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ARTICLE IN PRESS
0020-7489/$ - se
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International Journal of Nursing Studies 42 (2005) 159–166
www.elsevier.com/locate/ijnursto
Communication barriers perceived by older patients and nurses
Eun-kyung Parka, Misoon Songb,�
aSamsung Medical Center, Seoul, South KoreabCollege of Nursing, Seoul National University, # 28 Yunkeun-Dong, Chongno-Ku, Seoul 110-799, South Korea
Received 3 February 2004; received in revised form 31 May 2004; accepted 8 June 2004
Abstract
This study investigated the communication barriers perceived by older hospitalized patients and nurses in Korea,
with the aim of identifying disparities between the two parties. The authors developed a 50-item communication-barrier
questionnaire that includes patient, nurse, and environmental factors. One hundred older hospitalized patients and 136
nurses were asked to rate the importance of each communication-barrier item. Nurses and patients were found to
perceive the importance of barriers differently: nurses reported higher scores on patient-related communication
barriers, whereas patients reported higher scores on the nurse-related barriers. There were significant differences
between patients and nurses in 57%, 62%, and 71% of the nurse-, patient-, and environment-related communication
barriers, respectively. Based on these findings, it is necessary for nurses to understand older patients’ perceptions about
communication barriers and acquire better communication skills and attitudes.
r 2004 Elsevier Ltd. All rights reserved.
Keywords: Communication barriers; Older patients
The proportion of hospitalized patients that are older
adults is increasing rapidly in Korea. Effective commu-
nication between older patients and nurses is an
important factor for patient satisfaction, treatment
outcome, and patient compliance (Rost and Roter,
1987). And there is considerable evidence that significant
communication barriers exist between nurses and older
patients (Caris-Verhallen et al., 1997; Hines, 2000;
Kopp, 2001: Van Cott, 1993).
Three aspects of human communication have been
identified in the literature: speaker, subject, and envir-
onment (Caris-Verhallen et al., 1999; Kim, 1994; Kopp,
2001; Lubinski et al., 1985). Communication involves an
interaction between the speaker and subject, and the
environment influences this process. These three factors
e front matter r 2004 Elsevier Ltd. All rights reserve
urstu.2004.06.006
ing author. Tel: +82-2-740-8826.
ess: [email protected] (M. Song).
co-influence the communication outcome, and any
barriers to them can result in ineffective communication.
In a hospital setting, the above three aspects for
communications between nurses and older patients can
be translated as the nurse, the patient, and the hospital
environment, and all three factors should be addressed
when considering communication barriers. Previous
studies have identified several nurse-related communica-
tion barriers: stereotyping, poor articulation, and
excessive use of medical terminology (Lubinski and
Welland, 1997; Van Cott, 1993).
Older patient-related communication barriers have
been reported extensively in nursing literature. Studies
that delineated the communication barriers have mainly
focused on an older patient’s conditions related to aging.
Commonly reported barriers were impaired hearing and
vision (Lubinski and Welland, 1997), ways of acting and
verbal expression differing from that of younger people
(Kaplan et al., 1995; Kent and Burkard, 1981), cognitive
d.
ARTICLE IN PRESSE.-k. Park, M. Song / International Journal of Nursing Studies 42 (2005) 159–166160
and memory problems (Armerman and Parnell, 1992;
Lubinski and Welland, 1997), and physical problems
(Kopp, 2001; Van Cott, 1993). Noise and poor lighting
have been identified as environment-related barriers
(Kopp, 2001; Van Cott, 1993).
Methods of human communication are often classi-
fied as verbal, nonverbal, and written (Caris-Verhallen
et al., 1997; Thomas, 1994). Of these, very little written
communication takes place between the nurse and
patient in Korean acute-care settings, and hence this
method is usually not considered in such patient–nurse
communications (Lee and Chi, 1990).
Most of the previous studies on communication
barriers between patients and nurses (Herron and
Wharrad, 2000; Hines, 2000; Kato et al., 1996; Lubinski
and Welland, 1997) have examined either the nurses’ or
patients’ perceptions of communication barriers in
isolation. However, because communication is a two-
way interaction, it is more informative to examine
nurses’ and patients’ perceptions of communication
barriers simultaneously. Understanding the other
party’s perception of barriers should be considered the
first step to solving communication problems, since
satisfactory communication is impossible with an
inadequate understanding of the perceptions of the
other party. By examining the two parties simulta-
neously, nurses can understand the patient’s view of
communication barriers and the significant disparities
between them.
The present study determined and then compared the
communication barriers perceived by older inpatients
and nurses caring for them, with the aim of identifying
the disparities between the perceptions of the two
parties. The research specifically addressed how older
patients and nurses perceive patient-, nurse-, and
environment-related verbal and nonverbal communica-
tion barriers. Since there is no such questionnaire
available that evaluating the importance of communica-
tion barrier, it was necessary to progress the study by
two stages: 1) development of the questionnaire and 2)
application of the questionnaire. The resulting data can
be used to develop the nursing strategies required to
improve communication between nurses and older
patients.
1. Methods
1.1. Design and subjects
This study used a descriptive survey design, using data
collected during January and June 2002. A convenience
sample of 100 older patients and 136 nurses formed the
subjects of this study. Older-patient subjects were
recruited from 13 medical, surgical, and ophthalmology
units of three metropolitan hospitals in a large urban
city in South Korea. The patient subjects were selected
using the following inclusion criteria: age 460 years,
hospitalized for more than 2 days, oriented and alert,
able to communicate verbally, and no medical history of
dementia. Nurse and patient subjects were recruited
from the same hospital units.
1.2. Data collection
The head nurse in each unit identified potential
patient subjects, who were then screened by one of the
authors using inclusion criteria. The interviewer ex-
plained the study verbally to these eligible patients, and
a written description of the study was given to the
patients and their caregivers. They were told that their
response would remain confidential and refusing to
participate would not influence their care. Patients who
signed a written consent were included in the subjects. In
data collection, each subject chose either self-report on
the questionnaire or answer verbally when the
interviewer read the questionnaire to them. The patient’s
family was asked to leave during the interview or
self-report to avoid the introduction of family bias.
Data collection took approximately 30min for
each patient. All of the nurses in the units were asked
to participate in the study after the purpose and
procedures of the study had been explained to them.
Those nurses who volunteered to participate signed a
written consent and self-reported on the questionnaire.
Both patient and nurse subjects rated the perceived
importance of each of the barriers listed in the
questionnaire.
1.3. Instrument: Communication-barrier questionnaire
The researchers could not find previously developed
questionnaire appropriate for this study, and hence the
authors developed a new communication–barrier ques-
tionnaire. The items were constructed using literature
review, field study, and expert consultation. There were
four phases in the development of the questionnaire:
Phase 1. Forty-four nurse-, patient-, and environ-
ment-related communication barriers were derived from
a literature review.
Phase 2. Interviews were performed with 30 hospita-
lized older patients and 10 nurses on three open
questions: (1) what are the nurse-related communication
barriers? (2) what are the patient-related communication
barriers? and (3) what are the environment-related
communication barriers? Based on the result of this
survey, seven more items were added to the items
derived from the phase 1, resulting in a 51-item
questionnaire.
Phase 3. The 51-item questionnaire was given to two
experts to examine the content validity: one nurse
educator who had more than 20 years of experience of
ARTICLE IN PRESSE.-k. Park, M. Song / International Journal of Nursing Studies 42 (2005) 159–166 161
nursing and teaching the geriatric nursing, and one
nurse psychometrics expert. This process lead to the
removal of one item because of overlap with another
item; all the other scale items was evaluated as valid.
Phase 4. The 50-item questionnaire was pilot tested on
10 older patients and 10 nurses in a hospital, which
resulted in the wordings of several items being modified
to remove identified ambiguities. Finally, a 50-item, 4-
point Likert-type (not important=1, slightly impor-
tant=2, moderately important=3, very important=4)
questionnaire was finalized, comprising 30 items on
nurse-related barriers, 13 items on patient-related
barriers, and 7 items on environment-related barriers.
The range of possible scores for the questionnaire is
50–200, with a higher score indicating communication
barriers with a higher perceived importance. In terms of
the reliability of applying the questionnaire in this study,
the Cronbach a values were 0.97 for older patients and
0.96 for nurses.
1.4. Data analysis
All analyses were performed using SPSS-PC software
(version 8, SPSS, Chicago, IL). Descriptive statistics
were used to analyze all study variables. To compare the
perceived importance of communication barriers be-
tween patients and nurses, item means were calculated
and the t-test for independent samples was applied. The
significance level was set at a probability value of 0.05.
2. Results
2.1. General characteristics of the subjects
The mean age of the patient subjects was 68.15
(SD=6.07) years, and 59 (59%) of them were male.
Twenty-seven patients (27%) had some degree of
hearing impairment and 42 (42%) had some degree of
visual impairment. Among the patient subjects, 46
(46%) reported an education level of less than 6 years,
Table 1
Scores for the importance of communication barriers as perceived by
Barrier type Subject
Patients (n=100)
Mean7SD
Nurse-related 2.3170.83
Patient-related 1.9770.77
Environment-related 1.6070.62
Total score (range 1–4) 2.3270.83
�po0.05.
36 (36%) reported an educational level of 6–12 years,
and the remaining subjects (18%) reported an education
level of more than 12 years. Seventy-seven percent of the
older patients had family caregivers at the bedside
around the clock during this hospitalization.
All of the 136 nurse subjects were female; their mean
age was 27.27 (SD=4.43) years, with an average length
of clinical experience of 54.96 months. The nurse
subjects worked in medical units (37.5%), surgical units
(54.4%), or ophthalmology units (8.1%). Among the
nurses, 59 (43.4%) had a diploma, 73 (53.7%) had a
baccalaureate, and four (2.9%) had a master’s degree.
2.2. Mean levels of perceived communication barriers
There was no significant difference (t=1.1, p=0.27) in
the total perceived importance of communication
barriers between older patients and nurses (Table 1).
In terms of the three types of communication barriers,
nurse-related barriers were rated higher by patients than
by nurses (t=–2.67, p=0.01). Nurses rated higher
patient-related barriers than patients (t=6.23,
p=0.001). And there was no difference between the
groups in the rating of environment-related barriers.
2.3. Nurse-related communication barriers
The scores for nurse-related communication barriers
reported by nurses and patients are listed in Table 2. The
five most important nurse-related barriers reported by
patients were ‘using medical terminology’, ‘working
without a sincere attitude’, ‘ authoritative attitude’,
‘sudden change of subject’, and ‘being unfriendly’. The
five most important nurse-related barriers reported by
nurses were ‘being too busy’, ‘presenting several subjects
at one time’, ‘speaking too fast’, ‘using a long sentence
without a clear message’, and ‘not checking if patient
has hearing aid on’.
There were 17 out of 30 (57%) barriers for which the
scores of nurses and patients were significantly
different. Older patients scored 15 items higher and
elderly patients and nurses
Nurses (n=136)
Mean7SD t p
2.0870.56 –2.67 0.008�
2.5070.54 6.23 0.001�
2.1570.57 0.62 0.080
2.5070.54 1.098 0.274
ARTICLE IN PRESS
Table 2
Importance of nurse-related communication barriers as perceived by elderly patients and nurses
Nurse-related barrier Patients Nurses
Mean Mean t p
(1) Using medical terminology 2.91 2.17 –4.71 0.001�
(2) Working without a sincere attitude 2.91 1.76 –7.56 0.001�
(3) Authoritative attitude 2.85 1.84 –6.81 0.001�
(4) Sudden change of subject 2.83 2.08 –5.12 0.001�
(5) Being unfriendly 2.80 1.85 –6.18 0.001�
(6) Not enough explanation about procedure or treatment 2.78 2.23 –3.69 0.001�
(7) Interrupting a patient talking 2.74 2.15 –3.27 0.001�
(8) Presenting several subjects at one time 2.66 2.54 –0.776 0.439
(9) Showing no respect to elderly patients 2.65 1.73 –5.92 0.001�
(10) Using a long sentence without a clear message 2.63 2.34 –2.04 0.042�
(11) Not liking the elderly 2.55 1.72 –5.57 0.001�
(12) Transferring the hopelessness to the patient 2.55 1.56 –6.21 0.001�
(13) Approaching without the patient’s information 2.54 2.30 –7.15 0.081
(14) Showing a too-formal manner 2.52 2.09 –2.26 0.001�
(15) Speaking far away 2.49 2.07 –2.85 0.005�
(16) Speaking without eye contact 2.49 2.20 –2.94 0.0041�
(17) Having no interest in patient 2.48 2.23 –1.72 0.008�
(18) Speaking too fast 2.37 2.39 0.151 0.881
(19) Not checking whether the patient understands 2.36 2.28 0.571 0.569
(20) Speaking with mask on 2.36 2.06 –1.85 0.066
(21) Speaking without details 2.34 2.23 –1.15 0.251
(22) Speaking too loudly 2.20 1.99 –1.37 0.172
(23) Being too busy 2.16 2.71 4.12 0.001�
(24) Not checking if patient has hearing aid on 2.02 2.31 7.87 0.064
(25) Speaking when the patient is sleepy 2.01 2.10 –0.565 0.561
(26) Repeating the same question 1.99 2.05 5.12 0.001�
(27) Not knowing that the patient is hard of hearing 1.96 2.11 1.08 0.315
(28) Not being openhearted 1.94 1.73 –1.73 0.086
(29) Having poor skills at communicating with hearing-impaired patient 1.92 2.05 0.886 0.377
(30) Not coming into the patient’s room 1.92 2.13 1.03 0.300
Total (range 1–4) 2.31 2.08 –2.67 0.008�
*po0.05.
E.-k. Park, M. Song / International Journal of Nursing Studies 42 (2005) 159–166162
nurses scored 2 items higher (‘being too busy’ and
‘repeating the same question’). There were two nurse-
related barriers that both subject groups perceived as of
high importance (score 42.3), with no significant
difference between the groups: ‘presenting several
subjects at one time’ and ‘approaching without the
patient’s information’.
2.4. Patient-related communication barriers
Table 3 lists that the scores for the perceived
importance of patient-related communication barriers.
The five most important patient-related barriers re-
ported by patients were ‘not feeling well’, ‘being tired’,
‘being hard of hearing’, ‘pretending to understand’, and
‘being hesitant to interrupt the nurse’s work’. The five
most important patients-related barriers reported by
nurses were ‘being hard of hearing’, ‘having poor
articulation’, ‘not feeling well’, ‘forgetting things easily’,
and ‘being tired’.
There were eight out of 13 (62%) patient-related
communication barriers that were perceived significantly
differently by patient and nurses, all of which were
perceived as more important by nurses than by patients.
There were two patient-related barriers that both subject
groups perceived as of high importance (score 42.3),
with no significant difference between the groups: ‘not
feeling well’ and ‘being tired’.
2.5. Environment-related communication barriers
Table 4 lists that the scores for the perceived
importance of environment-related communication bar-
riers. The five most important environment-related
ARTICLE IN PRESS
Table 3
Importance of patient-related communication barriers as perceived by elderly patients and nurses
Patient-related barrier Patients Nurses
Mean Mean t P
(1) Not feeling well 2.59 2.68 0.687 0.493
(2) Being tired 2.44 2.62 1.18 0.238
(3) Being hard of hearing 2.30 2.99 4.43 0.001�
(4) Pretending to understand 2.24 2.47 1.58 0.012�
(5) Being hesitant to interrupt nurse’s work 2.24 2.38 1.04 0.297
(6) Having personal stress other than hospitalization 2.14 2.38 1.48 0.141
(7) Forgetting things easily 2.07 2.67 4.6 0.001�
(8) Having low educational level 2.04 2.42 2.91 0.004�
(9) Having poor eyesight 2.01 2.56 4.04 0.001�
(10) Having poor articulation 1.91 2.79 6.92 0.001�
(11) Not trusting the nurse 1.86 1.88 0.167 0.867
(12) Having a provincial accent 1.76 2.40 5.24 0.001�
(13) Not telling the nurse about being hard of hearing 1.17 2.43 5.51 0.001�
Total (range 1–4) 1.97 2.50 6.23 0.001�
�po0.05.
Table 4
Importance of environment-related communication barriers as perceived by elderly patients and nurses
Environment-related barrier Patients Nurses
Mean Mean t P
(1) Presence of severely ill patient in the unit (nurses are busy with the ill patient) 1.98 2.11 0.85 0.395
(2) Noisy environment 1.82 2.26 3.44 0.001�
(3) Being in an unfamiliar hospital environment 1.76 2.33 7.83 0.001�
(4) Patient not having a family caregiver around 1.69 2.57 7.24 0.001�
(5) Poorly lit room 1.45 2.00 5.24 0.001�
(6) Uncomfortable room temperature 1.42 1.80 3.74 0.709
(7) Generation gap 1.17 2.02 3.57 0.011�
Total (range 1–4) 1.60 2.15 0.62 0.080
�po0.05.
E.-k. Park, M. Song / International Journal of Nursing Studies 42 (2005) 159–166 163
barriers reported by patients were ‘presence of severely
ill patient in the unit (nurses are busy with the ill
patient)’, ‘noisy environment’, ‘being in an unfamiliar
hospital environment’, ‘patient not having a family
caregiver around’, and ‘poorly lit room’. The five most
important environment-related barriers reported by
nurses were ‘not having a family caregiver around’,
‘being in an unfamiliar hospital environment’, ‘noisy
environment’, ‘presence of severely ill patient in the unit
(nurses are busy with the ill patient)’, and ‘generation
gap’.
There were five out of seven (71%) environment-
related barriers that were perceived significantly differ-
ently by patients and nurses: ‘not having family
caregiver around’, ‘being in an unfamiliar hospital
environment’, ‘poorly lit room’, ‘noisy environment’,
and ‘generation gap’; all of these items were perceived as
more important by nurses than by patients. However,
either group scored none of the environment-related
communication barriers higher than 2.3.
3. Discussion
There was no significant difference in the total
perceived importance of communication barriers be-
tween the patients and nurses, but there were differences
for individual barriers. Older patients reported higher
scores than nurses on nurse-related communication
barriers, whereas nurses reported higher scores than
patients on patient-related barriers. This result indicates
that nurses and older patients perceive communication
ARTICLE IN PRESSE.-k. Park, M. Song / International Journal of Nursing Studies 42 (2005) 159–166164
barriers differently. However, there was no difference
between the groups in the mean score for environmental
barriers.
Fifty seven percents of nurse-related barriers were
scored significantly differently by patients and nurses,
with patients scoring 15 of these items higher. The most
important barriers reported by patients can be categor-
ized as nurses’ poor communication skills and poor
attitudes towards older patients: the former category
of barrier is illustrated by items such as ‘using medical
terminology’, ‘sudden change of subject’, ‘interrupting
a patient talking’, ‘presenting several subjects at one
time’, and ‘speaking without eye contact’; and the
latter is illustrated by ‘working without a sincere
attitude’, ‘transferring the hopelessness to the patient’,
‘authoritative attitude’, ‘being unfriendly’, and ‘showing
no respect to older patients’. The last three of these
barriers can be categorized as attitudes, and can be
attributed to power aspects of nurse–patient interac-
tions. The result is consistent with the study of Hewison
(1995), which found that nurses exert considerable
control in nurse–patient interactions and the language
used therein, thereby producing a communication
barrier.
Two nurse-related barriers were scored higher by
nurses than by patients: ‘being too busy’ and ‘repeating
the same question’. Nurses’ work overload was also
reported as a communication barrier with the older
adults in the study by Kato et al. (1996) of nursing home
nurses. This barrier cannot be easily ameliorated unless
organizational support is provided.
In order to ameliorate nurse-related barriers, nurses
must first need to gain insight into what older patients
perceive as barriers. Once these barriers are understood,
a training program—such as that used in the study of
Caris-Verhallen et al. (2000)—can be valuable for
improving the skills and attitudes of nurses. That study
analyzed videotapes of patient–nurse encounters and
tailored the nurse-training program according to the
results. As the result, the experimental group showing
better skills and a warmer and less patronizing attitude.
The study of Armstrong-Esther et al. (1989) revealed
that health workers with a preference for working with
older people showed a more positive attitude toward
them. This suggests that nurses who prefer to work with
the older adults should be assigned to work at units with
predominantly older patients.
Nurses scored higher in 62% of patient-related
communication barriers than patients. Barriers that
nurses consider more important can be categorized as
related to patients’ individual difficulties and unwilling-
ness to disclose weaknesses. The barriers which can be
categorized as individual difficulties are ‘being hard of
hearing’, ‘forgetting things easily’, ‘having low educa-
tional level’, ‘having poor eyesight’, ‘having poor
articulation’, and ‘having an accent. The barriers that
can be categorized as unwillingness to disclose weakness
are ‘pretending to understand and not telling the nurse
about being hard of hearing’ illustrate the barriers
categorized as unwillingness to disclose weakness. Most
of these types of difficulty are related to aging and
cannot be removed completely, but they can be
mitigated by environmental modification or prosthetic
support, such as by reducing noise levels and using
hearing aids or eyeglasses. Barriers categorized as
related to an unwillingness to disclose weakness can be
minimized if nurses pay attention to a patient’s
responses and provide support without threatening the
patient’s self-esteem. McGilton (2002) proposed that
continuity of care provider was important to these
factors. She stressed that engaging with patients is
essential to producing an understanding and caring
interaction, and implementing primary nursing can be a
strategy for this.
The scores for 71% of the environment-related
barriers differed between nurses and patients, with all
of them scored higher by nurses. The barriers can be
categorized into physical and interpersonal types: the
former type is illustrated by ‘noisy environment’, ‘being
in an unfamiliar hospital environment’, ‘poorly lit
room’, and ‘uncomfortable room temperature’; and the
latter is illustrated by ‘not having family caregiver
around’ and ‘generation gap’. Many of the physical-
environment barriers can be eliminated by modern
hospital construction technology, and barriers such as
‘being in an unfamiliar hospital environment’ and ‘noisy
environment’ can be decreased by nurses providing a
kind and detailed admission orientation and by control-
ling noise in the unit.
The nurses perceived ‘not having a family caregiver
around’ as the most important communication barrier.
This is attributable to it being customary in Korea for a
family caregiver to stay with an older patient during
their hospitalization, and in such cases nurses often
communicate with the older patient via the family
caregiver. Considering the current shortage of nurses in
Korean hospitals and the family centered Korean
culture, having a family caregiver at bedside does assist
the communication between older patient and nurse,
with young family members in particular relating to
older patients when nurses explain something. However,
the continuing industrialization of Korean society and
the increasing rate of women working outside the house
could soon make family caregivers at the bedside a rare
scene in Korea. This would increase the importance of
effective direct communications between nurses and
older patients.
Nurses also consider the ‘generation gap’ as an
important communication barrier. Improving nurses’
understanding of older patients’ perceptions may help
decrease the generation gap. Moreover, it is important
for the same person to provide care to an individual
ARTICLE IN PRESSE.-k. Park, M. Song / International Journal of Nursing Studies 42 (2005) 159–166 165
patient if at all possible (McGilton, 2002). Priority
should be given to developing strategies to ameliorate
those barriers identified by both patients and nurses as
highly important.
This study has identified differences and similarities in
the perceptions of communication barriers between
patients and the nurses. Most of the delineated
communication barriers have the possibility of being
modified. Nurses should understand perception differ-
ences between patients and nurses, and practice strate-
gies to reduce the associated communication barriers.
Several limitations of this study need to be taken into
consideration when interpreting its findings. The main
limitation is likely to be the use of a convenience sample:
our older-patient subjects were younger and had better
cognitive function than is usual for older inpatients,
which was due to the sample selection criteria used to
collect reliable data. A second limitation of this study is
that a newly developed instrument was used to evaluate
the perceived importance of communication barriers.
Although content validity and internal consistency were
tested, further evaluation of psychometric aspects of this
questionnaire is warranted.
4. Recommendations for practice and research
Older patients perceived nurse-related communication
barriers as more important, whereas nurses perceived
patient-related barriers as more important; strategies to
remove communication barriers between patients and
nurses should address this situation.
In order to reduce nurse-related barriers, nurses need
to improve their understanding of communication
processes and receive proper education and training
thereon. Understanding the patient’s perception of
communication barriers should be included in both
basic and in-service nursing education. In particular, an
approach with empathy which involves sensitivity to
patients’ responses (McGilton, 2002) should be stressed
in this education.
It is generally not feasible to modify the patient-
related barriers because they are mostly the result of
aging or illness. Instead, effective nursing approaches
should be adopted to compensate for patient-related
barriers. For example, nurses should always ensure that
patients have proper prosthetic aids, practice effective
communication strategies for sensory handicapped, and
keenly observe patient responses.
In terms of environment-related communication
barriers, physical barriers can rather easily decreased
by nurses in modern hospitals if they have intention to
improve and funding available, since construction
technologies have been developed to decrease barriers
such as noise, poor lighting, and uncomfortable
temperatures. To decrease nurse’s interpersonal envir-
onment barriers, the organizational environment, such
as the implementation of the primary nursing care
system and increasing nursing manpower should be
supported. Future studies should develop and test
strategies for decreasing communication barriers be-
tween older patients and nurses in acute care settings.
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