INTRODUCTION

Communication is defined as the transfer of knowledge, meanings and feelings through verbal and non-verbal ways^1,2. Communication is the most basic building block of nursing and is a dynamic process that lasts from the moment of first encounter with the patient to the moment of the end of care because nurses cannot fulfill their main roles such as physical care, education, and emotional support without communication^3,4.

It is very important for nurses to have nursing knowledge and experience and also to evaluate individuals holistically so that they can communicate effectively with the individuals for whom they provide care^1,5. Brain tumors, as one of the diseases that may affect the maintenance of life, may lead to different physiological and psychological consequences in individuals. Patients, their families and healthcare team members face a progressive, worsening process⁶. This process extending from diagnosis to treatment is quite tiresome. Furthermore, depending on the region of ​​the brain affected by the tumor, the problems in perception, motor and sensory functions, disability, memory and perception impairment, mental and behavioral problems, speech and communication problems may occur^7,8. Nevertheless, in addition to loss of speech and hearing, the losses in other gesture, mimic and motor functions that support verbal communication in patients with brain tumors cause healthcare team members to have communication difficulties with the patient⁹. The failure of healthcare professionals to allocate enough time for the patients with sensory and motor loss, the lack of information about providing and maintaining non-verbal communication with the patient, the failure to apply visual communication techniques, and the problems arising from the clinical environment make communication with the patient even more negative^1,10,11. On the other hand, the care of neurosurgical patients requires a nurse-centered team approach¹². When the relevant literature is reviewed, it is indicated that nurses mostly have communication difficulties with the patients hospitalized in oncology and neurology clinics, intensive care units, emergency departments, and elderly care clinics and with the patients diagnosed with dementia^11,13,14. Despite the limitations that occur in patients due to brain tumor, effective communication is very important in planning individual needs. In patients with brain tumors, psychosocial interventions are needed to reduce the cognitive effects of the disease and anxiety¹³. To cope with the changes in sensory functions is possible with effective communication and accurate information¹⁵. Although a limited number of studies examining the difficulties experienced by nurses providing care for patients with brain tumors were reached in the literature, no study on the communication difficulties experienced by nurses was found. Therefore, this study was planned to evaluate the communication difficulties experienced by neurosurgical nurses while providing care for patients with brain tumors, and the factors affecting them.

MATERIALS AND METHODS

Study Design

This study is a qualitative study conducted with the interpretative phenomenological analysis method to explain the experiences of nurses working in the neurosurgery clinic on their communication difficulties with patients having brain tumors. Phenomenological studies aim to create a common meaning for individuals with the same experience on a concept or phenomenon. Interpretative phenomenological qualitative studies are a way of interpreting and understanding the experiences of individuals¹⁶. Interpretative phenomenology focuses on the subjective experiences of individuals and groups. This approach aims to reveal experiences¹⁷.

Participants

Ten nurses with at least 2 years of experience in the field of neurosurgery, who worked in a neurosurgery clinic and agreed to participate in the study, were included in the study. While the mean age of nurses was 33.8±6.19 years, 80% of them had bachelor’s degree, the mean working experience was 10.6±6.23 years, and the duration of working experience in the field of neurosurgery was 7.8±7.02 years.

Data Collection

Data were collected using face-to-face, semi-structured in-depth individual interview technique between February and September 2016. The mean duration of the interviews was 50 minutes. Some warm-up questions such as “What are your experiences on communication difficulties with patients having brain tumors?”, “What are the factors affecting your communication difficulties with patients having brain tumors?”, “Which methods do you use to cope with communication difficulties?” and “What are your suggestions for preventing and resolving communication difficulties?” were used to detail the nurses’ experiences. Each interview was recorded, short notes were used for important points during the interview, and the data were written word by word.

Data Analysis

Descriptive statistical methods (mean, percentage) were used in the analysis of the individual characteristics of the nurses. Colaizzi’s seven-step method for data analysis, which is commonly used in phenomenological research, was used for the analysis of the data obtained from the interviews. This method involves the process of understanding and formulating the data and creating theme sets. In order to check the accuracy of the results obtained, they were presented to the participants and their approval was obtained^18-20. After the data were analyzed separately by two researchers, they were shared with other researchers and the themes were finalized by reaching a consensus. After analyzing the data, the emerging themes and comments were shared and verified to ensure their validity and reliability.

Ethical Considerations

Ethical approval from İstanbul University-Cerrahpaşa Clinical Research Ethics Committee (protocol no: 45977, date: 05/02/2016), and permission from the institution where the study was conducted were obtained to conduct the study. Nevertheless, researcher informed the participants about the aim of the study, the roles of the participants, the benefits and possible risks of the study, withdrawal from the study at any time, and the privacy of information. Verbal and written permissions were obtained. In the direct quotations in the results, the nicknames specified by nurses were used instead of their real names. The sound recordings were only listened and written down by the researchers and were not shared with anyone else.

RESULTS

As a result of the data analysis, the results were grouped under 3 sub-headings, including communication difficulties experienced by nurses, coping methods and solution suggestions. 2 main themes related to communication difficulties experienced by nurses, 2 main themes related to coping methods, and 2 main themes for the solution suggestions were determined. The results are discussed and explained in detail below. The main themes and sub-themes of communication difficulties experienced by nurses, coping methods and solution suggestions are presented in Table 1.

Communication Difficulties Experienced by Nurses

In the in-depth individual interviews, two main themes and sub-themes, including the patient-related factors and institutional factors, were determined for the difficulties of nurses with patients having brain tumors. While the sub-themes of individual characteristics of the patient, attitudes of patients’ relatives, patient’s lack of information and patient’s perspective on nursing were determined for the main theme of patient-related factors, the sub-themes of institutional opportunities and collaboration of healthcare team members were determined for the main theme of institutional factors.

Theme 1: Patient-Related Factors

Sub-theme 1: Individual characteristics of the patient

Nurses stated that they had communication difficulties due to the patients’ age, educational status, lack of knowledge of Turkish, psychological state, and the physiological effects of the disease on the individual.

The statements including the experiences of the 2 nurses who participated in the study on the educational levels of patients are as follows;

“Patients think that they know better and what we do is wrong because of their higher education.” (Nickname: Daisy).

“You cannot communicate with those with no education on many issues. They try to do something for their patients as they wish or they don’t understand us. We give information about the nutrition of their patients, they think nothing would happen. For example, I say let’s start nutrition 4 hours after the operation, they ask 10 more people when to feed, other than me.” (Nickname: Cat).

The nurses stated that the patients had communication difficulties because of the lack of knowledge of Turkish. The statements of 2 nurses on this subject are as follows;

“We have a patient in number 2 who does not speak any Turkish. Normally, when I administer the medicine, I ask the patient if he/she is nauseous. I cannot ask it to the patients who do not speak a language, I look at their facial expression. I wonder if their facial expression change.” (Nickname: Sun).

“I have a patient who speaks Arabic, I cannot communicate with my patient.” (Nickname: Rose).

The nurses stated that they had problems such as patients’ introversion, pessimistic mood, anger, fear, anxiety, depressive mood, impaired self-perception, and rejection of treatment due to the psychological effects of the disease, and communication difficulties associated with them. Meeting the expectations of the patients during the treatment process and the reactions of their relatives affect the psychological state of the patients. The statements of the nurses regarding this sub-theme are as follows;

“They are very anxious. They ask about their dressing, when will our dressing be done, do we have medication, when will you give my painkillers? Although we tell them about every treatment, they still ask again and again. Because pain is already a bad thing, and brain surgery is difficult, so of course, they start to ask more and more” (Nickname: Sun).

“Sometimes they do not hear anyone, say something as much as you want, they are in their own world. Say what you want, explain what you want. Whenever something begins to go well, even moving the finger and even a little use of their hand energize them, and they make sense with what we say.” (Nickname: Sun).

“Patients may be disappointed after surgery. Crying crisis, not speaking, patients who can speak, we know they speak, but they do not speak, they do not communicate eye to eye.” (Nickname: Sun).

“One of our patients is depressed because of staying for a long time, he is constantly crying, is conscious but does not speak. Since he has a tracheostomy, he points out his pain with signs, we suggest him to write on paper with movements when he needs toilet, but he does not obey the orders because he is depressed and agitated.” (Nickname: Rose).

“One of our patients is conscious, cannot speak, the patient’s relative is constantly complaining, gets angry with the patient, cannot accept this situation, which affects the patient’s psychology. The patient is always nervous, there was an attempt to attack my friend yesterday, there may be such situations, and of course it affects our motivation.” (Nickname: Freedom).

The nurses who participated in the study stated that they had communication difficulties due to brain tumor-related dysphagia, aphasia, impaired consciousness, presence of tracheostomy, impaired perception, loss of motor and muscle functions, vision, hearing loss, seizure, pain and insomnia. The statements of 2 nurses regarding the physiological effects of the disease are as follows;

“Especially disoriented patients do not accept care. They cannot perceive what we say.”(Nickname: Sun).

“There may be pain, sleep problems, fears about surgery in younger patients.” (Nickname: Rose).

Sub-theme 2: Attitudes of patients’ relatives

The nurses indicated that patients’ relatives caused difficulties in communicating with the patient during the care process. It was determined that conflicts with patients’ relatives made it difficult to maintain the patient’s care and negatively affected communication with the patient. The statements of the nurses on their communication difficulties are as follows;

“When the patient vomits or when the patient has a tendency to sleep, a sudden change occurs, the relatives of the patient are stressed too much, get angry and reflect it to us. They are constantly expecting from us to be with their patient.” (Nickname: Rose).

“Contact isolation was applied in one patient due to the growth of Klebsiella. The relative of the patient thinks that I have infected his patient, and according to my observation, he wants to get revenge against it. With gloves in his hand, he touches our counters, touches the door handle of our room, and argues with us when we warn him. Because when we cannot coordinate the patient’s relatives, we cannot coordinate the situations related to our patient. We have trouble, patient relatives reflect all crises to us and we cannot find a solution.” (Nickname: Rose).

“When we have a patient who does not know his disease, the patient’s relatives say that our patient does not know what happened, please do not reveal it, we told him that he was hospitalized for examination. At first step, we try not to tell the patient about his diagnosis. However, we also tell patient’s relatives that it is not true, we should tell your patient about it. ​By explaining that this process is temporary and that he is here for recovery, we raise the awareness of both the patient and the patient’s relatives and make them sleep more comfortably.” (Nickname: Fish).

“We have problems especially with patient relatives. Many of our chronic patients are unconscious and cannot express themselves. However, patient relatives may prevent us from providing care. They cannot accept the situation. When the care of the patient is left to one person, patient relatives are also sleepless and nervous.” (Nickname: Freedom).

“We may have problems with our patients with tracheostomy. While aspirating, the relatives of the patients may consider that we are drowning the patients and leaving them out of breath. Sometimes they interfere with this situation, so we have problems. If discharge is planned, we should provide training on nutrition and aspiration, they do not want to admit it, they say they can do anything but never be able to perform aspiration.” (Nickname: Cat).

Sub-theme 3: Lack of informing the patient

The nurses indicated that the lack of information was an important factor in their communication difficulties with patients. The statements of a nurse on this issue are given below.

“Physicians do not go into much detail about the patient’s condition, and when the patient has sequelae after surgery, patients and also thire relatives may go against us by shouting why I am in this state or constantly asking for something, and the patients who cannot speak do it with gestures.” (Nickname: Fish).

“Materials are requested during the surgery, and some tools such as tips, blades, microscope materials compatible with the devices are used. These are the necessary materials for a successful operation. These products are unfortunately not covered by health insurance. Patients are therefore required to pay some fees. The patients sometimes have difficulty to understand why these fees are asked to be paid. It is necessary to inform patients and their relatives to the last detail before the surgery. When patients cannot understand these situations, it is up to us to explain it in a way that the patient can understand.” (Nickname: Fish).

Sub-theme 4: Patient’s perspective on nursing

The nurses indicated that the society’s perspective on nursing profession affected them to have communication difficulties. It was determined that the perspective of the patient’s relatives on nursing together with the patient was important in experiencing communication difficulties. The statements of the nurses on this sub-theme are as follows;

“When we say that we have a lot of work right now and will be right there, they immediately respond by stating ‘but my patient is waiting, my patient will stand up’. However, they do not reflect too much stress on doctors as much as they do to us. In fact, they are constantly asking us the questions they should ask them. While some of them value nurses very much, some of them consider nurses simpler, I perceive it. I think that people who have a significant difference in their behaviors towards nurses and doctors have a negative perspective on nurses.” (Nickname: Rose).

“What annoys me the most is that they consider nurses worthless. Some patients think that they can shout, they have everything, they can get angry, nurses have to do all of them. There is not any work on this issue, an also the hospital administration... People think that they have all rights. They think that they can shout to the nurse as they wish. We are so worthless in the eyes of some patients’ relatives, this is what affects me the most (crying).” (Nickname: Freedom).

“Sometimes communication problems with doctors can be reflected to us. We may also have problems with dressings after surgery. They cannot say anything to the doctors about why they pulled the tapes fast while dressings and why they act like that, they feel the need to tell us since they find us closer to them. To be honest, there are also people who I think are saying it sometimes in bad faith, they reflect their problems to us to explain them by stating even the smallest thing they experienced in the hospital, for instance, channels on the TV or having no reception.” (Nickname: Cat).

Main Theme 2: Institution-Related Factors

It was determined that institution-related factors affected nurses to have communication difficulties with patients. For the main theme of institution-related factors, the sub-themes of institutional opportunities and collaboration of healthcare team members were determined.

Sub-theme 1: Institutional opportunities

It was determined that nurses experienced communication difficulties due to patients and their relatives requesting to go to different units outside of the clinic for laboratory and other examinations, questioning and rejecting in case of lack of material and equipment and when the missing materials are met by patients, the delay of treatments or postponement of surgery because of insufficient physical conditions and healthcare personnel, and the lack of interpreter support for patients who did not speak the language. The statements of the nurses on this theme are given below.

 “It is difficult for the relatives of the patients to take care of the chronic patient, to stay with them day and night and to adapt to the hospital conditions. The fact that the laboratory and imaging center are in the main building and we are in a separate building, and the fact that they have to go outside the building for blood samples and other imaging procedures negatively affect our communication. This process also causes us to get more tired in the same way.” (Nickname: Freedom).

“Some materials may not be present due to the terms of purchase from time to time. In particular, it may take time to supply expensive drugs and to complete the consultation process for reported drugs” (Nickname: Fish).

“Recently, we have received interpreter support for a few patients. However, interpreter is not always with you” (Nickname: Sun).

Sub-theme 2: Collaboration of healthcare team members

The nurses stated that the problems experienced in the collaboration of healthcare team members might affect their communication difficulties with the patients. The difficulties related to this theme were determined as physicians’ incomplete information/not informing nurses about the care and treatment processes of patients, failure to provide a professional work environment in cases where auxiliary staff disrupted their duties and responsibilities, and nurses having difficulty and feeling lonely from time to time when there were communication problems with patients and relatives. The fact that nurse received information from the patient when physicians did not inform them was also considered as an important problem. Some statements of the nurses on this theme are given below.

“Sometimes, physicians include the patient in the surgery list, which causes us to learn the patient to be operated late since the lists are not updated quickly. Therefore, it affects the patient’s oral feeding.” (Nickname: Wind).

“Even if you are right you may not be able to speak, we have difficulty in defending ourselves in case of exposure to any form of violence, such as the patient’s condition or working conditions, and experiencing such things makes you feel lonely.” (Nickname: Wind).

Coping Methods

The nurses were asked what coping methods they used when they had communication difficulties with patients. Two main themes and sub-themes, therapeutic and non-therapeutic methods, were determined for coping methods.

Main Theme 1: Therapeutic Methods

It was determined that the nurses who participated in the study mostly used therapeutic methods when they had communication difficulties with their patients. For this theme, the sub-themes of maintaining therapeutic communication, establishment of a therapeutic setting, and meeting the care needs were determined.

Sub-theme 1: Maintaining therapeutic communication

It was determined that the nurses maintained therapeutic communication to deal with cases where they had communication difficulties with patients. In this context, they stated that they used various therapeutic methods to strengthen communication with patients who had difficulties in hearing, speech and perception or in maintaining communication due to psychological reasons. Some statements of the nurses on this sub-theme are given below.

“If the patient cannot speak but write, we ask him to write. If the patient has a partial hearing loss, we try to speak loudly, or if he does not hear at all, we try to understand the expressions by showing the alphabet. The patient with tracheostomy cannot express himself by speaking, but after a while, we communicate by lipreading. If he does not see it, we let him touch because the patient wants to feel safe.” (Nickname: Blue).

“In functionally inadequate patients, we communicate by touching, eye-to-eye communication, and even just with the finger. Each patient has his own communication. We can understand some patients with their finger and others by blinking an eye. Even with his eyebrow, we know which way he will turn.” (Nickname: Sea).

“When patients feel panicked, we try to be revealing to them and we calm them down. Then, we go to the patient and talk to them more. For instance, when the patient has a seizure, we talk to them more and take time to communicate. After a while, their panic reduces, we see that their perspective towards us is also more moderate and their confidence increases.” (Nickname: Rose).

Sub-theme 2: Establishment of a therapeutic setting

It was determined that the nurses coped with communication difficulties by establishing a therapeutic setting and supporting the patients’ self-expression and coping with stress. Accordingly, they indicated that they performed interventions such as supporting the individual’s participation in the care process, orientation to the service, seeking interpreter support for patients not speaking the language, and strengthening communication with the patient’s family/relatives. Some statements on this sub-theme are given below.

“We introduce the service and provide training on service orientation such as mealtime and visitor restrictions” (Nickname: Wind).

“We observe the patient. For instance, does he eat his own food? If he has the strength to hold the spoon and the glass, I say you can shake my hand. I say hold your glass and drink by yourself. When he regains his self-confidence, he relaxes psychologically and communicates better with us.” (Nickname: Sun).

Sub-theme 3: Meeting the care needs

The nurses who participated in the study indicated that they coped with communication difficulties more easily when they met their patients’ care needs. They stated that it was effective to meet their care needs through nursing interventions such as relieving the pain of a patient, performing supportive interventions for sleeping in case of a problem in falling asleep or sustaining sleep, ensuring safety in case of seizures, or providing emotional support when they felt psychologically unwell. The statements of a nurse on this issue are as follows;

“When we support a patient with pain through interventions such as positioning, reducing the lights, and enabling him to listen to music, his trust in us also increases and our communication gets stronger.” (Nickname: Sea).

Main Theme 2: Non-Therapeutic Methods

It was observed that nurses sometimes used non-therapeutic methods along with the therapeutic methods when they had communication difficulties. It was determined that when the nurses had communication difficulties, they exhibited improper communication behaviors such as restricting communication with the patient individual, using the language of conflict, blaming, and reproaching the patient’s behavior with inappropriate sexual content. The statements of some nurses are given below.

“I sometimes say the patient that he/she is not happy,’if you are not happy, then I will not come to the room.’ ” (Nickname: Sun).

“If the patient or his relative communicates with us in a very disrespectful and bad manner, we try not to spend too much time in that room. Because as the event grows, we are exposed to physical violence, so we restrict communication and deal with it in that way. Of course, there is no restriction on his care.” (Nickname: Wind).

“The patient or his relative shouts and gets angry, we try to soothe them properly, but of course, when the occasion arises, people may be out of patience. There are also cases where the nurse reacts. At one point, people may not be patient. Being unjustly insulted and attacked, of course, also try one’s patience.” (Nickname: Freedom).

“Some patients behave abusively if the frontal region is affected. Next to her wife, they say nurse lady is very beautiful, let’s go out to dinner and propose to marriage. We say words like

‘it does not suit you at all’ ” (Nickname: Blue).

Solution Suggestions

The nurses who participated in the study were asked about their solution suggestions to prevent communication difficulties with patients and to strengthen communication. For solution suggestions, the themes of establishment of the therapeutic care setting and strengthening of the nurse were determined.

Main Theme 1: Establishment of the Therapeutic Care Setting

The nurses indicated that by strengthening the therapeutic care setting, communication difficulties could be prevented and the problems could be solved. To this end, suggestions were made on nurse’s empathy and approach with a professional language, informing the patients and their relatives by the nurse regularly, informing the patients and their relatives by physicians, informing nurses by physicians, organizing educational seminars/meetings for the patients and their relatives, providing regular psychological support to patients and their relatives in the process of accepting the disease, regulation of the number and ratio of patients/nurses, solving the material supply, patient referral and insurance problems, and adopting a professional approach in the relations with auxiliary staff. Some statements of the nurses are given below.

“At school, we have learned to put oneself in the patient’s shoes or in the patient’s relative’s position. Empathizing. If we can really do it, I think we can solve everything.” (Nickname: Sun).

“Psychological support can be provided to patients and their relatives. Training can be provided for the relatives of patients. There are meeting rooms, meetings can be held. Information can be given, moral support can be given.” (Nickname: Freedom).

“Physicians should inform the patients and their relatives. In every respect, for instance on drugs, information given before and after may be a solution.” (Nickname: Fish).

Main Theme 2: Strengthening of the Nurse

The nurses indicated that they needed motivating factors to deal with the situations where they had difficulties and to solve the problems. In this context, they stated that organizing regular and interactive in-service trainings, strengthening professional solidarity, institutional support of nurses, organizing social activities with managerial support and motivation would contribute to the strengthening of nurses. Some suggestions of the nurses are given below.

“An information symposium can be held. No matter how much we follow, we need to participate in more activities about how to approach such patients” (Nickname: Sea).

“I think we need training all the time. We improve ourselves through in-service training programs. Interactive trainings would be more effective.” (Nickname: Wind).

“Getting psychological help may be important for strengthening communication.” (Nickname: Blue).

“I think we can deal with problems more easily if we cooperate with nurses andif physicians also support.” (Nickname: Wind).

DISCUSSION

Communication is a complex and multidimensional process, and human responses are decisive in maintaining the communication. In the clinical setting, nurse-patient communication is also affected by the individual’s responses⁶. Awareness of the patient’s responses to the disease and treatment/care process is essential for maintaining effective communication and providing quality care. In this context, nurses are expected to turn to therapeutic and individual-centered communication^3,4. In particular, physical, psychological and social changes experienced in patients with brain tumors should be addressed with a holistic perspective, and a multi-faceted approach should be adopted^12,21. In a study conducted with patients with brain tumors, it was reported that communication was one of the most important indicators of the quality of care²². In this study conducted based on this information, it was aimed to reveal nurses’ experiences on communication difficulties with patients having brain tumors.

In the interviews conducted with the nurses within the scope of this study, it was observed that their experiences on communication difficulties were gathered under two main themes, namely patient-related and institution-related. The sub-themes of individual characteristics, patient relatives, lack of information and perspective on nursing determined in relation to diseased individuals revealed that communication was affected in a multidimensional way. Studies demonstrated that patients diagnosed with brain tumors frequently experienced high levels of distress, including emotional and physical problems such as depression, insomnia, fatigue, pain, constipation, difficulty in concentrating, for reasons such as the presence of functional disorders and negative prognosis²³. Similarly, in this qualitative study, it was determined that psychological state and the experiences regarding the physiological effects of the disease on the individual caused communication difficulties. The nurse should diagnose the possible and current problems in the individual by making a comprehensive nursing diagnosis from the first moment he/she meets the patient. Thus, the nurse will evaluate the patient and their relatives with a holistic perspective and recognize their needs at the earliest time, and possible problems will be avoided^24,25. This diagnostic process can make a significant contribution to preventing possible communication difficulties.

While carrying out the caregiver roles of diseased individuals and their relatives, nurses should be aware that they may experience depression, anxiety, and mental health problems. Patients’ relatives may consider that they are sometimes unable to cope and are left alone while providing care to this individual with a high level of addiction. In this regard, the health care professional should evaluate the individual with himself/herself and his/her environment and continue his/her care with a holistic perspective²⁶. It should be accepted that anxiety and fear reactions of individuals are normal¹². The experiences revealed by this study demonstrated the importance of including the individual and their family in the care as much as possible and the family centered care approach. Based on this information, the establishment of a reliable and calm communication environment for providing psychosocial support to patients and their relatives and the adoption of effective communication methods constitute the basis of nursing practices^27,28.

Failure to adequately meet the information needs of patients with brain tumors is an important problem^21,29. However, giving information is also a way of involving the individual in his or her care process²². The reasons such as occasional intense work, long working hours and large number of patients significantly affect the communication. The fact that the hospital where the study was conducted was a university hospital and the presence of a single neurosurgery clinic, and insufficient number of specialist physicians working in the relevant clinic led to disruptions in the patient-nurse-physician communication in institutional factors. Furthermore, the risks of the interventional procedures to be performed disturb the relatives of the patients nervous and cause an increase in the expectations from the healthcare professionals. Accordingly, the functionality of comprehensive and systematic information processes of patients and their relatives regarding all effects of the disease and the treatment/care processes can make significant contributions to the solution of problems^21,30.

The perspectives and attitudes of patients and their relatives towards the nursing profession are also affected by the socio-cultural factors experienced. This theme was also identified as one of the barriers in nurse-patient interaction in the qualitative research conducted by Arkorful et al.³¹. It may be suggested that nurses, professional organizations and administrations should conduct information and awareness studies so that the society would develop a positive perspective on nursing profession. It may be useful to clarify the duties and responsibilities of health professionals at the institutional level and to declare/announce them in a way that patients/their relatives can see and reach.

Another factor affecting nurses to have communication difficulties is the institution-related factors. The sub-themes of institutional opportunities and collaboration of healthcare team members were determined for this main theme. When the experiences of the nurses on this theme were examined, it was observed that there was a need for structural changes for the solution of problems related to the institutional infrastructure. On the other hand, the fact that nurses are the team members to whom patients and their relatives communicate their problems and from whom they expect solutions can also be considered as an indicator of their easier communication with nurses and their belief that nurses can produce solutions. It can be said that the continuous presence of the nurses in the clinical setting and their open communication with the patient/relatives affected this situation. This situation, which is defined as a communication difficulty, can also be considered as an indicator of the trust of patients/their relatives in nurses.

Nowadays, the importance of a multidisciplinary team approach in health care settings is emphasized. Open and effective communication and collaboration among healthcare team members have a key role in the management of treatment and care processes³². Team communication is also an issue of safety in healthcare^33,34. In this study, it was demonstrated that the problems experienced in the collaboration of healthcare team members were effective in communication difficulties with patients/their relatives. Accordingly, it may be useful to organize activities (scientific, social, educational, etc.) for the effective communication of the healthcare team, collaboration, determination of workflows for taking responsibility in accordance with the job/job descriptions, organization of in-service trainings, and the adoption of the concept of team.

When nurses’ experiences of coping with communication difficulties were examined, two main themes, therapeutic and non-therapeutic methods, were determined. It was stated that therapeutic methods were mostly adopted and that special efforts were made in this regard. On the other hand, it was observed that improper attitudes and behaviors such as restricting the communication, blaming and using the language of conflict were exhibited, although they were not frequent. In cases where nurses had difficulty in coping with the problems, it was observed that they tended towards non-therapeutic approaches since they felt helpless. In this context, it is observed that educational activities are needed so that nurses’ coping skills in crisis situations can be improved and they have more information about professional approaches^24,33. A supportive setting established with therapeutic interventions will make significant contributions for patients and their relatives to gain awareness, to reduce anxiety, and to encourage communication^8,35.

When nurses were asked about solution suggestions to reduce/eliminate communication difficulties, they made suggestions on the necessity of strengthening the therapeutic care setting and the nurses in parallel with the difficulties experienced and coping behaviors. In line with these results, it can be said that the nurses who participated in the study had a high level of awareness. However, it was determined that they had difficulties in implementing their suggestions and finding solutions. Strengthening the therapeutic care setting is an issue that requires multifaceted attempts. Therefore, it is a long-term working area that requires nurses to collaborate with the patients and their relatives, other members of the healthcare team, managers and other stakeholders^31,34. Good communication and teamwork with the patients, their relatives and the team, supporting the patient and their families, and education are essential requirements for qualified nursing care³⁶. A multi-stage approach involving primarily nurses at the clinical level and then other stakeholders can be suggested for the solution of problems.

Study Limitations

This study was conducted through purposive sampling, by including the nurses who had experience in communication difficulties with patients having brain tumors. This non-probabilistic sampling method is limited to the generalizability of study results. This study can create a data source for examining the phenomenon with quantitative research designs in larger different sample groups using probabilistic sampling methods.

CONCLUSION

Communication between nurses and patients and between nurses and other team members is an area that needs more focus as an issue of patient safety. In line with the communication difficulties, coping methods and solution suggestions defined in this study, the importance of establishing the therapeutic care setting, eliminating the lack of information given to patients/their relatives, and adopting an individualized care approach with the participation of individuals and their families in care processes was revealed for the management of possible/existing communication difficulties. Nevertheless, it may be suggested that nurses should communicate effectively with other healthcare team members, collaboration should be strengthened, institutional factors causing communication difficulties should be identified, and attempts should be made for solutions.

Ethics

Ethics Committee Approval: Ethical approval from İstanbul University-Cerrahpaşa Clinical Research Ethics Committee (decision number: 45977, date: 05/02/2016).

Informed Consent: Consent form was filled out by all participants.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Concept: A.Ö., G.Ö.A., H.K., R.A., Design: A.Ö., H.K., R.A., Data Collection or Processing: A.Ö., G.Ö.A., K.Ş., Analysis or Interpretation: A.Ö., H.K., R.A., Literature Search: A.Ö., G.Ö.A., K.Ş., Writing: A.Ö., G.Ö.A., H.K.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.