both awareness of
interpreter-related guidelines and use of authorized and
unauthorized interpreters. It was more common to use
authorized interpreters for describing a medical treat-
ment, while information about nursing care was more
often communicated via unauthorized interpreters. A
study regarding healthcare professionals pointed out that
interpreters were used almost exclusively in discussions
with a physician regarding the child’s medical care, but
very rarely in discussions with a registered nurse con-
cerning nursing the child [24]. An exploration of this
difference may be, as suggested by previous studies, that
it is almost impossible to engage an interpreter for all
nursing tasks, and it is often easier to ask a family mem-
ber to interpret [4]. This can be an ethical dilemma, as
there is no guarantee when a family member interprets
that the health care professionals are safeguarding the
patient’s rights. For example, there is often low transpar-
ency and the health care professional does not know
what the family member is saying and whether their in-
terpretation is a true interpretation [25].

Awareness of the guidelines pertaining to interpret-
ation differed between the professional categories and
was highest among registered nurses. Written guidelines
for interpreted communication, if implemented and
known by health care professionals, can be facilitative
when language barriers arise [26]. Providing written
guidelines is necessary because the need to use autho-
rized interpreters in communication between health care
professionals and parents cannot always be predicted, as
shown by previous studies in paediatric care [9, 26, 27].
In Sweden, there are no guidelines on a national level,
each neonatal unit develop independently their own
guidelines.
Regarding the availability of interpreters, in this inves-

tigation we can report that health care professionals in
all neonatal departments in Sweden used authorized in-
terpreters, although there was a discrepancy between
physicians’ and registered nurses’ communications. Stud-
ies show that when authorized interpreters are used, pa-
tients and professionals feel more secure because the
interpreter has a high level of linguistic skill, under-
stands medical terminology and has a duty of confidenti-
ality through their training [12]. The importance of
planning ahead of interpreted communications has been
demonstrated in earlier studies, as has that of the choice
of location where the conversation takes place. It is

Table 2 Characteristics of healthcare professionals

Test between groupsp-value

Physicians Nurses Nurse
assistants

Nurse assistants vs
Nurses

Nurse assistants vs
Physicians

Nurses vs
Physicians

Respondents, n = 858 54 484 320

Percentage based on total response
frequency

6.3 56.4 37.3

Age, m (range) SD 41.7
(26.1;
66.7)
9.5

40.6
(21.3;
65.9)
11.3

44.4
(18.8; 65.8)
12.9

< 0.0001* 0.13 0.51

Missing 1 6 10

Distribution men/professional, m (%) 21 (39.6) 14 (2.9) 6 (1.9) 0.51 < 0.0001* < 0.0001*

Missing 1 4 3

Spoke a third language/professional
category, m (%)

21 (40.4) 87 (18) 58 (18.1) 0.33 < 0.0001* < 0.0001*

Missing 2 2 0

Years in profession, m (SD) 11.9 (9.9) 13.1
(10.5)

19.4 (13.9) < 0.0001* 0.0003* 0.46

Missing 2 19 40

Numbers of emergency conversations
with interpreters the latest month, m (SD)

5.21 (6.06) 2.24
(3.90)

1.82 (4.83) 0.22 0.0001* < 0.0001*

Missing 2 63 62

Numbers of planned conversations
with interpreters the latest month, m (SD)

4.76 (4.46) 1.95
(3.05)

1.06 (4.84) 0.0026* < 0.0001* < 0.0001*

Missing 3 61 90

*p < 0.05

Patriksson et al. BMC Health Services Research (2019) 19:586 Page 5 of 8

important not only to the family, but also from a cost-
efficiency perspective [12, 28]. Interpreting has become a
large item in hospital budgets and it is therefore import-
ant that these communications are informative, alleviate
parents’ concerns and give them the opportunity to ex-
press their opinions and the family’s wishes for the stay
during the care episode. The aim is to reduce the risk
of misunderstanding that can arise when professionals
and families of foreign origin do not understand each
other [29].
Authorized interpreters are used for communica-

tions that concern the child’s medical needs to a
greater extent than for communications that concern
the child’s nursing needs. The results showed that
nurse assistants used relatives/friends as interpreters
to a greater extent, instead of authorized interpreters.
Other studies report that a member of the family
often interprets communications between patients and
health care professionals [30]. When health care pro-
fessionals are bilingual, they are often used as inter-
preters in nursing contexts [26, 31]. That health care
professionals have not been trained in dealing with
medical interpreting is an obstacle in these inter-
preted communications, which can lead to erroneous
interpretations and misunderstandings in the commu-
nication [9]. An ethical dilemma also arises in the

form of an imbalance of power and positioning, when
one parent has better Swedish language skills than
the other. When the parent with Swedish language
skills interprets for the other parent, an ethical di-
lemma arises because the health care professional
cannot determine whether the parent has misunder-
stood the information because of inadequate know-
ledge of medical terminology [29].
Sweden is becoming increasingly multicultural [31],

implying many potential language barriers in medical
contexts. In one study, the question was asked
whether relatives should act as interpreters [12]. The
results suggested that this may be preferable in simple
situations. The authors found that relatives were easy
to get hold of, provided a sense of security and confi-
dence, were aware of the person’s worries and were
able to provide support of a different nature than that
provided by authorized interpreters. However, situa-
tions in which a relative acted as the interpreter
could also result in poorer interpretation and confi-
dentiality concerns. As well, relatives often do not
understand the terminology and using children as in-
terpreters is not recommended because of their inad-
equate language skills [12, 28]. Moreover, using
children as interpreters may violate the inherent
rights of the child [32].

Table 3 Characteristics of the survey

Total
n (%)

Physicians Registered Nurses Nurse assistants P value

Are there guidelines for interpreted conversations
in your department?

Yes 169 (20.5) 7 (13.2) 88 (18.5) 74 (25.0) 0.0001*

No 257 (31.2) 12 (22.6) 185 (38.9) 60 (20.3)

Don’t know 399 (48.4) 34 (64.2) 203 (42.6) 162 (54.7)

Missing 33 1 8 24

How often are authorized interpreters used for
emergency conversations?

Always/often 421 (60.6) 44 (84.6) 271 (65.5) 106 (46.3) < 0.0001*

Not very often/never 274 (39.4) 8 (15.4) 143 (34.5) 123 (53.7)

Missing 163 2 70 91

How often are authorized interpreters used
for planned conversations?

Always/often 525 (84.1) 45 (93.8) 363 (91.4) 117 (65.4) < 0.0001*

Not very often/never 99 (15.9) 3 (6.3) 34 (8.6) 62 (34.6)

Missing 234 6 87 141

How often are non-authorized interpreters
used for emergency conversations?

Always/often 258 (36.4) 11 (20.8) 164 (38.8) 83 (35.6) 0.38

Not very often/never 451 (63.6) 42 (79.2) 259 (61.2) 150 (64.4)

Missing 149 1 61 87

How often are non-authorized interpreters used
for planned conversations?

Always/often 101 (16.4) 3 (6.5) 55 (14.3) 43 (23.0) 0.0013*

Not very often/never 516 (83.6) 43 (93.5) 329 (85.7) 144 (77.0)

Missing 241 8 100 133

Healthcare professionals’ rating of their ability to
communicate with non-Swedish-speaking parents
through an interpreter.

Extremely weak/weak 19 (2.6) 1 (1.9) 8 (1.8) 10 (4.2) 0.0003*

Neither strong nor weak 234 (31.7) 11 (20.8) 132 (29.5) 91 (38,2)

Strong/Extremely strong 485 (65.7) 41 (77.4) 307 (68.7) 137 (57.6)

Missing 120 1 37 82

*p < 0.05

Patriksson et al. BMC Health Services Research (2019) 19:586 Page 6 of 8

In our study population it was more common to use
authorized interpreters for communications about med-
ical care, while information about nursing care was more
often communicated via unauthorized interpreters.
There may be alternatives to using unauthorized inter-
preters in communication with families in neonatal care.
These alternatives may provide support in nursing care,
but cannot replace an interpreter in communications
concerning sensitive topics. Health care professionals in
Swedish neonatal departments currently use technical
aids such as Google™ translate [33].
Regarding individual resources to communicate

through an interpreter, in the present study all health
care professionals rated their ability to communicate
with parents through an interpreter as strong. Several
studies have shown that health care professionals tend
to overestimate their ability and that self-assessments
may be positively coloured [34]. Hence, mothers in peri-
natal care felt a loss of control over their situation when
hindrance to communicate or understand necessary in-
formation [35]. Studies also show that there is a need
and a desire for registered nurses to receive training in
communication through an interpreter, and that this
would reduce the risk of misunderstandings [9]. Estab-
lishing guidelines for communications via an interpreter
would be one way to enable parents to be involved in
their child’s care and treatment [3].
There are methodological shortcomings in this study

that must be addressed. One is the non-response rate, as
only 41% of health care professionals chose to answer
the survey. The question about academic degrees was
shown to be unclear, and this question was excluded in
this study. However, the strengths of the study include
that respondents from all neonatal departments in
Sweden participated and that the overall number of
completed surveys was relatively high. Another meth-
odological shortcoming is that the self-reported aware-
ness and use of interpreters by health care professionals
in the survey may differ from actual use in clinical prac-
tice. Consequently, the study needs to be followed up
with observations of the use of interpreters.

Conclusion
The present results suggest that it is more common to use
authorized interpreters for medical communications, while
communications about nursing care are more often com-
municated via unauthorized interpreters. The results also
show insufficient awareness of guidelines for interpreted
communication in all neonatal units in Sweden. Clinical
implications might include providing health care profes-
sionals with guidelines, training clinical skills in using inter-
preters and increasing the availability of interpreters by
employing interpreters at the hospital. Further research

might involve developing innovative solutions that facilitate
communication in all types of health care.

Additional file

Additional file 1: Talking with parents who don’t speak Swedish.
National survey. (DOCX 104 kb)

Acknowledgements
None.

Authors’ contributions
Study conception and design: KP, HW, MB, SN. Collection and analysis of the
survey: KP, HW, SN. Drafting of the manuscript: KP, HW, SN. All authors read
and approved the final manuscript.

Funding
Funding for this article was obtained from the Department of Research and
Development, NU-Hospital Group, and the Health & Medical Care Committee of
the Regional Executive Board, Region Västra Götaland. They founded design of
the study, data collection, analysis, interpretation of data and writing the
manuscript.

Availability of data and materials
The datasets used and/or analysed during the current study available from
the corresponding author on reasonable request.

Ethics approval and consent to participate
The respondents gave their consent by completing the survey. Further, they
were able to choose which questions to answer. The respondents were
informed that the results of the study would be analysed at the group level;
that no individual would be able to be identified; and that data would be used
for research purposes only. According to national regulations ethical approval is
not required for surveys on health care professionals when no sensitive
personal data is obtained [22].

Consent for publication
Not applicable.

Competing interests
The authors declare that they have no competing interests.

Author details
1Institute of Health and Care Sciences, Sahlgrenska Academy, University of
Gothenburg, Arvid Wallgrens Backe, Box 457, S-405 30 Gothenburg, Sweden.
2Division of Paediatrics, NÄL Hospital, S-461 85 Trollhättan, Sweden. 3Division
of Neonatology, Sahlgrenska University Hospital, S-416 85 Gothenburg,
Sweden. 4Norra Älvsborgs Länssjukhus, Lärketorpsvägen, S-46185 Trollhättan,
Sweden.

Received: 18 September 2018 Accepted: 13 August 2019

References
1. Swedish Statut (svensk författningssamling). Hälso- och sjukvårdslagen

(Health Care Act). Stockholm: Socialdepartementet; 2017. p. 30.
2. Wigert H, Dellenmark Blom M, Bry K. Parents’ experiences of

communication with neonatal intensive-care unit professionals: an interview
study. BMC Pediatr. 2014;14:304. https://doi.org/10.1186/s12887-014-0304-5.

3. Skene C, Gerrish K, Price F, Pilling E, Bayliss P, Gillespie S. Developing family-
centred care in a neonatal intensive care unit: an action research study.
Intensive Crit Care Nurs. 2018. https://doi.org/10.1016/j.iccn.2018.05.006.

4. Patriksson K, Berg M, Nilsson S, Wigert H. Communicating with parents who
have difficulty understanding and speaking Swedish: an interview study
with health care professionals. J Neonatal Nurs. 2017;23(6):248–52. https://
doi.org/10.1016/j.jnn.2017.07.001.

5. IOM. International organization for migration 2018. Available from: https://
www.iom.int Accessed 25 Oct 2018.

Patriksson et al. BMC Health Services Research (2019) 19:586 Page 7 of 8

6. Statistiska centralbyrån [Central Bureau of Statistics], Available from: https://
www.scb.se/hitta-statistik/statistik-efter-amne/befolkning/befolkningens-
sammansattning/befolkningsstatistik/ Accessed 18 Nov 2018.

7. Sobo JE. Good communication in pediatric Cancer care: a culturally-
informed research agenda. J Pediatr Oncol Nurs. 2004;21(3):150–4. https://
doi.org/10.1177/1043454204264408.

8. Pergert P, Ekblad S, Enskär K, Björk O. Bridging obstacles to transcultural
caring relationships- tools discovered through interviews with professionals
in pediatric oncology care. Eur J Oncol Nurs. 2008;12(1):35–43. https://doi.
org/10.1016/j.ejon.2007.07.006.

9. Berlin A. Cultural competence in primary child health care services –
interaction between primary child health care nurses and parents of foreign
origin and their children. Stockholm: Thesis, Karolinska Institutet,
Department of Neurobiology, Care Sciences and Society; 2010.

10. Hadziabdic E. The use interpreter in healthcare. Perspectives of individuals,
healthcare professionals and families. Växjö: Thesis, Linnaeus University
Press; 2011.

11. Eklöf N, Hupli M, Leino-Kilpi H. Nurses’ perceptions of working with
immigrant patients and interpreters in Finland. Public Health Nurs. 2015;
32(2):143–50. https://doi.org/10.1111/phn.12120.

12. Hadziabdic E, Hjelm K. Arabic speaking migrants’ experiences of the use of
interpreters in healthcare: a qualitative explorative study. Int J for Equity in
Health. 2014;16(13):49. https://doi.org/10.1186/1475-9276-13-49.

13. DeCamp LR, Kuo Z, Flores G, O’Conner K, Minkovitz SC. Changes in
language services use by Us pediatricians. Pediatrics. 2013;132(2):e396–406.
https://doi.org/10.1542/peds.2012-2909.

14. Swedish Legal, Financial and administrative services agency
(Kammarkollegiet). God tolksed. Vägledning för Auktoriserade tolkar (Good
interpreting Pracitce. Guidance for authorized interpreters). Stockholm; 2010.
Available from: https://www.kammarkollegiet.se/download/18.27f1fe4c168c1
d817515205f/15517770227993/God_tolksed_mars2019pdf. Accessed 20 Mar
2019.

15. Socialstyrelsen (National Board of Health and Welfare). Available from:
http://www.socialstyrelsen.se/publikationer2016/2016-5-7. Accessed 25
May 2018.

16. Committee on Fetus and Newborn. Levels of neonatal care. Pediatrics. 2012;
130:587–97. https://doi.org/10.1542/peds.2012-1999.

17. Renberg T, Lindblad Kettis Å, Tully MP. Testing the validity of a translated
pharmaceutical therapy-related quality of life instrument, using qualitative
“think aloud” methodology. J Clin Pharm Ther. 2008;33:279–87. https://doi.
org/10.1111/j.1365-2710.2008.00921.x.

18. Swedish neonatal quality register, SNQ. (2016). Available from: https://www.
medscinet.com/pnq/Uploads/Årsrapport%20SNQ%202016_2.pdf. Accessed
10 Oct 2017.

19. SPSS (IBM SPSS Statistics). International Business Machines Corporation. New
York; 2016.

20. SAS Institute Inc. SAS 9.3. Cary; 2011.
21. Codex. (2013). Rules and guidelines for research. The humanities and social

sciences. Available from: http://www.codex.vr.se/en/forskninghumsam.sthlm.
Accessed 20 Oct 2018.

22. SFS. The Act of change in the act (2003:460) concerning the Ethical Review
of Research Involving Humans 2018. Available from: https://www.lagboken.
se/Lagboken/sfs/sfs/2018/100-199/d_3207706-sfs-2018_147-lag-om-andring-
i-lagen-2003_460-om-etikprovning-av-forskning-som-avser-manniskor.
Accessed 30 Aug 2018.

23. WMA (2008). World medical association declaration of Helsinki: the
Swedish Research Council’s guidelines for ethical evaluation of medical
research of humans.

24. Patriksson K, Nilsson S, Wigert H. Conditions for communication between
health care professionals and parents on a neonatal ward in the presence
of language barriers. Int J Qual Stud Health Well-being. 2019;14(1):1652060.

25. Van Eechoud I, Grypdonck M, Leman J, Van Den Noortgate N, Deveugele M,
Verhaege S. Balancing truth-telling: relatives acting as translators for older
adult cancer patients of Turkish or northwest African origin in Belgium. Eur
J Cancer Care. 2017;26:5. https://doi.org/10.1111/ecc12498.

26. Attard M, McArthur A, Rittano D, Aromataris E, Bollen C, Pearson A.
Improving communication between health-care professionals and patients
with limited English proficiency in the general practice setting. Aust J Prim
Health. 2015;21(1):96–101. https://doi.org/10.1071/PY13095.

27. Abbe M, Simon C, Angiolillio A, Ruccione K, Kodish ED. A survey of
language barriers from the perspective of pediatric oncologists, interpreters

and parents. Pediatr Blood Cancer. 2006;47(6):819–24. https://doi.org/10.1
002/pbc.20841.

28. Hadziabdic E, Albin B, Hjelm K. Arabic-speaking migrants’ attitudes, opinions,
preferences and past experiences concerning the use of interpreters in
healthcare: a postal cross sectional survey. BMC Res Notes. 2014;7:71. doi:
https://doi.org/10.1186/1756-0500-7-71. Available from: http://www.
biomedcentralen.com/1756-0500/7/71. Accessed 10 May 2018.

29. Thompsom-Elderkin V, Silver Cohen R, Waitzkin X. When nurses double as
interpreters: a study of Spanish-speaking patients in a US primary setting.
Soc Sci Med. 2001;52(9):1343–58. https://doi.org/10.1016/S0277-9536
(00)00234-3.

30. Kuo ZD, O’Conner GK, Flores G, Minkovitz SC. Pediatricians’ use of language
services for families with limited English proficiency. Pediatrics. 2007;119:
e920–8. https://doi.org/10.1542/peds.2006-1508.

31. Lundqvist A, Nilstun T, Dykes A-K. Neonatal end-of-life care in Sweden: the
views of Muslim woman. J Perinat Neonatal Nurs. 2003;17(1):77–86. https://
doi.org/10.1046/j.1362-1017.2003.00027.x.

32. United Nations. Convention on the rights of the child. Treaty Series.
1989;1577:3.

33. Cooper-Haith M. Mobile translators for non-English speaking women
accessing maternity services. BJM. 2014;07. https://doi.org/10.12968/bjom.2
014.22.11.795.

34. Hudelson P, Perneger T, Kolly V, Perron Junod N. Self-assessed competency
at working with a medical interpreter is not associated with knowledge of
good practice. PLoS One. 2012;7(6):e38973. https://doi.org/10.1371/journal.
pone.003897.

35. Barkensjö M, Greenbrook J, Rosenlundh J, Ascher H, Elden H. The need of
trust and safety inducing encounters: a qualitative exploration of women’s
experiences of seeking perinatal care when living as undocumented
migrants in Sweden. BMC Preganancy and Childbirth. 2018;18:217. https://
doi.org/10.1186/s12884-018-1851-9.

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EMPIRICAL STUDIES

Communication between parents and neonatal healthcare professionals
using pictorial support when language barriers exist – parents’ experiences
Eva-Karin Gotting a,b, Ulrika Ferm c and Helena Wigert a,d

aInstitute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; bDivision of Paediatrics,
ANS Hospital, Angered, Sweden; cDART Centre for Augmentative and Alternative Communication and Assistive Technology,
Sahlgrenska University Hospital, Gothenburg, Sweden; dDivision of Neonatology, Sahlgrenska University Hospital, Gothenburg, Sweden

ABSTRACT
Purpose: Families arriving in Sweden after being forced to flee their home need health care.
Communication is a key component to establishing good care relations and becomes difficult
when there are language barriers between families and healthcare professionals. In the
context of neonatal care, communication is carried out with parents. The aim of the study
was to describe parents’ experiences of communication with neonatal healthcare profes-
sionals and using pictorial support when language barriers exist.
Method: The study takes a qualitative approach based on seventeen interviews with parents
who had experienced neonatal ward. Qualitative content analysis was used.
Results: The parents needed to communicate through supports, which caused distress and
misunderstanding. The relationship between parents and the healthcare professionals
affected the communication. Pictorial support was used to different degrees. Four categories
were identified from the data analysis: Communicating through supports, Facing barriers in
communication, Facing external influences and The need for a good healthcare relationship.
Conclusion: The present study is the first to describe parents’ experience with using the
pictorial support developed in the project KomHIT Refugee and therefore fulfils the function
of being a first evaluation of the pictures from parents’ perspective.

ARTICLE HISTORY
Accepted 2 September 2022

KEYWORDS
Communication;
interpreters; interviews;
language barriers; pictorial
support

Introduction

An important part of neonatal care is the relationship
between the paediatric nurse and the newborn child’s
family. Maintaining children’s and parents’ trust might
be challenged by the fact that the nurse often must
conduct procedures that are unpleasant for the chil-
dren. In these kinds of situations, it is important that
the children and parents are as involved as possible
so that they feel prepared for the procedure (Coyne
et al., 2016). The Swedish Health Care Act (2017) high-
lights the importance of healthcare providers taking
parents into account when a child is ill. Parents have
the right to be part of the healthcare configuration
when their child is hospitalized (a.a).

Establishing good care relationships between
families and healthcare professionals can be difficult
when language barriers exist. Communication is an
important component within the care relationship,
and if it does not function well, there is a risk that
the families may feel that the health care provided is
not satisfactory (Kroening et al., 2016). Language bar-
riers is found to be the most common influencing
factor for communication problems (Kaufmann et al.,
2020). Earlier studies describe that staff within neona-
tal care experience frustration and powerlessness

when they communicate with parents where lan-
guage barriers exist. They found their own strategies
to communicate, using body language and assistive
technology (Patriksson et al., 2017). A field study
shows that health care professionals preferred to use
an interpreter when language barriers exist, while
parents in neonatal care wished to speak for them-
selves or asked for multilingual professionals to inter-
pret (Patriksson et al., 2019).

Simplified language and pictorial support are stu-
died as potential ways to communicate more effec-
tively and thereby secure the quality of health care for
patients with both high and low health literacy
(Meppelink et al., 2015). Projects where pictorial sup-
port is used to facilitate communication with refugees
in different contexts are ongoing around the world
(ICOON for refugees, 2021). KomHIT Refugee (2018) is
one example which has been implemented in health-
care facilities in Sweden. KomHIT Refugee seeks to
facilitate information exchange and communication
between healthcare professionals and patients in
care situations. Based on statistics from the
Migration Authority, the pictorial support is translated
to eleven languages common among asylum seekers
in Sweden. The pictorial support is audited by

CONTACT Eva-Karin Gotting [email protected] Institute of Health and Care Sciences, Sahlgrenska Academy, University of
Gothenburg, Arvid Wallgrens Backe, Box 457, Gothenburg S-405 30, Sweden

INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING
2022, VOL. 17, 2122151
https://doi.org/10.1080/17482631.2022.2122151

© 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

medically knowledgeable healthcare professionals. All
healthcare units that have participated in the KomHIT
Refugee project, such as the Neonatal Intensive Care
Unit (NICU) where this study was conducted, have
identified care situations where they find there is
a need for pictorial support. According to Swedish
law, anyone in need of an interpreter is entitled to
one when in contact with authorities (SFS, 2017). The
pictures are used as a complementary support when
communicating with an interpreter (a.a.).

Language barriers challenge family-centred care
and research is needed exploring parents’ perceptions
regarding care by other-language spoken health pro-
fessionals (Stephen, 2021). There is a lack of knowl-
edge regarding parents’ experiences from
communicating with neonatal health professionals
and using pictorial support when language barriers
exist.

Aim

The study had two aims: to describe parents’ experi-
ences of communication with neonatal healthcare
professionals when language barriers exist, and to
describe their experiences of using the KomHIT
Flykting pictorial support.

Method

A qualitative content analysis according to Graneheim
and Lundman (2004) was the design of the study, and
the results were construed from narrative interviews
conducted with semi-structured guidelines.

Settings

The study commenced with a literature review focus-
ing on newly arrived patients’ needs in Swedish
health care, as well as earlier studies about pictorial
support within health care. Six months before the first
interviews took place, the first author (E-KG), together
with a project worker from KomHIT Refugee, visited
two workplace meetings on neonatal wards in
a university hospital from which the study participants
would be recruited. The purpose of these visits was to
inform the healthcare providers in these wards about
the research subject and engage the medical staff to
use the pictorial support in care interactions as much
as possible. These meetings were intended to increase
the chances for prospective participants to be
exposed to pictorial support before upcoming inter-
view sessions where the author would ask questions
about the participants’ experiences with the pictorial
support. The author then kept in contact with one
person in each neonatal ward to regularly remind the
medical staff about using the pictorial support and
about the ongoing research project.

Ethics

This study received approval from the Ethical Review
Board of Gothenburg (ref:102–18) and obtained con-
sent from the operations manager of the Care Unit.
The participants were informed that personal data
would be anonymized and that they could withdraw
their data at any time during the research process
without having to give any special reason. All partici-
pants in the study gave their written consent to par-
ticipate in the study.

Participants

Seventeen mothers, twelve fathers and two other
family members whose native language was not
Swedish, connected to a Neonatal Intensive Care Unit
(NICU) in southwestern Sweden, entered the study
(Table 1). The inclusion criteria for participation were:
at least one of the parents was not Swedish speaking,
their child had been hospitalized for at least a week in
one of the units, and that they had been discharged
one to six months before the interview session.

Data collection

When the operations manager approved the study,
the NICU’s secretary gave the first author contact
details of caregivers. Parents were then contacted by
telephone by professional interpreters who were not
part of the research team and informed verbally about

Table 1. Demographic data (n = 17).
Families Number

Interview with both parents 12
Interview with mother 3
Interview with mother and one other family member 2
Mother’s age in years, mean (min-max) 25 (19–40)
Father’s age in years, mean (min-max) 30 (19–48)
Other family members’ age in years, mean (min-max) 46 (20–52)
Years living in Sweden at time of interview, mean

(min-max)
3 (0–10)

Exposed to KomHit Flykting pictorial support
Never 15
Rarely 7
Often 7
Professional interpreter participated in the room 9
Professional interpreter on telephone 3
Parents preferred to speak English 2
Parents wanted partner/friend to interpret 3
Length of interviews
Less than 30 minutes 5
30–44 minutes 8
45–60 minutes 2
More than 1 hour 2

Languages spoken by parents
Albanian 2
Arabic 4
Gujarati/English 1
Kurdish 2
Malyalam/English 1
Somali 11
Sorani 3
Urdu 2
Vietnamese 2
Tagalog/English 1

2 E.-K. GOTTING ET AL.

the aim of the study. If they agreed to participate, the
author called back, with an interpreter, to provide
further information about the study and to book
a time and place for the interview with the approval
of the caregivers. Before the interview started, the
parents signed a consent form indicating their agree-
ment to participate. The interviews were held in pri-
vate locations, to meet the confidentiality needs of
the parents.

The author is a specialist in paediatric nursing and
has experiencefrom communicating with parents
within health care.

In most interviews, both parents were present,
although in some cases there was one parent or
another family member who had also been present
during the hospitalization at the NICU. Most care-
givers agreed to having a professional interpreter at
the interview sessions. Some preferred one of the
partners to interpret to the other, or else they wanted
a friend to interpret for them. Most interviews took
place in the homes of the families. One parent wanted
to meet at a public library. The length of the inter-
views was 19–72 minutes (Table 1). The interviews
were digitally recorded and transcribed verbatim.

A semi-structured interview guide was used with
open questions to create a conversation where the
parents could feel free to share their experiences. The
author encouraged the parents to speak freely and
with their own words regarding the research subject.

Data analysis

The interviews were analysed according to qualitative
content analysis, with an inductive approach
(Graneheim & Lundman, 2004). The interview tran-
scripts were read though several times by the author
to obtain a general sense of their content. Manifest
content was studied, based on what was concretely
said in the text. The text was studied in its entirety
and then broken down into smaller units. The mean-
ings of the units were condensed into smaller units of
text that still contained the essence of the data in its
original form. Every condensed unit was labelled with
a code name. The codes created categories with

different subcategories based on related content
(Table 2). In total, four categories, each with two to
three subcategories, emerged from the data analysis.

The categories included all data in the text that
responded to the aim of the study, and no parts of
the text were excluded due to the lack of a suitable
category. All data concerning the parents’ experience
of communication with healthcare providers when
language barriers existed at the NICU were included
in the coding as being potentially relevant. No data
were placed into two different categories; all relevant
data were placed into a suitable category.

Results

Analysis resulted in four categories describing par-
ents’ experiences of communication with neonatal
healthcare professionals and using pictorial support
when language barriers exist. Each category has two
to three subcategories (Figure 1).

Communicating through supports

Parents in the study discussed different types of supports
regarding communication that they had been intro-
duced to during their child’s hospitalization at the NICU.

Communicating through an interpreter

All parents mentioned that they had communicated
with healthcare professionals through an interpreter
at some point during their child’s hospitalization.
Whether or not an interpreter was present could
depend on which category of healthcare professionals
the parents were meeting with. Interpreters were not
booked frequently for when nurses were communi-
cating compared to when doctors were. One reason
mentioned to this was that the nurses talked rather
slowly and explained things in a careful way. Parents
felt that when they were talking to the healthcare
professionals working daily at the NICU, the nurses
were listening carefully to what the parents said and
that the nurses tried to understand them. Another
reason was that parents sensed that the subjects

Table 2. Examples of analysis process.
Unit of meaning Condensed unit of meaning Code Subcategory Category

What they are saying of course they are doing for
the good of my daughter so I should be taking
care of it, whatever they are saying exactly,
because they want us to be better and go from
here, I understand that.

they are doing for the good of
my daughter, I understand
that.

Sense that staff
is doing
good.

Feeling trust and
confidence.

The need for
a good
healthcare
relationship.

Sometimes, someone who talks to me really quick
and I say “Yes, I understand,” but from inside
I don’t understand, I don’t understand anything
and I get really mad at myself because of this,
that I don’t understand. It’s really, really tough
actually.

I say “I understand” even though
I don’t and I get really mad at
myself and it’s really tough.

Feeling it’s
tough and
feeling mad
at oneself.

Facing
misunderstandings.

Facing barriers in
communication.

INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 3

they were talking about with the nurses were rather
simple, concerning milk and diapers, for example, and
for these no interpreter was needed. They thought it
was not necessary to always have an interpreter, but it
was when it concerned special meetings and impor-
tant information. Some parents also mentioned that
they did not want any interpreters booked because of
the cost; they thought that the money spent on inter-
preters could have been saved for other purposes in
the NICU. There were situations described by parents
where, in a care meeting, the interpreter did not
speak the same dialect as themselves. Sometimes,
too, the interpreter did not understand the dialect of
the doctors they were interpreting for. This would
sometimes lead to severe misunderstandings that
made the parents feel overwhelmed.

“The interpreter that you book, you have to be sure that
they have the right education and are able to interpret
the information very well. If the interpreter, for example,
says that you have a serious disease, it can be the baby
or yourself. But maybe that’s not right, maybe the
interpreter interpreted wrong. When you are shocked,
you can be deaf to what is being said.” (Parent 1)

In some cases, it helped if someone else in the room
besides the interpreter was explaining what the
healthcare professional said. Sometimes, after
a disappointing experience with one interpreter, par-
ents found that a different interpreter present at their
next meeting worked out fine, and they were relieved
to know that that interpreter would be booked at
their meetings thereafter.

Other parents described that a healthcare profes-
sional acted as the interpreter initially at the hospital
stay. Most commonly, it took a few days before
a professional interpreter was booked. Parents
thought that with the professional interpreter, they
were able to communicate, explain more, and ask
more questions and that there was more time for
this communication. However, parents expressed

that there was greater understanding regarding med-
ical vocabulary when a healthcare professional, with
the same mother tongue as the parent, was interpret-
ing. They also revealed that it took longer to commu-
nicate through an interpreter. Sometimes the
interpreter was booked to communicate by
telephone.

“It might be difficult sometimes, because it takes longer.
Sometimes it is also difficult to hear through the telephone
and you often have to wait for the interpreter.” (Parent 8)

Using pictorial support

Some parents had not experienced the use of pictorial
support such as KomHIT Refugee, but they described
experiences from care meetings where they would
have liked to use pictorial support and thought posi-
tively about this communication tool. Parents thought
pictorial support would be helpful, for example, when
providing information about the kinds of items that
would be needed for the hospital stay, such as blan-
kets or pillows. Parents explained that not being able
to ask for certain things caused feelings of loneliness.

“Sometimes I felt alone. When I couldn’t explain some-
thing and when I didn’t have a picture to show for
explanation. At the hospital there is a bureau with
clothes and diapers and stuff, and it was labelled in
Swedish but there were no pictures if you couldn’t
understand Swedish.” (Parent 5)

Parents who were introduced to pictorial support
explained that the interpreter would go over the
pictures and that the pictorial support was in their
room during the hospital stay.

“We got the pictorial support from the hospital to help
with communication. To communicate, they fetched
one of these and they said, “What you want, you can
point to. They even had it in Arabic so that I could point
to the picture. I had a schedule with pictorial support in

Figure 1. Overview of the findings, categories and subcategories.

4 E.-K. GOTTING ET AL.

my room at all times until we were discharged. Without
the pictures, I would need an interpreter at all times,
you could say.” (Parent 2)

It was revealed that some parents learned Swedish
words from the pictorial support. Other participants
mentioned that the pictorial support was helpful, but
not enough. They requested larger and more pictures
with further explanations, and the participants said
that they found the pictures to be most helpful
when communicating about simpler subjects.

The pictures helped me a lot when I needed supplies in our
room or when my husband was not there and I was in
need of the bathroom. When the doctor came, he asked
deeper questions than the pictures could be used to
answer, and the doctor was not often there . . . ” (Parent 17)

Some parents suggested that there should be pictures
in the reception area and on different bulletin boards
in the wards to aid with communication and under-
standing. Other parents also suggested that the pic-
tures should always be labelled in English as well,
since the labels are not translated into all languages.

It was also revealed that some parents had been
exposed to pictorial support in other contexts before
their hospitalization but did not see the pictures at
the NICU. Other parents explained that when they
were discharged from the hospital, they got the infor-
mation together with pictures describing how to pro-
ceed at home with their child.

“We got them before his surgery with information on
how the procedure would be done. And then when we
left from surgery after one day, we got a rather big
paper with several pictures explaining what he couldn’t
do, for example, that he couldn’t run or jump.”
(Parent 10)

Creating other solutions

Sometimes neither interpreter nor pictorial support
was available when communication was nevertheless
needed. The parents described different types of solu-
tions that they took into care relationships to support
communication.

If one partner could speak English, parents men-
tioned that they used English when their Swedish was
limited. At other times, parents used the internet to
search on Google for translations to help them com-
municate with the healthcare professionals. It was not
mentioned whether the healthcare professionals used
this approach. Calling a friend and either asking them
to translate a specific word or letting them speak to
the healthcare professional directly was also men-
tioned in the interviews as a way of facilitating com-
munication. Some parents mentioned that when they
discovered something new with their child, they
recorded it with their mobile camera so that they

could show the healthcare professional the video
instead of trying to explain.

Parents also mentioned that they and the health-
care professionals both used their hands to commu-
nicate by making gestures and pointing to different
things. Parents described these as common ways that
people communicate with each other when they do
not speak the same language and that one can man-
age that way.

“For example, this picture was not there (pointing at
a picture of a baby being bathed brought by the
author to the interview); ‘shower the baby’; this picture
was not there, and every week we had decided, but
when she talks; I don’t understand, but when she says
“Shower” and points to her head, then I understand.”
(Parent 2)

Some parents explained that, before visiting hospital,
they had looked up words they thought they would
need to know in order to understand information
given there, and to make themselves understood.

Facing barriers in communication

Different types of factors emerged that led to chal-
lenges in communication. Even though parents were
very satisfied with their time spent at the NICU, dis-
tressing events caused by communication barriers
were described in the interviews.

Facing misunderstandings

The parents described different kinds of misunder-
standings that occurred during conversations, which
caused unnecessary stress. The misunderstandings
occurred for different reasons, such as the inter-
preter misinterpreting a word so that parents did
not get an accurate understanding of the situation.
The misunderstandings caused worries and stress
about their child’s health. These misunderstandings
also led to feelings of discouragement because the
parents felt that they and the healthcare profes-
sionals did not understand each other well enough.
One mother described how her already high blood
pressure went even higher after facing misunder-
standings in communication with healthcare profes-
sionals. In other cases, parents felt that the
healthcare professionals misunderstood or that dif-
ferent staff members gave different advice.

“In certain situations, it happens that we misunderstand
and we are trying to find a proper conversation so that
we can explain ourselves and why something has hap-
pened, for example, why I was half an hour late in
feeding the baby, because she was sleeping so soundly.
I just simply say that ‘she was sleeping so soundly’. The
nurse would not understand; she was like, ‘You should
wake her up, you should feed her. You know, these
times are very important, every three hours she should

INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 5

have a feeding.’ Then I also have to explain to her that,
you know, ‘she was very sleepy’. I went to the other
nurse, I explained to her, and she said, ‘Wait another
half an hour; she will wake up if she is hungry.”
(Parent 6)

When talking about communication, emotions were
expressed. One mother explained that when a person
is shocked, they can become deaf to anything said
right afterwards. Other feelings included a fear of
being misunderstood.

“I got very scared. How am I supposed to tell them that
my daughter has pulled out her feeding tube?
(Parent 7)

Dealing with administrative barriers

Parents revealed that not having an internet connec-
tion affected communication with healthcare provi-
ders. Other barriers to communication included
a lack of pictures on signs at the hospital, and a lack
of written instructions in languages other than
Swedish.

“’Cause when I buy the medicine from an international
market, I found that there are many languages; the
whole-country language is there, but English is always,
always, always there. So many times, it happens here
that we do not have that in the instructions. For that
particular medicine, I have to search in Google. Many of
them (other immigrants) are not so educated, they just
blindly follow what they understood, and sometimes it
can be harmful for the child. So, I think it’s very impor-
tant to add more languages in the product informa-
tion.” (Parent 6)

Facing external influences

Even though the author of the study did not ask
questions regarding the parents’ conditions outside
their child’s hospitalization at the NICU, this was
brought up by the parents themselves in relation to
communication. They also discussed what they had
heard friends and relatives talking about concerning
communication in other situations and how they per-
ceived that supportive communication is being dis-
cussed in other places outside the NICU.

Comparing support

When parents talked about friends’ experiences with
Swedish health care, they were similar to their own
experiences. Also, when talking about communicating
with other authorities in Sweden, such as the
Migration Authority and universities, they perceived
that authorities perform their duties well and commu-
nicate in similar ways as they do within health care.
There were other experiences with communication
they encountered in other parts of society, and they

had thoughts about how to integrate similar supports
into health care.

“I always use these kinds of apps, like Google Translate
and also another app. But I mean that this should be
installed on a screen. It would be just a small screen
located maybe at the reception. When certain persons
come in, you ask them to write.” (Parent 6)

The need for psychosocial support

Some parents expressed the importance of the
healthcare system to understand that patients like
themselves are in a unique situation. Apart from
being ill, or having a sick child, with all the feelings
that come with that, they also cannot speak the
same language as the healthcare professionals.
Another psychosocial condition that parents men-
tioned as affecting communication was whether or
not it was their first and only child that was hospita-
lized. Parents found it difficult not to spend all their
time at the hospital. They expressed that they had
feelings of loneliness and frustration when they got
home; that they felt they could do nothing at home,
and they were scared of what would happen when
they left the hospital. Some parents lived in the
suburbs at a long distance from the hospital and
revealed that they did not have a car or had not
been granted asylum, which exacerbated feelings of
isolation and anxiety. Some enabling factors were
also mentioned; for example, that this was not their
first time in a new country, they were used to coping
with different situations that occurred in their new
society and healthcare system.

“We had our children after we had been living here
for some years, so we were not completely blank
when we came here, but we didn’t understand as
much as now.” (Parent 9)

Some parents explained that it helped a lot when
staff enabled the parents to go home to their other
children. They expressed the importance of the staff
considering everything regarding this break from
the hospitalization, helping the parents feel that it
was safe to leave their sick child at the hospital for
a while.

The need for a good healthcare relationship

Throughout the interviews, parents talked about
other ways to communicate besides verbally, and
about feelings that affected patients’ perceptions
around communication.

Feeling trust and confidence

Parents felt that they knew the Swedish language, but
when it came to situations regarding health care, they

6 E.-K. GOTTING ET AL.

felt less confident. They felt responsible for the care of
their child since they knew their child better than the
healthcare providers did. When the child’s health sta-
tus changed, parents felt obligated to explain these
improvements or impairments. When at home and
when they went to follow-up appointments at out-
patient clinics, parents noticed that they could
express themselves better and that the outpatient
clinics chose not to book an interpreter. After
a meeting with no interpreter, parents felt empow-
ered and confident. Also, some expressed that they
were happy when they were able to offer a correction
when the interpreter was wrong. Another factor that
had an impact on the parents’ confidence was when
they learned new words from the healthcare profes-
sionals, expanding their vocabulary during their time
at the NICU. Some parents also explained that the
healthcare professionals informed them that the
videos they had made of their child’s improvements
and impairments were shown to other experts at the
hospital so that they could learn from each other,
which encouraged the parents and assured them
that what they were doing was good. Parents also
explained that they felt joy and felt encouraged by
the staff when they were making eye contact and
telling them that they were good parents and that
their child would be better soon.

“Every time I talked with them (healthcare staff), the
pain was relieved. They were really kind . . . I was com-
forted by them and able to hug them; it felt like they
were part of my family.” (Parent 16)

Some parents expressed appreciation and trust when
the healthcare staff noticed that they were not able to
follow the conversation in Swedish and switched
instantly to English; sometimes this was enough
rather than talking in their mother tongue.

“I think it’s fine because they also talk in English and
understand my situation.” (Parent 14)

“They don’t say anything just because you can’t speak
Swedish. We had so many questions and so many
things that we were not sure about: how it’s gonna
happen, but everything was explained to us so well and
we didn’t have any doubts.” (Parent 15)

Other experiences revealed the opposite, when no
trust was established between parents and healthcare
professionals, and the communication was clearly
affected.

“She had just started and knew nothing about what we
had done before. That has to be communicated between
the nurses before, I think. Not by us. We knew what was
best for the child, but we sensed that the nurse did not
believe so. I felt that I did not care about her; she only said
something quickly and then disappeared again. I listened
to someone else instead.” (Parent 4)

Analysing silent language/communication

Some parents mentioned that communication is not
only about words. They felt, for example, that they
could tell whether a nurse was attentive when com-
municating by the way the nurse was looking at them
and if eye contact was established. Different types of
body language were important for the parents to
decide whether they liked the nurse or not, which
had significance in terms of whether or not they
trusted the nurse.

“We talked like usual, like we talked with the others. But
it felt as if she was standing aside and talked just a little
and then left from there. In the beginning, she came
with someone else, but every time when she came
alone this happened; she was not comfortable some-
how.” (Parent 4)

Other parents explained that they were more likely to
feel understood if the person they were communicat-
ing with acted in an attentive way, that this helped to
make communication positive. They also explained
that they felt happier and calmer when staff helped
out with more than they were obliged to, for example,
by providing a sandwich if they noticed that the
parents had not eaten for a long time.

“It is not easy to talk if you feel that someone is
annoyed at you . . . One nurse was good . . . she helped
me so that I could have him in my arms, even though
he was getting his light treatment . . . To bring the
lamps for me and do some things that were kind of
extra, not only what was convenient for them (the staff)
but also taking what I want into account. With com-
passion you come far when you don’t understand each
other.” (Parent 13)

Other parents indicated that some silent communica-
tion is similar in all languages.

“There are certain things that are similar in all lan-
guages when it comes to body language and signs;
for example, when they told me to wait or explained
to me that it was time for breastfeeding, these kinds of
things I could understand when they were instructing
me.” (Parent 12)

Having expectations

Parents revealed that when they knew they were
scheduled to have an information meeting at the
NICU that included an interpreter, they did not sleep
well the night before as they had expectations and
enquiries before the meeting. They expressed that
when an interpreter was booked, they expected that
the information was going to be important. Therefore,
it was possible that misunderstandings could arise
that may be difficult to deal with. Parents also
expressed that they felt powerless regarding how
the healthcare professionals would provide the infor-
mation—whether it would be given with or without

INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 7

an interpreter, or with or without pictorial support.
Parents did not feel comfortable asking about how
the information would be provided, and they did not
feel that they had the right to make that kind of
request. Further expectations among parents included
assumptions that healthcare professionals could
speak English along with more general thoughts
around health care, such as that there may be delays
due to staff shortages or that they might have to
speak up in order to be listened to.

“Sometimes it feels like if you don’t insist, they can be
a bit ignorant or not take things seriously. What I mean
is that if you can communicate and stand up for your-
self, they will listen better to you, and of course the
language matters in this matter too.” (Parent 12)

Other parents revealed that they were surprised
about the great health care provided to their child
since their own health had not been taken care of
since their arrival to Sweden because they had not yet
attained legal resident status.

Main interpretation and discussion

When parents were asked about their general experi-
ence regarding communication with healthcare pro-
fessionals during their child’s hospitalization at the
NICU, most indicated that they were very satisfied.
Despite this, parents also revealed distressing experi-
ences caused by misunderstandings in communica-
tion. Parents expressed that they felt calm when
healthcare professionals were comforting them, and
this could possibly have contributed to the overall
positive experience of communicating with health-
care professionals. Similar findings were made in
another Swedish study about experiences of commu-
nication with pictorial support among children aged 7
to 13 (Benjaminsson & Nilsson, 2016). Even though
the study was based on Swedish-speaking children,
the similarities regarding feeling a sense of encour-
agement, trust and confidence were striking, consis-
tent with the adult non-Swedish-speaking parents in
this study. In both studies, the participants thought
that it was reassuring when healthcare professionals
were saying that all would be well and that they
shouldn’t worry about the medical procedures. The
information that was given to participants in the
study conducted by Benjaminsson and Nilsson
(2016) helped the children to calm down (a.a).
Parents in the current study explained situations
where they had different stressful perceptions about
their child’s condition. When a healthcare professional
refuted these assumptions, the parents felt relieved.
Thus, the barriers to communication were first experi-
enced as parents worried about their child, but when
they were informed about their child’s ongoing

medical treatment, they could let go of their worries
and were more amenable to communication. Parents
mentioned that it was more likely to establish good
communication if they felt that the healthcare staff
acted in an attentive way. The results from a study in
Switzerland explains that nurses felt frustrated when
they were not able talk to patients but only comfort
them in other ways (Kaufmann et al., 2020). Present
study establish that this kind of comfort is valuable to
enable trust and well-functioning communication.

In our study had not all participants been exposed
to the pictorial support distributed within the project
KomHIT Refugee (2018). There might be different
explanations for this according to a study that aimed
to investigate the early implementation process of
pictorial support in neonatal care from a healthcare
professional’s perspective (Blom et al., 2019). Even
though the healthcare professionals were motivated
to use the pictorial support and experienced a great
need for it, the results revealed that education and
having someone formally in charge is an important
part of making the implementation successful (a.a).
Considering both the context and year of the above-
mentioned study, it is very likely that these reasons
would be applicable to the present study as well.

The parents explained that when one or both
partners had not yet obtained asylum, this would
be a stressful factor that could affect communica-
tion. This might be because these participants are
more likely to have lower health literacy compared
to those who have obtained asylum. Limited health
literacy amongst asylum seekers is described in
a review article of qualitative studies; healthcare
provision might be challenging when there are dif-
ferent understandings of health, illness and health
care (Robertshaw et al., 2017). Healthcare concepts
such as preventative care were also described as
sometimes unfamiliar, making patients that are asy-
lum seekers prone to missing appointments (a.a).
Similar findings in the present study indicated that
parents did not understand why they were sent
messages to come to the hospital for follow-up
treatment when they felt that their child was well
and healthy. They explained that they did not under-
stand why they had to go back to the hospital.
Therefore, knowledge and understanding about the
cultures of refugees and asylum seekers are viewed
as important facilitators in cross-cultural care
(Robertshaw et al., 2017).

Parents in the present study described stressful
situations when they were told by healthcare profes-
sionals to go home for the night. They expressed that
they lived far away from the hospital and felt stressed
about what would happen when they were not with
their child at the hospital. Other stressful factors
might be anxiety about how to get back and forth

8 E.-K. GOTTING ET AL.

between home and hospital when they did not have
an identification number to give should a ticket
inspector ask for identification. This stress before
appointments with healthcare providers could affect
communication, as explained above. Parents in the
present study described feelings of relief when the
healthcare professionals let them stay overnight.
According to Robertshaw et al. (2017), one way to
facilitate a trusting relationship between patients
that are asylum seekers and healthcare professionals
is for healthcare professionals to assist the patients
with their wider needs, such as by enabling the par-
ents to stay with their child at the hospital overnight if
needed (a.a). This is similar to the findings of this
study, where the parents described a good healthcare
relationship as a factor that affects the communica-
tion with healthcare professionals when language
barriers exist.

The parents did not feel that they had the right to
ask whether or not the pictorial support would be
used or if an interpreter would be booked. They
claimed that this decision was in the hands of the
healthcare professionals. This can be discussed as
a consequence of low health literacy amongst partici-
pants who are not aware of their rights, but also as
a failure of healthcare professionals in meeting the
patients’ needs to understand their right to informa-
tion. According to results from a Swedish study nurses
tend not to be trained in using interpreters (Jungner
et al., 2021). If healthcare professionals, specifically
nurses, are to take a key role in helping migrants
acquire health literacy, it is important to consider
the changes to clinical best practices that would be
required to strengthen both the level of health and
legal literacy for migrants and also the pedagogical
skills of nurses (Vissandjée et al., 2017). Some parents
in the present study experienced that they felt more
confident in expressing themselves when visiting
health care outside hospital. This might be the result
of having spent more time in the country and not
having to face as stressful health care as at the NICU,
and therefore having higher health literacy and being
more communicatively adaptable, but it may also be
a result of the nurses having more time in non-acute
outpatient clinics to take a more pedagogical role
(a.a).

Methodological reflections
Some parents wanted a professional interpreter pre-
sent during the interview but indicated that one of
the partners always acted as the interpreter during
the hospitalization at the NICU. Other parents wanted
an interpreter during the interview but told the
author that during hospital visits they did not use
interpreters. A possible reason for this is that when
it comes to deeper conversations there is greater

need to speak in their mother tongue. Parents
expressed feelings of frustration, even during the
interviews, that they were not able to speak in their
mother tongue since they felt sometimes that the
interpreter was not interpreting correctly. Some par-
ents wanted an interpreter on the phone because
they didn’t want to have a lot of visitors in their
home at the same time, while other parents preferred
not to have an interpreter at all but wanted to carry
out the interviews in English. When the interviews
were in English, and no interpretation was done, the
length of the interviews was rather long compared to
others. This might indicate that when the author and
the parents speak the same language, it is likely that
both parties feel freer to speak directly to each other
and greater communication is enabled. When speak-
ing the same language, even though it is neither the
author’s nor the parents’ first language, the possibility
for a parent to interrupt a question and lead the
conversation in another direction is greater. All par-
ents were offered an interpreter. When it became
clear that the desire to have an interpreter present
differed from parent to parent, the author chose to let
the parents decide for themselves. The author consid-
ered that this could have affected the study, but not
necessarily in a negative way. Most importantly, the
parents had to feel comfortable with how the inter-
view was being conducted, otherwise, the absence of
comfort would likely have greater negative effects on
the study.

Difficulties with qualitative content analysis
include different ways of interpreting the data, and
the probability that the interpretation will be influ-
enced by who is reading the text and analysing the
data (Graneheim & Lundman, 2004). There are limita-
tions in this study since there were fewer possibilities
to collect additional data due to language barriers.
For the same reason, it was difficult for the author to
establish member checks, where the parents review
the interviews and the analysed data. Member check-
ing is done to fulfil credibility as one of the compo-
nents to achieve trustworthiness in qualitative
studies, as described by Guba and Lincoln (Polit &
Beck, 2016). Thus, the author strove for credibility
through triangulation by asking the same questions
to all parents in the study. A semi-structured inter-
view guide was used to keep the focus on credibility
and the aim of the study throughout the interview
sessions. Other components to achieve trustworthi-
ness in qualitative studies are transferability, depend-
ability and confirmability. The parents in the study are
described in order to achieve transferability to other
studies in the research subject field. Quotes from
different parents are represented in the study to
show dependability. It was a challenge for the author
of this study to enable confirmability, meaning to let
the data speak for itself. The author strove to enable

INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 9

her own perspective from the data collection without
giving meanings for subjects that were not included
in the data. In order to achieve these perspectives, all
of the study authors made their own interpretations
of the data followed by discussions together that
formed the data analysis.

The parents, when they were participating in the
study, were no longer parents with children at the
NICU, but observational studies looking at the actual
care meetings between healthcare professionals and
parents when language barriers exist would be of
significance when further evaluation is done regard-
ing the use of pictorial support.

Conclusions

The present study sheds light on the challenges per-
taining to communication within neonatal health care
where language barriers exist. The parents described
the communication as stressful and that misunder-
standings were common. When a trustful relationship
between the health care professionals and the parents
were established, this was described to enable less
feelings of isolation and anxiety and made the parents
feel calmer. When pictorial support was used this
increased understanding and decreased risks of misun-
derstanding. This study is the first to evaluate parents’
perspective from pictorial communication support dis-
tributed within the project KomHIT Flykting.

Acknowledgements

The authors thank all the staff and parents who participated
in the study. The authors also thank Kimberly Manalili for
help with translation of the manuscript.

Authors’ contributions

All authors, E-KG, UF and HW contributed to all stages of the
research, from planning to the final manuscript, except for
the data collection and the transcribtions, which was per-
formed by E-KG.

Disclosure statement

No potential conflict of interest was reported by the
author(s).

Funding

Funding for this article was obtained from the Department
of Research and Development, Angereds Hospital, Region
Västra Götaland. The study was also part of the evaluation
of the project KomHIT Flykting which was conducted at Dart
– Center for Augmentative and Alternative Communication
(AAC) and Assistive Technology (AT) at Sahlgrenska
University Hospital. KomHIT Flykting received government
funding allocated for handling the refugee situation in

Sweden, through the Regional Executive Committee,
Region Västra Götaland..

Notes on contributors

Eva-Karin Gotting, Paediatric Nurse, Institute of Health and
Care Sciences, Sahlgrenska Academy, University of
Gothenburg, Arvid Wallgrens Backe, Box 457, S-405 30
Gothenburg, Sweden. Angereds Närsjukhus, Halmtorget 1,
42422 Angered, Sweden.

Ulrika Ferm, PhD, SLP, Sahlgrenska University Hospital,
DART Centre for Augmentative and Alternative
Communication and Assistive Technology, Kruthusgatan
17, S-411 04 Gothenburg, Sweden.

Helena Wigert, Associate Professor, RN, MSc, PhD, Institute
of Health and Care Sciences, Sahlgrenska Academy,
University of Gothenburg, Arvid Wallgrens Backe, Box 457,
S-405 30 Gothenburg, Sweden.

ORCID
Eva-Karin Gotting http://orcid.org/0000-0001-7485-6715
Ulrika Ferm http://orcid.org/0000-0002-0631-1163
Helena Wigert http://orcid.org/0000-0002-1615-1925

References

Benjaminsson, M. V., & Nilsson, S. (2016). Experiences of
communication in the caring process by children aged
7-13 where there is a requirement for nitrous oxide for
needle related procedures. Clinical Nursing Studies, 5(1),
2324–7959. https://doi.org/10.5430/cns.v5n1p13

Blom, Å., Ferm, U., Karlsson, M., Nilsson, S., & Thunberg, G.
(2019). Implementation of pictorial support for communica-
tion with people who have been forced to flee: Experiences
from neonatal care. Journal of Child Health Care, 23(2),
311–336. https://doi.org/10.1177/1367493518819210

Coyne, I., Hallström, I., & Söderbäck, M. (2016). Reframing the
focus from a family-centred to a child-centred care approach
for children’s healthcare. Journal of Child Health Care, 20(14),
494–502. https://doi.org/10.1177/1367493516642744

Graneheim, U. H., & Lundman, B. (2004). Qualitative content
analysis in nursing research: Concepts, procedures and
measures to achieve trustworthiness. Nurse Education
Today, 24(2), 105–112. https://doi.org/10.1016/j.nedt.
2003.10.001

ICOON for refugees. (2021). Retrieved January 23, 2021, from
http://icoonforrefugees.com/

Jungner, J. G., Tiselius, E., & Pergert, P. (2021). Reasons for
not using interpreters to secure patient-safe communica-
tion – A national cross-sectional study in paedtiatric
oncology. Patient Education and Counseling, 104(8),
1985–1992. https://doi.org/10.10/16/j.p.2021.01.017

Kaufmann, B., Helfer, T., Pedemonte, D., Simon, M., &
Colvin, S. (2020). Communication challenges between
nurses and migrant paediatric patients. Journal of
Research in Nursing, 25(3), 256–274. https://doi.org/10.
1177/1744987120909414

KomHIT Refugee. (2018). KomHIT: Kommunikationsstöd
i vårdsituationer [Supporting communication in health-
care situations]. Available at: www.kom-hit.se/flykting/
(accessed 17 November 2019).

10 E.-K. GOTTING ET AL.

Kroening, A. L. H., Moore, J. A., Welch, T. R., Halterman, J. S.,
& Hyman, S. L. (2016). Developmental screening of refu-
gees: A qualitative study. Pediatrics, 138(3), 1–11. https://
doi.org/10.1542/peds.2016-0234

Meppelink, C., Smit, E. G., Buurman, B. M., & van
Weert, J. C. M. (2015). Should we be afraid of simple
messages? The effects of text difficulty and illustrations
in people with low or high health literacy. Health
Communication, 30(12), 1181–1189. https://doi.org/10.
1080/10410236.2015.1037425

Patriksson, K., Berg, M., Nilsson, S., & Wigert, H. (2017).
Communicating with parents who have difficulty
understanding and speaking Swedish: An interview
study with health care professionals. Journal of
Neonatal Nursing, 23(6), 248–252. https://doi.org/10.
1016/j.jnn.2017.07.001

Patriksson, K., Nilsson, S., & Wigert, H. (2019). Conditions
for communication between health care professionals
and parents on a neonatal ward in the presence of
language barriers. International Journal of Qualitative
Studies on Health and well-being, 14(1), 1652050.
https://doi.org/10.1080/17482631.2019.1652060

Polit, D. F., & Beck, C. T. (2016). Nursing research: Generating
and assessing evidence for nursing practice (10th ed.).
Wolters Kluwer.

Robertshaw, L., Dhesi, S., & Jones, L. L. (2017). Challenges
and facilitators for health professionals providing primary
healthcare for refugees and asylum seekers in
high-income countries: A systematic review and thematic
synthesis of qualitative research. British Medical Journal
Open, 7, e015981. https://doi.org/10.1136/bmjopen-2017-
015981

Stephen, J. M. (2021). Pediatric nurses’ experiences in caring
for non-English speaking patients and families. Journal of
Transcultural Nursing, 32(6), 690–696. https://doi.org/10.
1177/1043659620986607

Swedish Statute. (2017). Swedish Statute (Svensk
författningssamling) Hälso- Och Sjukvårdslagen [Health
Care Act], vol. 30, Socialdepartementet, Stockholm (2017).

Vissandjée, B., Short, W. E., & Bates, K. (2017). Health and legal
literacy for migrants: Twinned strands woven in the cloth of
social justice and the human right to health care. BMC
International Health and Human Rights, 17(10). https://doi.
org/10.1186/s12914-017-0117-3. ISSN: 1472-698X.

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Taher et al.
International Journal of Emergency Medicine (2022) 15:62
https://doi.org/10.1186/s12245-022-00464-y

ORIGINAL RESEARCH

Improving safety and communication
for healthcare providers caring for SARS-COV-2
patients
Ahmed Taher1,2* , Peter Glazer1,3, Chris Culligan1,3, Stephanie Crump1, Steven Guirguis1, Jennifer Jones1,
Alia Dharamsi1,2 and Lucas B. Chartier1,2

Abstract

Background: Decreasing healthcare provider (HCP) exposure to the severe acute respiratory syndrome coronavirus
2 (SARS-COV-2) virus in emergency departments (EDs) is crucial. Approaches include limiting the HCP presence and
ensuring sealed isolation rooms, which can result in communication difficulties. This quality improvement (QI) initia-
tive aimed to decrease by 50% duration of isolation room door opening and increasing HCP-perceived communica-
tion clarity by one point on a five-point Likert scale.

Methods: This was a prospective, multi-stage project with three Plan-Do-Study-Act (PDSA) cycles between May and
July 2020: (1) an educational intervention, (2) the introduction of a novel transceiver communication device, and (3)
utilizing a clinical champion. Statistical Process Control XbarR charts were used to assess for special cause variation,
and two-tailed Mann-Whitney U tests were used for statistical significance between Likert survey means. Qualitative
responses underwent thematic analysis.

Results: Observation of 174 patient encounters was completed over 33 days, with 95 meeting the inclusion crite-
ria. Door opening decreased from baseline (n=40; mean 72.97%) to PDSA 3 (n=21; mean 1.58%; p<0.0001). HCP-
perceived communication clarity improved from baseline (n=36; mean 3.36) to PDSA-3 (n=49; mean 4.21; p<0.001).
Survey themes included positive effects on communication and workflow, with some challenges on the integration
of the new device into the clinical workflow. HCP-perceived errors, workarounds, and workflow pauses showed signifi-
cant improvements.

Conclusion: This QI initiative with a novel transceiver showed significant decreases in isolation room door opening
and increases in communication clarity. Future work will expand to operating rooms and intensive care units.

Keywords: Patient safety, Healthcare providers, Safety, SARS-CoV

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Background
The severe acute respiratory syndrome coronavirus
2 (SARS-COV-2) pandemic has caused over 173 mil-
lion cases worldwide, with over 3.7 million deaths, by
June 2021 [1]. Healthcare provider (HCP) infections are
thought to comprise a notable proportion of these cases
[2]. The emergency department (ED) is a high-risk set-
ting of exposure to SARS-COV-2, especially given the
performance of aerosol-generating medical procedures

Open Access

International Journal of
Emergency Medicine

*Correspondence: [email protected]

2 Department of Medicine, Division of Emergency Medicine, University
of Toronto, C. David Naylor Building, 6 Queen’s Park Crescent West, Third Floor,
Toronto, ON M5S 3H2, Canada
Full list of author information is available at the end of the article

Page 2 of 8Taher et al. International Journal of Emergency Medicine (2022) 15:62

(AGMPs) such as endotracheal intubation [3]. There-
fore, EDs have sought to follow international guidance
on personal protective equipment (PPE) practices [4],
increase isolation rooms [5], utilize dedicated intuba-
tion teams [6] [7], increase the use of ED telemedicine
[8], and implement updated resuscitation guidance [9].

Patients with SARS-COV-2 requiring intubation [10]
represent a risk to HCPs [11] given the potential aero-
solization of the virus [12]. The risk is increased, in part
because of the duration of exposure and proximity to
the patient increase [13]. Therefore, it is important to
minimize the door opening of AGMP patients, which
may transmit aerosolized material and to minimize
the number of HCPs present inside isolation rooms. It
is also necessary to minimize doffing and re-donning
of PPE, which produces self-contamination risks and
over-use of resources [14].

Given the importance of maintaining closed isolation
room doors, it is important to continue clear commu-
nication between HCPs across closed doors. This pre-
sented multiple challenges for our ED during the first
wave of the pandemic, which prompted multiple in situ
simulation exercises [15] to prepare HCPs and increase
safety practices with AGMPs. A variety of communi-
cation methods across the closed doors were trialed,
including a “call bell” system (paging the nurse desk),
a whiteboard and marker through glass windows, and
finally a commercial baby monitor system, which was
in use  during our baseline period. Communication
remained the most common challenge cited in debriefs
after ED resuscitations.

Given the communication challenges across isolation
rooms along with the risks of the continued door open-
ing and potential doffing and re-donning, we conducted
a quality improvement (QI) initiative with the aim to
decrease isolation room door opening and improve
HCP communication clarity.

Methods
Study setting
Toronto General Hospital (TGH) is a quaternary care
adult academic 371-bed medical center part of the Uni-
versity Health Network in Toronto, Ontario, Canada.
TGH is a referral center for SARS-COV-2 critically ill
patients. The ED sees approximately 55,000 patients
per year. The TGH ED has 24 beds in the acute zone,
of which 17 are isolation rooms. Isolation rooms have
glass doors with curtains outside them (for privacy) or
anterooms leading to the patient room. Baseline com-
munication with the outside team was through door
opening or by using a commercial baby monitor system.

Participants
Our HCP participants consisted of ED nurses, physi-
cians, and trainees on shift during the data collection
period. Patient encounters were included if the patient
was greater than 16 years old, placed in an isolation
room, and met any of the potential infectious symp-
toms for SARS-COV-2 (Additional file 1: Appendix 1),
regardless of presentation acuity.

Study design
This QI initiative was completed in a prospective,
multi-stage approach consisting of a baseline period
and three discrete Plan-Do-Study-Act (PDSA) cycles.
The SQUIRE 2.0 Guidelines were used for study design
and reporting [16]. We received a formal exemption
from our organization’s research ethics board. We were
supported by a local grant: The Mount Sinai Hospital
– University Health Network (MSH-UHN) Academic
Medicine Organization COVID-19 Innovation Grant.

Interventions
An initial period of stakeholder engagement was
undertaken at daily nursing huddles and ED physician
business meetings, which helped devise three sequen-
tial PDSA cycles. PDSA-1 was an educational inter-
vention, whereby HCPs were educated about the need
and rationale for closing isolation room doors through
email and daily departmental huddles.

Given the limitations of educational interventions,
concurrent search was done for a better informa-
tion communication technology (ICT). PDSA-2 was
the introduction of an ICT developed by a co-author
(CC) called the TQC 200 “the transceiver” [17]. The
transceiver was initially developed for use in sports
but was adapted to our local ED setting to replace the
existing use of the commercial baby monitor system.
The transceivers are wireless radiofrequency wearable
paired headsets that allow for two-way uninterrupted
communication across closed isolation room doors
(Fig. 1). HCPs entering an isolation room would wear
one transceiver headset as part of the PPE donning
process, and the remaining team members would wear
paired transceiver headsets. Team members would
then be able to talk to each other freely without push-
ing any buttons. Devices would be disinfected accord-
ing to approved infection prevention and control
protocols and plugged in to recharge in between use.
PDSA-3 was mainly to embed and sustain the change
that was noted. It included a local clinical champion
(registered nurse) who was identified to demonstrate,
remind, and support nurses and physicians in their use
of the new technology available. During this phase,

Page 3 of 8Taher et al. International Journal of Emergency Medicine (2022) 15:62

further refinement of the transceiver was also made
based on ongoing clinician feedback.

Data collection
A dedicated research coordinator (SG; not involved
in transceiver development) directly observed patient
encounters that met the inclusion criteria throughout
the baseline period and PDSA cycles. The total number
of minutes HCPs spent during a clinical encounter (an
episode of going into the room until exiting it) and the
total number of minutes of door opening during that
encounter were recorded. Data collection consisted of a
convenience sample that occurred during research coor-
dinator availability, between 09:00 and 15:00 on week-
days, between May and July 2020.

Baseline surveys were distributed to nursing staff and
included quantitative (Likert scale) and qualitative (two
open-ended questions) portions. Following the con-
clusion of PDSA 3, a follow-up survey was collected
(Additional file  1: Appendix  2). Likert scale surveys
included rating communication clarity, communication
errors, the need for opening isolation doors to commu-
nicate, using other means to communicate (e.g., hand
gestures, whiteboard), or having to alter clinical work-
flow to communicate adequately. The follow-up survey
included questions comparing the baby monitor system
to the transceiver. Finally, open-ended questions were
asked about the team’s communication approach. Sur-
veys were collected in the ED during HCP shifts. All
surveys were developed locally and piloted with a sam-
ple of HCP prior to administration. Transceiver-specific

qualitative data was collected during PDSAs 2 and 3 to
allow for rapid improvements during the corresponding
PDSA cycle.

Outcome and balancing measures
The primary outcome measure was the duration of the
isolation room door opening, which was the percentage
of time the isolation room door was left open between
the HCP(s) entering and exiting the room for that cor-
responding patient encounter. Our aim was to decrease
isolation room door opening by 50% over a period of 3
months. Our secondary outcome measure was HCP-
perceived communication clarity across closed isolation
room doors. This was measured using a Likert scale sur-
vey. Our aim was to increase HCP-perceived communi-
cation clarity using an ICT by one point on a five-point
Likert scale over a period of 3 months.

Our balancing measures were HCP-perceived com-
munication errors across the closed isolation room
door during patient encounters, perceived use of worka-
rounds across the closed door (e.g., hand gestures), and
HCP pausing their workflow to communicate with team
members outside rooms (all using a Likert scale). We also
measured the percentage of patients seen in the ED who
were placed in isolation rooms, i.e., failed triage screen
presenting with one or more infectious symptoms to
monitor the infectious landscape.

Data analysis
We utilized Statistical Process Control ([SPC] or
Shewhart) XbarR charts [18] to assess for special cause
variation. SPC charts were completed with QI Macros©
(Version 2018.04, KnowWare International Inc., Denver,
CO, USA) for Microsoft© Excel© (Microsoft Corporation,
Redmond, WA, USA, Version 14.5.9). Centerline calcula-
tion utilized formulae [19] and control limits utilized rules
recommended by the Institute for Healthcare Improve-
ment [20]. Four discrete periods of data were collected
(baseline and three PDSA cycles). For the baseline and
follow-up surveys, we used a two-tailed Mann-Whitney
U test to assess for statistical significance between means,
with a significance level set at p<0.05. The qualitative
(open-ended questions) underwent thematic analysis [21].

Exclusion criteria for points used to create the SPC
charts included: subgroups with less than three data
points according to accepted rules [22], patients who
passed the triage infectious assessment (no infectious
symptoms reported), patient interactions lasting less
than 5 min (chosen as a minimum to include meaningful
clinical interaction), and patient interactions when HCP
were discharging patients from the ED (e.g., disconnect-
ing from monitors and patient leaving).

Fig. 1 Transceiver headset

Page 4 of 8Taher et al. International Journal of Emergency Medicine (2022) 15:62

Results
Direct observation of 174 patient encounters was
completed over 33 days. Ninety-five encounters were
included in the final analysis, while 79 met exclusion
criteria and were removed from the analysis (38 did not
fail the infectious screen; 25 encounters were less than 5
min; 16 subgroup days had less than three data points).
Door opening (primary outcome) increased from base-
line (n=40) with a mean of 72.97 to 96.93% in PDSA-1
(n=28; p=0.04). Then, there was a statistically signifi-
cant decrease as compared to the baseline in PDSA-2
(n=6; mean 1.58%; p<0.001) and in PDSA-3 (n=21; mean
1.47%; p<0.0001). The primary outcome across the study

period is illustrated in the SPC chart shown in Fig. 2. The
baseline period and PDSA-1 met the criteria for special
cause variation, i.e., a possible external influence of the
system that would need investigation. An improvement
was noted by PDSA-2 and 3, with no further special
cause variation.

The themes that emerged from the baseline nurs-
ing staff qualitative survey (when HCPs were using
baby monitors) were varied (Table  1). Positive find-
ings included the facilitation of isolation door closure,
increased HCP safety, and some positive effects on com-
munication. Negative effects pertained to workflow and
difficulty with the quality of communication, and they

Fig. 2 Isolation door opening XbarR statistical process control chart. CL center line; UCL upper control limit; LCL lower control limit; PDSA
Plan-Do-Study-Act; medians are adjacent to the control limits

Table 1 Qualitative responses during baseline period

Facilitation of isolation door closure
“Allowed room door to remain closed”

Increased healthcare worker safety
“Allows the team to minimize exposure to potentially infected COVID patients”

Positive effects on communication
“The clarity and quality of communication with the baby monitors is satisfactory most of the time”

Challenges with workflow
Proximity to device: “Person has to be close to the baby monitor in order to hear orders”
Lack of portability: “Having to walk to the baby monitor to speak into it”
Multiple people taking: “Radio communication ➔ information not being heard if both sides are talking the same time or one side starts talking and
other side has not realized or heard”

Poor quality of communication
Ambient noise: “Hard to hear if lots of background noise or if department is busy”
Poor clarity/static: “Hard to hear. Too much static”
Hardware: “Requires occasionally troubleshooting, sound quality is often poor, especially through mask and shield. Issues with connecting between
monitors”

Page 5 of 8Taher et al. International Journal of Emergency Medicine (2022) 15:62

exceeded the positive findings in both frequency and
intensity.

The qualitative themes identified post-PDSA-3 nurs-
ing staff survey included increased HCP safety, facilita-
tion of door closure, positive communication effects, and
increased patient confidentiality (Table  2). Moreover,
positive effects were noted on workflow including being
hands-free, improved efficiency, and portability. Themes
also included some challenges with the new workflow,
device design, and sound quality with the initial roll-out.

Our secondary outcome of HCP-perceived sound
clarity had a statistically significant improvement on
the Likert survey (5 is best) from baseline (n=36; mean
3.36) to post-PDSA-3 (n=49; mean 4.21; p<0.001). Our
three balancing measures of HCP-perceived errors,
using other means of communication and alterations in
workflow did not show any worsening; in fact, they all
showed statistically significant improvements (Table  3).
The post-PDSA-3 survey also showed the majority of
respondents agreeing or strongly agreeing with utiliz-
ing the transceiver in making care for their patients less
stressful, improved satisfaction with communication,
and improved quality as compared to the previously used
baby monitor (Fig. 3).

Throughout the PDSA cycles, specific feedback was
also obtained to improve the transceiver system and bet-
ter integrate it into the workflow. Feedback and result-
ant actions are illustrated in Table 4. Finally, changes in

patients presenting to the ED who failed the infectious
screen are shown in Additional file  1: Appendix  3 and
appear to show a slow general decline in patients meeting
the criteria as the study period progressed.

Discussion
Our QI project with [1] HCP education, [2] the intro-
duction of the transceiver, and [3] engagement through
a local nurse champion substantially decreased door
opening for infectious patients beyond the apriori
50% aim (primary outcome). Our secondary out-
come also showed a significant improvement, but nar-
rowly missing our a priori one Likert scale point. This
improvement in communication was also supported

Table 2 Qualitative responses after PDSA-3

PDSA Plan-Do-Study-Act

Increased healthcare worker safety/stress
“Being able to have less people in the room during codes which makes it less stressful”

Facilitation of isolation door closure
“Good audio volume. Not needing to open main door. Having members on outside of code room being in communication loop”

Positive effects on workflow
Hands free: “Not having to push any buttons e.g. baby monitor to talk – constant communication (even when in medication room, etc.)”
Efficiency in patient care: “Not having to leave the room. Orders received right away and initiated – no lag time”
Portability: “I was still able to hear the communication inside of the room when I was away to get blood work supplies”

Challenges with workflow
Multiple/different groups of people speaking: “Sometimes people talk at the same time and it can get confusing at times”
Difficulties with others not using transceiver: “Can’t hear people not on transceiver –> maybe have one ear shorter?”
Length of use: “Needs longer battery life for long codes”

Positive effects on communication
Clarity: “Clear communication between members wearing headsets. Range is very good (when in medication room the sound is clear)”
Ambient Noise: “Can hear everyone clearly. No background noise.”

Increased patient confidentiality
“Definitely better than baby monitors in terms of patient confidentiality because people outside the room need not to shout for clearer communica-
tion”

Challenges with device design
“Uncomfortable after sometime”

Challenges with communication quality
“Sometimes the sound quality was not the best but improved with the new set”

Table 3 Baseline and post-PDSA-3 nurse Likert survey

PDSA Plan-Do-Study-Act; Survey Items correspond to Appendix 2

Measure Survey item Baseline
mean
(n=36)

Post-PDSA 3
mean (n=49)

P value

Outcome Communication
clarity

3.36 4.21 <0.001

Balancing Errors 2.61 2.13 0.026

Balancing Door opening 3.00 2.06 <0.001

Balancing Workarounds 3.89 2.46 <0.001

Balancing Alerting workflow 4.08 2.21 <0.001

Page 6 of 8Taher et al. International Journal of Emergency Medicine (2022) 15:62

by qualitative feedback, which demonstrated a positive
experience with the transceiver as a communication
device. While there have been many reports of frontline
HCPs using baby monitors in the ED [23], operating
room [24], and intensive care units [25], our qualita-
tive surveys revealed substantial problems with their
use pertaining to communication clarity and workflow,
especially in high-acuity situations when they are even
more important for safe patient care.

The special cause variation in the baseline period
(Fig.  2) coincided with the addition of new curtains
placed in front of isolation room glass doors, which
was organized by ED leadership and was unrelated to
the conduct of our project. As a result of this increased
privacy, HCPs often kept the glass doors open, thereby
posing a potential risk to others. A significant decrease
in door opening was noted after the introduction of the
transceiver by PDSA-2, and it was maintained through
PDSA-3. A search for potential confounders leading to

this notable decrease such as a new local policy, incen-
tive, or critical incident did not reveal any contributors.

The educational intervention was not noted to have a
difference on decreased door opening, but we posit it may
have helped prime the participants towards further PDSA
cycles along with the transceiver introduction. Moreover,
we leveraged a local nurse champion in PDSA-3 to further
support and coach HCPs in keeping with the technology
acceptance model [26]. While this was anecdotally appre-
ciated, a further change was not captured on the SPC
chart given the already low values by PDSA-2.

We coupled the introduction of the transceiver with
ongoing feedback. The introduction of (ICT) into a com-
plex work ecology such as in the ED necessitates ongoing
stakeholder engagement and feedback, also referred to as
participatory design [27]. This feedback led to ongoing
improvements in design and use as illustrated in Table 4.
Moreover, key factors that enable the successful adoption
and integration of ICTs in healthcare include portability,

Fig. 3 Post-PDSA-3 Likert survey questions. PDSA Plan-Do-Study-Act

Table 4 Feedback and actions for transceiver system improvement

Period Feedback Resultant actions

Baseline period Bulky headsets; casing not robust Changed casing–decreased size of the headset

Foam ear covers (infection control) Eliminated foam ear covers
Staff educated on device cleaning

Large ambient noise Noise cancellation optimization

Add an extra speaker in the room Adding a speaker was not found to be effective

Long wire connecting the headset Removed wire and mounted device on the headset

PDSA 1 Battery life short for long resuscitations Improved battery life to 2 h
Staff educated on device docking and recharging

Static noted Adjusted settings to decrease static and ambient noise

Improve storage and accessibility New storage units placed beside accessible areas in the ED

PDSA 2 Not enough headsets per room for workflow Increased the number of headsets per room to 6 headsets

Casing handling issue Casing upgraded for more robust materials

PDSA 3 Multiple people talking at once Working towards possible 1 ear headset
Working towards simulation exercises integrating headsets
and new communication patterns

Page 7 of 8Taher et al. International Journal of Emergency Medicine (2022) 15:62

user satisfaction, and communicability [28]. The main
focus of the QI approach was to engage relevant stake-
holders at every stage of the project, thereby optimiz-
ing adoption and integration into the workflow. A large
proportion of HCPs found that using the transceiver
decreased their stress during patient care and increased
their satisfaction in communication with team members.

Qualitative surveys also highlighted further improve-
ment opportunities, such as optimizing communica-
tion strategies with multiple team members speaking in
parallel. While allowing continuous communication for
all users (instead of only one at a time like talkie-walkie
push-to-talk systems) facilitated efficient communication,
there was some confusion when multiple people spoke at
the same time, as would be inherent in real-time in-per-
son interactions. To optimize continuous communication
and shared mental models for resuscitation patients [29],
in situ simulation [30] may improve team performance.

Limitations
Our pragmatic QI approach used a convenience sample
based on the research coordinator availability. We also
did not collect patient demographics (to reduce risk to
participants), which may limit generalizability. Moreover,
(CC) who developed the transceiver was not involved in
study design, data collection, and data analysis to miti-
gate conflict of interest. Data collection was done as soon
as patients entered the isolation rooms prior to the per-
formance of infectious illness screening done by nurses,
which led to a proportion of encounters being excluded.
Moreover, we could not identify an adequate validated
survey for our initiative, so a new instrument was devel-
oped to capture important measures instead.

The SPC chart shows special cause variation in the
baseline period. Methodologically, the baseline should
extend until no further special cause variation is noted.
However, a change in practice was noted (the addition of
curtains, leading to greater door opening), which high-
lighted the need to proceed for potential HCP safety. We
elected to continue with PDSA-1 after seeing the follow-
ing week of baseline data stabilize.

Conclusion
Our iterative QI approach with HCP education, trans-
ceiver introduction, and leveraging a local champion dem-
onstrated significant decreases in the door opening and
improvement in communication clarity without increasing
communication errors, workarounds, or alterations in the
workflow. Future work may include scaling this initiative
to other EDs, operating rooms, and intensive care units.

Abbreviations
HCP: Healthcare provider; SARS-COV-2: Severe acute respiratory syndrome –
coronavirus 2; ED: Emergency department; QI: Quality improvement; PDSA:
Plan-Do-Study-Act; AGMPs: Aerosol-generating medical procedures; PPE:
Protective equipment; MSH-UHN: Mount Sinai Hospital – University Health
Network; ICT: Information communication technology; SPC: Statistical Process
Control.

Supplementary Information
The online version contains supplementary material available at https:// doi.
org/ 10. 1186/ s12245- 022- 00464-y.

Additional file 1.

Acknowledgements
We would like to acknowledge Jamie Forest for his contributions to the trans-
ceiver design and Konika Nirmanalathan for her assistance with the project.

Authors’ contributions
AT: study concept and design acquisition of the data, data analysis, manuscript
drafting, and critical revision of the manuscript. PG: study concept and design,
acquisition of funding, and critical revision of the manuscript. CC: intellectual
content, acquisition of funding, and critical revision of the manuscript. SC:
acquisition of the data, data analysis, and critical revision of the manuscript.
SG: acquisition of the data, data analysis, and critical revision of the manu-
script. JJ: study concept and design, statistical expertise, and critical revision of
the manuscript. AD: data analysis and critical revision of the manuscript. LBC:
study concept and design, acquisition of funding, drafting of the manuscript,
critical revision of the manuscript for important intellectual content, and
statistical expertise. The authors read and approved the final manuscript.

Funding
The study was supported by a Mount Sinai Hospital – University Health
Network (MSH-UHN) Academic Medicine Organization COVID-19 Innovation
Grant. The funding body was not involved in the study design, data collection,
analysis, interpretation, or manuscript writing.

Availability of data and materials
The datasets during and/or analyzed during the current study are available
from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate
We received formal exemption from the University Health Network Research
Ethics Board. Given that this was a local quality improvement project with
no patient information was collected and no research assistant interaction
with patients; therefore, the exemption was obtained, and no consent was
collected.

Consent for publication
Not applicable.

Competing interests
CC developed the transceiver [17], and this was adapted for ED use with the
support of the innovation grant. The other authors declare no competing
interests.

Author details
1 University Health Network, 200 Elizabeth Street R. Fraser Elliott Building,
Ground Floor, Room 480, Toronto, ON M5G 2C4, Canada. 2 Department
of Medicine, Division of Emergency Medicine, University of Toronto, C. David
Naylor Building, 6 Queen’s Park Crescent West, Third Floor, Toronto, ON M5S
3H2, Canada. 3 Department of Family and Community Medicine, Division
of Emergency Medicine, University of Toronto, 500 University Avenue, Fifth
Floor, Toronto, ON M5G 1V7, Canada.

Page 8 of 8Taher et al. International Journal of Emergency Medicine (2022) 15:62

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Received: 18 October 2021 Accepted: 23 October 2022

References
1. COVID Dashboard by the center for systems science and engineer-

ing at Johns Hopkins University. https:// coron avirus. jhu. edu/ map. html
Accessed June 6, 2021.

2. ICN calls for data on healthcare worker infection rates and deaths.
International Council of Nurses. May 6 2020. https:// www. icn. ch/ news/
icn- calls- data- healt hcare- worker- infec tion- rates- and- deaths Accessed on
23 Aug 2020.

3. Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating
procedures and risk of transmission of acute respiratory infections to
healthcare workers: a systematic review. PLoS One. 2012;7(4):e35797.

4. World Health Organization. Rational use of personal protective equip-
ment for coronavirus disease 2019 (COVID-19). Published February 27,
2020. https:// apps. who. int/ iris/ bitst ream/ handle/ 10665/ 331215/ WHO-
2019- nCov- IPCPPE_ use- 2020.1- eng. pdf Accessed 23 Aug 2020.

5. Wee LE, Fua TP, Chua YY, et al. Containing COVID-19 in the emergency
department: the role of improved case detection and segregation of
suspect cases. Acad Emerg Med. 2020;27(5):379–87.

6. Yao W, Wang T, Jiang B, et al. Emergency tracheal intubation in 202
patients with COVID-19 in Wuhan, China: lessons learnt and international
expert recommendations. Br J Anaesth. 2020;125(1):e28–e3.

7. Sorbello M, El-Boghdadly K, Di Giacinto I, et al. The Italian coronavirus dis-
ease 2019 outbreak: recommendations from clinical practice. Anaesthesia.
2020 Jun;75(6):724–32.

8. Turer RW, Jones I, Rosenbloom ST, et al. Electronic personal protective
equipment: a strategy to protect emergency department providers in the
age of COVID-19. JAMIA. 2020;27(6):967–71.

9. Brewster DJ, Chrimes NC, Do TB, et al. Consensus statement: Safe Airway
Society principles of airway management and tracheal intubation spe-
cific to the COVID-19 adult patient group. Med J Aust. 2020;16:16.

10. Grasselli G, Zangrillo A, Zanella A, et al. Baseline characteristics and
outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of
the Lombardy Region, Italy. JAMA. 2020;323(16):1574–81.

11. Weissman DN, De Perio MA, Radonovich LJ. COVID-19 and risks posed to
personnel during endotracheal intubation. JAMA. 2020;323(20):2027–8.

12. Simpson JP, Wong DN, Verco L, et al. Measurement of airborne particle
exposure during simulated tracheal intubation using various proposed
aerosol containment devices during the COVID-19 pandemic. Anaesthe-
sia. 2020;19.

13. Wilson NM, Norton A, Young FP, et al. Airborne transmission of severe
acute respiratory syndrome coronavirus-2 to healthcare workers: a narra-
tive review. Anaesthesia. 2020;20.

14. Kwon JH, Burnham CA, Reske KA, et al. Assessment of healthcare worker
protocol deviations and self-contamination during personal protec-
tive equipment donning and doffing. Infect Control Hosp Epidemiol.
2017;38(9):1077–83.

15. Dharamsi A, Hayman K, Yi S, et al. Enhancing departmental preparedness
for COVID-19 using rapid cycle in situ simulation. J Hosp Infect. 2020:13.

16. Ogrinc G, Davies L, Goodman D, et al. SQUIRE 2.0 (Standards for QUality
Improvement Reporting Excellence): revised publication guidelines from
a detailed consensus process. J Contin Educ Nurs. 2015;46(11):501–7.

17. Culligan C., Shellhammer B., (2015). US10250514B2. United States.
Accessed online August 23 2020. https:// paten ts. google. com/ patent/
US201 70171 093A1/ en.

18. Fretheim A, Tomic O. Statistical process control and interrupted time
series: a golden opportunity for impact evaluation in quality improve-
ment. BMJ Qual Saf. 2015;24(12):748–52.

19. Xbar Chart Formulas. QI Macros. https:// www. qimac ros. com/ contr ol-
chart- formu las/x- bar-r- chart- formu la/Accessed 20 Oct 2020.

20. Control Chart rules are used to perform stability analysis. QI Macros. 2019.
Accessed online December 11 2019. https:// www. qimac ros. com/ contr
ol- chart/ stabi lity- analy sis- contr ol- chart- rules/ Accessed 20 Oct 2020

21. Charmaz K, Belgrave LL. Grounded theory. The Blackwell encyclopedia of
sociology; 2007. p. 15.

22. Provost LP, Murray S. The health care data guide: learning from data for
improvement: John Wiley & Sons; 2011 Oct 4.

23. St. Joe’s turns to baby monitors to communicate during COVID-19
pandemic. Hamilton. CBC News. April 29 2020. https:// www. cbc. ca/ news/
canada/ hamil ton/ baby- monit ors- covid- 19-1. 55488 23 Accessed 2 Nov 2020.

24. Hospital Staff use Baby Monitors to communicate. Misericordia operating
room adds two-way technology to enhance safety. The vital beat Jun 8
2020. https:// www. thevi talbe at. ca/ news/ hospi tal- staff- use- baby- monit
ors- commu nicate/ Accesses 2 Nov 2020.

25. Baby monitors in the ICU: nurses get creative to save lives, critical equip-
ment. ABC news. Aprl 1 2020. https:// abcne ws. go. com/ Health/ nurses-
find- monit or- patie nts- virus- baby- monit ors/ story? id= 69907 152 Accessed
2 Nov 2020.

26. Davis FD. Perceived usefulness, perceived ease of use, and user accept-
ance of information technology. MIS quarterly. 1989;1:319–40.

27. Sjöberg C, Timpka T. Participatory design of information systems in health
care. JAMIA, 1998;5(2):177–83.

28. Chatterjee S, Chakraborty S, Sarker S, et al. Examining the success factors
for mobile work in healthcare: a deductive study. Decis Support Syst.
2009;46(3):620–33.

29. McComb S, Simpson V. The concept of shared mental models in health-
care collaboration. J Adv Nurs. 2014;70(7):1479–88.

30. Petrosoniak A, Auerbach M, Wong AH, et al. In situ simulation in emer-
gency medicine: moving beyond the simulation lab. Emerg Med Australas.
2017;29(1):83–8.

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