Posted: February 28th, 2023
Miscommunication in pattient interviews
techniques for effective patient interviews. What happens though if the interviewer or person being interviewed does not communicate well? write a 750 over miscommunication or a lack of communication and how it effects the patient.
RESEARCH ARTICLE
Can patient-physician interview skills be implemented with peer simulated
patients?
Funda İfakat Tengiz a, Hale Sezerb, Aysel Başerc and Hatice Şahind
aSchool of Medicine, Medical Education Department, Izmir Katip Çelebi Üniversitesi Tıp Fakültesi Tıp Eğitimi Anabilim Dalı; Izmir Katip
Celebi University, Izmir, Turkey; bFaculty of Health Sciences, Nursing Department, Izmir Bakırçay Üniversitesi Sağlık Bilimleri Fakültesi
Hemşirelik Bölümü; Izmir Bakırçay University, Izmir, Turkey; cSchool of Medicine, Medical Education Department, Izmir Demokrasi
Üniversitesi Tıp Fakültesi Tıp Eğitimi Anabilim Dalı; Izmir Demokrasi University, Izmir, Turkey; dMedical Education Department, Ege
Üniversitesi Tıp Fakültesi Tıp Eğitimi Anabilim Dalı, Ege University School of Medicine, Izmir, Turkey
ABSTRACT
: Patient-physician interviewing skills are crucial in health service delivery. It is
necessary for effective care and treatment that the physician initiates the interview with the
patient, takes anamnesis, collects the required information, and ends the consultation.
Different methods are used to improve patient-physician interview skills before encountering
actual patients. In the absence of simulated patients, peer simulation is an alternative method
for carrying out the training. This study aims to show whether patient-physician interview
skills training can be implemented using peer simulation in the absence of the simulated
patient.
: This is a descriptive quantitative study. This research was conducted in six stages:
identification of the research problem and determination of the research question, develop-
ment of data collection tools, planning, acting, evaluation, and monitoring. The data were
collected via the patient-physician interview videos of the students. The research team
performed descriptive analysis on quantitative data and thematic analysis on qualitative data.
: Fifty students participated in the study. When performing peer-assisted simulation
applications in the absence of simulated patients, the success rate in patient-physician inter-
views and peer-simulated patient roles was over 88%. Although the students were less
satisfied with playing the peer-simulated patient role, the satisfaction towards the application
was between 77.33% and 98%.
and
: In patient-physician interviews, the peer-simulated patient
method is an effective learning approach. There may be difficulties finding suitable simulated
patients, training them, budgeting to cover the costs, planning, organizing the interviews,
and solving potential issues during interviews. Our study offers an affordable solution for
students to earn patient-physician interview skills in faculties facing difficulties with providing
simulated patients for training.
ARTICLE HISTORY
Received 6 July 2021
Revised 18 January 2022
Accepted 18 February 2022
KEYWORDS
Patient-physician interview
skills; peer-assisted learning;
simulation; peer simulated
patient; peer simulation
Introduction
Medical students need to practice patient-physician
interviews to develop essential clinical communica-
tion and clinical reasoning skills and find the neces-
sary space to apply their basic professional skills [1].
Patient-physician interviewing skills have an impor-
tant place in health service delivery. A good interview
is crucial for effective diagnosis and treatment.
Medical educators agree that medical students should
be humane and have the necessary communication
skills for patient-physician interview skills. However,
for years, there has been uncertainty about the ways
to achieve this learning goal [2]. Having students
experience a mock patient-physician interview is con-
sidered the easiest method to accomplish this goal
[2]. Methods based on small group activities, such
as problem-based learning, role-playing, and
simulated/standardized patient simulation, are used
to improve patient-physician interview skills [2,3].
Today, it is a common and accepted method to con-
duct patient-physician interviews with simulated/
standardized patients [1,4–6]. Simulated patients can
be theatre actors, professional actors, trained volun-
teers (retirees, students, employees, etc.). There is no
evidence that the simulated patient has to be
a professional actor for the interview to be efficient
[4,7]. There are certain advantages and disadvantages
to interviewing simulated patients. Simulated patients
offer a student-centered educational opportunity that
is the closest to reality without time constraints. They
can impersonate different patient profiles and condi-
tions, allowing students to experience patients and
cases that are difficult to encounter in real life [4,5].
CONTACT Funda İfakat Tengiz fundatengiz@gmail.com School of Medicine, Medical Education Department, Zmir Katip Çelebi Üniversitesi, Tıp
Fakültesi Tıp Eğitimi Anabilim Dalı, İzmir 35620, Turkey
MEDICAL EDUCATION ONLINE
2022, VOL. 27, 2045670
https://doi.org/10.1080/10872981.2022.2045670
© 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.
http://orcid.org/0000-0002-8491-9190
http://www.tandfonline.com
https://crossmark.crossref.org/dialog/?doi=10.1080/10872981.2022.2045670&domain=pdf&date_stamp=2022-03-01
On the other hand, using simulated patients also has
disadvantages related to the cost or training require-
ments [8]. There may be difficulties finding proper
simulated patients, training them, budgeting to cover
the costs, planning, organizing the interviews, and
solving possible issues during interviews [4,5,7–12].
Furthermore, the need to train faculty members` for
simulated patient training, the time spent on it, cor-
porate commitments, and, most importantly, the
truth that it is not a sustainable method are some
other downsides [4,5].
In modern medical education, to improve patient-
physician interviewing skills, it has become impera-
tive to use modernized, affordable and sustainable
models, instead of teacher-centered and expensive
methods with a traditional approach. Peer-assisted
learning (PAL) serves this purpose [3,13,14]. One
can define PAL as knowledge and skills acquisition
through active help and support among peers. Peer
trainers (tutors) are non-professional teachers who,
by helping their friends, help themselves as well to
have a broader understanding of the topic at hand
[3,14,15]. Peer-assisted learning (PAL) has long been
used informally in medical education by medical
educators as an auxiliary tool for learning since its
inclusion among the effective models in the literature
[3,13,16]. The primary advantage of PAL is econo-
mizing resources. Another advantage is that it
immensely reduces the burden of the faculty member.
It increases the cultivation of a lifelong learning men-
tality for students, leads to continuous professional
development, and enhances interest in an academic
career, boosting skills such as leadership, coaching,
confidence, and inner motivation [13,14,16,17]. Peer
simulation is presented as a new concept that
increases the advantages of PAL [5]. Peer simulation
is a structured form of role-playing in which students
train to play the patient role for their peers [5].
Having peer support in peer simulation (peer simu-
lated patient) presents many advantages offered by
PAL, and it has a positive effect on learning out-
comes. Students learn together and from each other
through peer simulation. Peer simulation is an alter-
native method to using simulated patients in precli-
nical applications. Playing the patient role in peer
simulation is an opportunity to facilitate the develop-
ment of empathy and culture-sensitive medical prac-
tice skills [5]. There are very few examples of
professional skills training using peer simulation [5].
According to the literature, there are no examples
in Turkey yet. In the medical school, where the study
was carried out, patient-physician interview skills
training was implemented in the second year. The
patient-physician interview skills training goal was to
teach students the proper way to start the interview,
take and expand the anamnesis, inform the patient,
and end the interview. There are no simulated/stan-
dardized patients in this medical school. For students
to gain skills, a different teaching strategy, which is
low cost but meets the same function, is required.
In our school, action was planned to solve this
problem. Results from action are the solution to the
problem. Action research, used to improve and mod-
ify educational practices, is a method that helps
faculty and students better understand the work car-
ried out in the institution. If the results are not
satisfactory, researchers retry [18]. The action process
is carried out in six stages (Figure 1). The first stage is
Figure 1. Mixed-Method Methodological Framework for Research.
2 F. İ. TENGIZ ET AL.
‘diagnosing,’ which means identification of the pro-
blem. The second stage is ‘reconnaissance,’ in which
data collection tools are developed and the problem is
analyzed and interpreted. The third stage contains the
development of the action/intervention plan. The act-
ing stage includes the implementation of the action/
intervention plan. The fifth stage is the evaluation
stage comprising data collection and analyzing the
action/intervention. The last stage includes monitor-
ing the data to make revisions and test the action/
intervention.
This study aims to show whether peer simulated
patient-physician interview skills training can be suc-
cessfully implemented to practice patient-physician
interviewing skills of medical students in the absence
of simulated patients.
Methods
This is a descriptive quantitative study. With the
descriptive methodological framework, the problem
was subjected to a comprehensive initial assessment,
and multiple data are collected and integrated. Thus,
a more rigorous evaluation of the action was obtained
[18–20]. In this study, first, the problem was defined,
then data collection tools were developed with the
support of literature, remedial action was planned,
and finally, the developed training model was applied.
The process of this research was carried out in stages
and is shown in the figure (Figure 1).
Figure 1- Descriptive Methodological Framework
for Research
The method of the research will be presented in
accordance with the stages:
In the literature review ‘patient-physician inter-
view skills, peer-assisted learning, simulation, peer-
simulated patient, peer simulation’ keywords were
used. Applications on peer-assisted learning and
peer simulation were examined in 51 studies.
Based on the literature information, data collection
tools aimed at obtaining the opinions of different
parties have been developed to evaluate peer-
assisted patient-physician interview skills.
i. Physician’s Role Observation Form (PROF).
Using the literature, the researchers identified obser-
vational headings related to patient-physician inter-
view skills [4, 7, 21], Katharina Eva [22], Katharina
Eva [1, 23–26]. After four consecutive meetings, the
researchers reached a consensus on the identified
headings. An observation form on patient-physician
interview skills was created by grouping the agreed
items in line with their conceptual similarities.
PROF consists of three groups (verbal communica-
tion, nonverbal communication, questioning of the
main complaint) and 54 items. Each answer is rated
as “0-no” for missing the objective and “1-yes” for
reaching the objective.
ii. Peer Patient Observation Form (PPOF). Using the
literature, the researchers identified headings related
to the role of simulated patients [4,21,26]. The
researchers agreed on PPOF consisting of eight
items. Each answer is rated as “0-no”, “1-yes”.
iii. Satisfaction Assessment Form (SAF). The form
consists of socio-demographic variables (four items),
and items related to the satisfaction with the patient-
physician interview (six items), and related to the
peer-assisted patient-physician interview (15 items
related to the physician’s role, three items related to
the peer-simulated patient’s role, and three items
related to the observer). All questions except two
are closed-ended. Data on whether the peer-assisted
patient-physician interview was beneficial was
obtained by evaluating the open-ended questions of
the SAF.
Data analysis methods
Student interview videos were viewed separately by
researchers. Each student received grades for their
roles as a physician and a patient. Accordingly,
a student playing the physician’s role received
a minimum score of 0 and a maximum score of 54
from the PROF. The student playing the peer-
simulated patient’s role received a minimum score
of 0 and a maximum score of 8 from the PPOF. The
internal consistency of the scales was evaluated with
the Crohnbach’s alpha coefficient. For the analysis of
the results from the SAF, descriptive analysis was
performed for the answers to two open-ended ques-
tions, and frequency values and means were calcu-
lated in closed-ended questions. The statistical
software SPSS 24 (Statistical Package for Social
Sciences for Windows 24.0) was used for
calculations.
In addition, it is aimed that students can reach all the
gains in the expressions specified in the form.
Therefore, the success-satisfaction ratio of the items
on the form was calculated using the formula “num-
ber of successful-satisfied answered items/total num-
ber of items*100”. This ratio was calculated for the
physician’s role observation form (54 items), peer
simulated patient observation form (8 items), and
the peer-assisted patient-physician interview satisfac-
tion section (21 items) of the SAF.
Planning
a. Preparation of simulated patient scenarios.
A patient scenario for history taking was created by
the researchers using the literature. Scenario creation
stages are as follows: the determination of learning
objectives and outcomes, determination of context
and content (the physician’s and patient’s roles, ana-
mnesis information, physical environment, available
source, etc.), evaluation of technical infrastructure
(computer, camera, sound system), and preparation
of supporting documents [27,28]. The scenario was
MEDICAL EDUCATION ONLINE 3
submitted to the expert opinion and was made ready
for application after making the necessary revisions.
Patient scenarios, which were finalized with the feed-
back from expert, were prepared for information
sessions with students.
b. Conducting pilot application.
The pilot application was conducted with eight
volunteering second-year students who had no
experience with interviewing simulated patients.
Information sessions were held with the volunteering
students, and patient-physician interviews were
planned. Within the scope of the pilot application,
volunteering students made interviews with their
peers playing the physician’s role, patient’s role,
interviews were video-recorded, and feedback ses-
sions were held with students. Video recordings
were evaluated by the researchers using data collec-
tion forms. Technical problems encountered in the
pilot application (internet, computer screen resolu-
tion, sound quality, etc.) and data collection tools
were fixed.
c. Setting up the peer-assisted patient-physician
interview.
During the 2019–2020 academic year, second-year
students, at Izmir Katip Çelebi University Faculty
of Medicine participated in the peer-assisted patient-
physician interviews. Throughout the module,
a student had three different responsibilities: playing
the physician’s role, playing the peer-simulated
patient’s role, and being the peer observer. Thus,
students were able to experience all the components
of the interview directly. Students made interviews,
which were video-recorded. After the interview, they
filled out a satisfaction form, wrote a self-assessment
report, and attended a feedback session. Those play-
ing the patient’s role simulated the disease required
by the role, monitored the interviewing physician,
gave constructive feedback to the physician, and
filled out the satisfaction form. Finally, those who
acted as an observer monitored the physician’s per-
formance, gave constructive feedback, and filled out
the satisfaction form.
d. Planning a feedback session with students after the
interviews.
Students watched a video recording of the interview,
wrote the self-assessment report, and participated in
the feedback session
Acting
At this stage, patient-physician interviews were made,
and information sessions were delivered about stu-
dent responsibilities, and feedback sessions were held.
Before this, second-year students who participated in
basic communication skills, clinical communication
skills, and professional skills courses had a patient-
physician interview at the student outpatient clinic
during appointment hours. The interviews were con-
ducted simultaneously in five outpatient clinics by
teams of five people. In these teams, one of the
students played the physician’s role, one played peer-
simulated patient’s role, and three participated in
interviews as observers. In subsequent interviews,
the students exchanged their roles: each student was
allowed to play the physician’s and peer simulated
patient roles once, and the observer roles three times.
The student playing the physician’s role was required
to prepare the outpatient clinic, initiate video record-
ing, meet the patient, take anamnesis, and make gen-
eral situation assessment. The student playing the
peer-simulated patient’s role was informed that they
could improvise if the answer to the question was not
specified in the scenario. Observing students were
required to monitor the interview and give feedback
to the interviewing physician at the end. Once the
interview was over, the student playing the physi-
cian’s role took the video recording, wrote the self-
evaluation report, and participated in the feedback
session held the following week. In the feedback ses-
sion, the patient-physician interview experience was
evaluated using discussion, reflection, and feedback
techniques. This stage was completed in March 2020.
Student interview videos were monitored and ana-
lyzed by researchers with PROF, PPOF, and SAF.
The findings obtained after the analysis of the data
were interpreted with triangulation, and a decision
was made regarding the continuation of the peer-
assisted simulated patient-physician interview. All
data obtained by triangulation are combined and
interpreted in a table.
Ethics committee
Approval was obtained from the research ethics com-
mittee of the ICU Social Research Ethics Committee
in March 2020 with the decision numbered
2020/03–04.
Results
It was aimed to ensure that all second-year students
(n:193) participated in patient-physician interviews.
Patient-physician interviews were planned to be held
throughout eight weeks according to a schedule, in
which each week 25 students participated in the
interviews. After the first two weeks, the COVID-19
pandemic was declared by the WHO, so the remain-
ing students were unable to make the interviews.
Thus, the interview videos of a total of 50 students
were monitored by researchers and analyzed by
obtaining data with PROF and PPOF. Cronbach’s
alpha of PROF was found to be 0.71.
A total of 50 students (31 males and 19 females)
participated in the study. The mean age of the stu-
dents is 20.56 (min:19 max:23).
a. In the analysis of the data obtained from the
patient-physician interview video recordings (n:50),
4 F. İ. TENGIZ ET AL.
the total score and success percentage for each stu-
dent were calculated with PROF. Accordingly, the
mean and standard deviation of the scores form
PROF were 70.43 ± 9.81 (min. 40.12, maximum
88.27), respectively. Students are expected to get at
least 60 points in order to be considered successful.
The rate of students who were successful with a score
of 60 or above from PROF was 92%. The distribution
of achievement scores is presented as a graph
(Chart 1).
Chart 1. Students` performance scores from the
PROF
When evaluating the students playing the physi-
cian’s role, the headings on the PROF were examined:
96.29% of the 54 items were found to be used effec-
tively during the observation. Students were success-
ful in over 95% of the topics of welcoming patient,
asking questions about the patient’s demographic
characteristics, making eye contact, listening to the
patient’s main complaints, observing the patient’s
profile, and asking questions about background. On
the other hand, students achieved less than 50%
success in summarizing the case, using body lan-
guage, using the proper tone of voice, and using
understandable language.
b. Students playing the peer-simulated patient’s
role were evaluated via the PPOF by considering
patient-physician interview video recordings (n:50).
Students were found to be more than 90% successful
in seven items of the form. However, only 32% suc-
cess was achieved in the eighth item related to the
peer patient giving feedback to the interviewing phy-
sician, (Table 1).
c. Findings regarding the satisfaction with the
peer-assisted patient-physician interview were pre-
sented under the following headings: sociodemo-
graphic characteristics of the participants, their
opinions on satisfaction with the patient-physician
interview, and their opinions on satisfaction with
the peer-assisted patient-physician interview.
After the evaluation on the satisfaction of the peer-
assisted patient-physician interview, it was determined
that 98% (n:49) of the students were satisfied with the
peer-assisted patient-physician interview, and 84%
(n:42) were satisfied with the presence of their peers
in the patient role in the peer-assisted patient-physician
interview. The other, 16% (n:8) stated that they would
prefer to have an real patient or doctor instead of their
peers. It was also determined that 92% of the students
wanted to re-experience the peer-assisted patient-
physician interview in the coming years, and 96%
found the peer-assisted patient-physician interview
experiences useful.
Regarding their answers to the open-ended ques-
tions, the students stated that they found it valuable
to have experienced the patient-physician interview
in the early period during the pre-graduation medical
education process. They noted that they realized their
Table 1. Peer-Simulated Patient Success Rate.
PPOF Items %
1. The peer patient focused on the script. (good recall,
concentrated)
91,33
2. The peer played the role of patient well. 94,67
3. The peer patient was able to present alternative topics to
the topics highlighted in the scenario
95,33
4. The oral communication skills of the peer patient were
appropriate (clear, clear, understandable, scripted)
99,33
5. The nonverbal communication skills of the peer patient
were appropriate (body language, gesture, gesture).
99,33
6. The peer patient listened to the physician interview topics
effectively
100,00
7. The peer patient answered the questions of the interviewer
consistently. (credible-reliable)
99,33
8. The peer patient gave effective feedback. 32,00
Total 88,92
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
0 10 20 30 40 50
Pe
rf
or
m
an
ce
G
ra
de
Number of Students
Chart 1. Students` performance grade distributions from PROF.
MEDICAL EDUCATION ONLINE 5
weaknesses and what needed to be done about them.
They said that it would be useful to repeat this
instructive practice, that peer-assisted learning was
valuable, and that it was a good opportunity to self-
evaluate. On the other hand, some of the negative
remarks related to the process were inexperience,
excitement, personal inadequacies, lack of knowledge,
unnecessary role-playing, and difficulty communicat-
ing with the patient”.
When the satisfaction with peer-assisted patient-
physician interviews was evaluated, it was determined
that 77.33% of the students were satisfied. 80.53% of
the students were satisfied with being interviewing
physician, 56.66% with being the peer-simulated
patient, and 82% with being observer in the
interviews.
d. All the data obtained is combined with triangu-
lation and combined and interpreted in the table.
In triangulation, the students playing the physi-
cian’s, and patient’s roles were evaluated together
with ‘success in being simulated patients’ and ‘satis-
faction with the peer-assisted patient-physician
interviews’(Table 2).
In the absence of simulated patients, it was deter-
mined that students achieved an over 88% success rate
in the patient-physician interviews and peer-simulated
patient roles. Although they were less satisfied with
playing the peer-simulated patient’s role, the satisfac-
tion with the peer-assisted patient-physician interviews
was rated between 77.33% and 98%.
Discussion
This study was conducted to determine whether
medical students’ patient-physician interview skills
could be implemented by peer simulation in the
absence of simulated patients.
In faculties facing difficulties with providing
simulated patient for patient-physician interview
skills training, a different teaching strategy that
meets the same function is needed to ensure that
students gain skills at a low cost. Indeed, in this
study, nearly all of the students were successful in
patient-physician interviews performed using peer-
simulated patients.
The 26,found that changing a student’s role
during learning experiences encourages students
to learn [26]. In another study conducted with
peers, it was determined that patient-physician
interviews contributed to the students’ ability to
take anamnesis, manage emotional problems, and
self-assess [5, 23]. Similarly, peer simulation devel-
ops communication, empathy, trust, and profes-
sional skills [5]. In our study, we observed that
students playing the physician’s role were success-
ful in starting patient interviews, taking ana-
mnesis, and using the appropriate nonverbal
communication skills. These students were evalu-
ated through the PROF, which Cronbach’s alpha
reliability coefficient was found to be 0.71. In the
literature, Cronbach’s alpha reliability coefficient
is interpreted as good if it is between 0.70 and
0.90 [29].
1,and 30,emphasized that design features such as
feedback, planned implementation, the difficulty of
simulation, clinical variation, and individualized
learning should be taken into account in simulation
training [1,30]. In our study, it was seen that stu-
dents playing the peer-simulated patient’s role
failed to give feedback to those playing the physi-
cian’s role. However, although the students were
trained in giving feedback, they were found to be
biased. 31,emphasized that peers evaluated each
other generously in peer evaluation, while another
study stated that peers may rate each other highly
in small groups (small circle collusion) or large
groups (pervasive collusion) [31,32].
In studies related to patient-physician inter-
views performed with peer simulation method, it
is said that students can carry out the training
process more easily than they do with simulated
patients as they play the peer-simulated patient’s
role [5]. In our study, while playing the physi-
cian’s and observer’s roles was satisfactory for
the students, playing the peer-simulated patient’s
role was not that satisfactory. One can speculate
that they had difficulty getting into the role, as the
patient-physician interview skills training using
the peer-simulation method was conducted for
Table 2. Triangulation of Patient-Physician Interview Skills Data.
Merged Data %
Success Rate of Being an Interviewer Physician 92,00
Peer Simulated Patient Success Rate 88,92
Patient
Physician
Interview
Satisfaction
Rate
Satisfaction with patient-physician interview 98,00
Satisfaction with the fact the simulated patient is a peer simulated patient 84,00
Interest to have a patient-physician interview in the years to come 92,00
Finding the patient-physician interview experience helpful 96,00
Finding the patient-physician interview experience useful 77,33
● Satisfaction of being an interviewer physician
● Peer-to-peer simulated patient satisfaction
● Satisfaction of being an observer
80,53
56,66
82,00
6 F. İ. TENGIZ ET AL.
the first time. It is thought that students’ satisfac-
tion may increase as they become more familiar
with the patient-physician interview skills training.
During peer simulation, students contribute to
each other’s learning ‘as patients’ not by ‘teaching’
[5]. 7,similarly state that students could develop the
ability to conduct patient-physician interviews if
they observed other physicians [7]. In our study,
students expressed their satisfaction and contribu-
tion to their learning by playing the observer’s role.
According to the systematic review of the studies
that perform patient-physician interviews with
peer-simulated patients, peer simulation is an effec-
tive learning approach [5]. In our study, as a result
of the evaluation of the action, the patient-
physician interviews with the peer-simulated
patient was successfully completed.
One limitation of this study is failing to practi-
cally compare the peer simulation technique with
standardized patient simulation due to the lack of
standardized patient simulation in the medical
school where the application was carried out.
Another limitation is the inability to include
all second-year students in this study due to the
pandemic.
Conclusion
In the absence of simulated patients, peer-assisted
simulation can be performed to contribute to medical
students’ patient-physician interview skills. To obtain
better results from peer-assisted patient-physician
interviews, making the following arrangements
within institutions is recommended:
• Organizing additional training to increase stu-
dents’ ability to give constructive feedback to their
peers,
• Planning multicenter researches that evaluate the
institution gains (time, cost, workforce, etc.) obtained
through peer-simulated patient usage.
• Ensuring the sustainability of the action research
cycle by evaluating peer-simulated patient practice in
the coming years.
Consideration of peer-assisted simulation by edu-
cators, students and administrators will ensure that
the practice becomes widespread.
We would like to thank Associate Professor Zeynep
Sofuoğlu, Associate Professor Nilüfer Demiral Yılmaz and
Associate Professor Esra Meltem Koç for supporting us
with expert opinions when creating the patient scenario.
We would like to thank the second-year students who
participated in the study and conducted the patient physi-
cian interviews.
No potential conflict of interest was reported by the
author(s).
The author(s) reported there is no funding associated with
the work featured in this article.
ORCID
Funda İfakat Tengiz http://orcid.org/0000-0002-8491-
9190
[1] Motola I, Devine LA, Chung HS, et al. Simulation in
healthcare education: a best evidence practical guide.
AMEE Guide No. 82. Med Teach. 2013;35(10):10.
[2] Branch WT, Arky RA, Woo B, et al. Teaching medi-
cine as a human experience: a patient-doctor relation-
ship course for faculty and first-year medical students.
Ann Intern Med. 1991;114(6):482–489.
[3] Bugaj TJ, Blohm M, Schmid C, et al. Peer-assisted
learning (PAL): skills lab tutors’ experiences and moti-
vation. BMC Med Educ. 2019;19(1):353. https://doi.
org/10.1186/s12909-019-1760-2
[4] Cleland JA, Abe K, Rethans JJ. The use of simulated
patients in medical education: AMEE Guide No 42 1.
Med Teach. 2009;31(6):477–486.
[5] Dalwood N, Bowles KA, Williams C, et al. Students as
patients: a systematic review of peer simulation in
health care professional education. Med Educ.
2020;54(5):387–399.
[6] Senol Y, Yardım S, Başarıcı İ. Öğrencilerin
Standart Hasta Uygulaması Hakkındakı Görüşleri:
birinci Yil Sonuçları. Tıp Eğitimi Dünyası. 2014;13
(41):19–26.
[7] Friedman M, Sutnick AI, Stillman PL, et al. The use of
standardized patients to evaluate the spoken-English
proficiency of foreign medical graduates. Acad Med.
1991;66(9):61–63.
[8] Zendejas B, Wang AT, Brydges R, et al. Cost: the missing
outcome in simulation-based medical education research:
a systematic review. Surgery. 2013;153(2):160–176.
[9] Bowman MA, Russell NK, Boekeloo BO, et al. The
effect of educational preparation on physician per-
formance with a sexually transmitted
disease-simulated patient. Arch Internal Med.
1992;152(9):1823–1828.
[10] Lane C, Rollnick S. The use of simulated patients and
role-play in communication skills training: a review of
the literature to August 2005. Patient Educ Couns.
2007;67(1–2):13–20.
[11] Riaz S. How simulation-based medical education can
be started in low resource settings. J Ayub Med Coll
Abbottabad. 2019;31(4):636–637.
[12] Rollnick S, Kinnersley P, Butler C. Context-bound
communication skills training: development of
a new method. Commun Skills. 2002;36:377–383.
[13] Ross MT, Cameron HS. Peer assisted learning: a planning
and implementation framework: AMEE Guide no. 30.
Med Teach. 2007;29(6):527–545.
MEDICAL EDUCATION ONLINE 7
https://doi.org/10.1186/s12909-019-1760-2
https://doi.org/10.1186/s12909-019-1760-2
[14] Topping KJ. Trends in peer learning. Educ Psychol.
2005;25(6):631–645.
[15] Nestel D, Kidd J. Peer assisted learning in patient
centred interviewing: the impact on student tutors.
Med Teach. 2005;27(5):439–444.
[16] Burgess A, McGregor D, Mellis C. Medical students as
peer tutors: a systematic review. BMC Med Educ. 2014;14
(1):1–8.
[17] Dandavino M, Snell L, Wiseman J. Why medical students
should learn how to teach. Med Teach. 2007;29
(6):558–565.
[18] Ivankova NV. Applying mixed methods in action
research. In: Mixed methods applications in action
research, SAGE publıcatıons. 2015. p. 50–83.
[19] Altunışık R, Coşkun R, and Bayraktaroğlu S, et al.
Bilimsel Araştırmalarda Veri. In: Sosyal Bilimlerde
Araştırma Yöntemleri -SPSS Uygulamalı (5. Baskı.
Sakarya Publıcatıons: Sakarya Yayıncılık; 2007. p.
63–97.
[20] Ivankova N, Wingo N. Applying mixed methods
in action research: methodological potentials and
advantages. Am Behav Sci. 2018;62(7):978–997.
[21] Barrows HS, and Barrows HS. Simulated Patients
in Medical Teaching. Canad Med Ass J April.
1968;98(14):674–676.
[22] Keifenheim KE, Teufel M, Ip J, et al. Teaching history
taking to medical students: a systematic review. BMC
Med Educ. 2015;15(1):1.
[23] Keifenheim KE, Junne F, Erschens RS, et al. Peer-
assisted history-taking groups: a subjective assessment
of their impact upon medical students’ interview
skills. GMS J Med Educ. 2017;34(3):1–15.
[24] Laidlaw A, Hart J. Communication skills: an essential
component of medical curricula. Part I: assessment of
clinical communication: AMEE Guide No. 51. Med
Teach. 2011;33(1):6–8.
[25] Nestel D, Kidd J. Peer tutoring in patient-centred inter-
viewing skills: experience of a project for first-year
students. Med Teach. 2003;25(4):398–403.
[26] Yu TC, Wilson NC, Singh PP, et al. Medical
students-as-teachers: a systematic review of
peer-assisted teaching during medical school. Adv
Med Educ Pract. 2011;2:157–172.
[27] Alinier G (2011). Developing high-fidelity health
care simulation scenarios: a guide for educators
and professionals. 10.1177/1046878109355683
[28] Bambini D. Writing a Simulation Scenario: a Step-By-
Step Guide. AACN Advanced Critical Care. 2016;27
(1):62–70.
[29] George D, and Mallery P. SPSS for Windows step by
step: a simple guide and reference. In: “Alpha de
Cronbach.” 11.0 update, 4th. Allyn & Bacon:
Boston; 2003. p. 231.
[30] McGaghie WC, Issenberg SB, Petrusa ER, et al. A critical
review of simulation-based medical education research:
2003–2009. Med Educ. 2010;44(1):50–63.
[31] Borkan B. Akran Değerlendirmesinde Puanlayıcı
Katılığı Kayması. Eğitimde ve Psikolojide Ölçme
ve Değerlendirme Dergisi. 2017;8(4):469–488.
[32] Song Y, Hu Z, and Gehringer EF (2017). Collusion in
educational peer assessment: how much do we need to
worry about it? Proceedings – Frontiers in Education
Conference, Indianapolis, IN, USA, FIE, 1–8. 10.1109/
FIE.2017.8190621
8 F. İ. TENGIZ ET AL.
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- Abstract
Introduction
Methods
Data analysis methods
Planning
Acting
Ethics committee
Results
Discussion
Conclusion
Acknowledgments
Disclosure statement
Funding
References
Research Article
Breaching the Bridge: An Investigation into Doctor-Patient
Miscommunication as a Significant Factor in the Violence against
Healthcare Workers in Palestine
Munther Saeedi ,1 Nihad Al-Othman ,2 and Maha Rabayaa 2
1Language Centre/Faculty of Human Science, An-Najah National University, Nablus, State of Palestine
2Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, State of Palestine
Correspondence should be addressed to Nihad Al-Othman; n.othman@najah.edu
Received 18 March 2021; Revised 25 June 2021; Accepted 13 July 2021; Published 23 July 2021
Academic Editor: Arundhati Char
Copyright © 2021Munther Saeedi et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background. Workplace violence is a common issue worldwide that strikes all professions, and healthcare is one of the most
susceptible ones. Verbal and nonverbal miscommunications between healthcare workers and patients are major inducers for
violent attacks. Aim. To study the potential impact of verbal and nonverbal miscommunications between the patients and
healthcare workers upon workplace violence from the patients’ perspectives. Methods. A descriptive cross-sectional study was
performed from November to December 2020. Patients and previously hospitalized patients were asked to complete a self-
reported questionnaire that involved items of verbal and nonverbal miscommunication. With the use of a suitable available
sample composed of 550 participants, 505 had completed the questionnaire and were included in the study. The data were
analyzed by using SPSS version 22 software. Results. 7.2% of the study population reported participating in nonverbal violence
and 19.6% participated in verbal violence against healthcare workers. The nonverbal and verbal violence was characteristically
displayed by the patients who are male, younger than 30 years old, and bachelor’s degree holders. The results of the study
demonstrated that the verbal and nonverbal miscommunications between the patients and healthcare workers were the major
factors in provoking violent responses from patients. Factors, such as age, gender, and level of education, were significant
indicators of the type of patients who were more likely to respond with violence. Conclusion. Workplace violence, either verbal
or nonverbal, in the health sector is a public health concern in Palestine. The verbal and nonverbal communication skills of
healthcare workers should be developed well enough to overcome the effect of miscommunication provoking violent acts from
patients and their relatives as well.
The National Institute for Occupational Safety and Health
(NIOSH) defines workplace violence as “ any physical
assault, threatening behavior, or verbal abuse occurring in
the work setting” [1]. Globally, workplace violence has
gained a greater concern in the recent century. Assaults and
acts of violence were observed against all professionals irre-
spective of the nature of their profession, and the healthcare
professional is not an exception. However, it has been
reported that retailing and service sector encounter more
than 80% of workplace violence in the United State. And
the health sector workers encounter workplace violence six-
teen times more than workers in any other service sector
[2]. Violent attacks against healthcare workers abound in
clinics, health care centers, and hospitals; every day, the
media shows something related to violence against health-
care workers around the world. Several factors, including
individual, organizational, and environmental factors, are
the likely origins of the various forms of violence in the
healthcare sector [3]. Unfortunately, the precise incidence
of workplace violence globally is not documented, especially
in developing countries. However, workplace violence is neg-
atively affecting work performance since it is associated with
decreased productivity, decreased morale, increased stress
and depression, and lower service efficiency among
Hindawi
BioMed Research International
Volume 2021, Article ID 9994872, 8 pages
https://doi.org/10.1155/2021/9994872
https://orcid.org/0000-0003-4912-9000
https://orcid.org/0000-0002-5096-3353
https://orcid.org/0000-0002-8702-5213
https://creativecommons.org/licenses/by/4.0/
https://doi.org/10.1155/2021/9994872
employees [4]. Healthcare workers, irrespective of where they
work, are very likely to be abused verbally and physically,
which may result in disappointment, despair, and in certain
circumstances, frustration among them [5]. Healthcare
workers, in general, and doctors, in specific, are always tar-
geted by patients or patients’ relatives; doctors serving in
Accident and Emergency Departments are more likely to be
victims of violent attacks by patients and relatives more than
any other healthcare workers [6].
Patient-healthcare worker communication is a central
clinical requirement, and it is taken for granted that the suc-
cess of healthcare workers is no longer attributed to their
capacity to provide health care and medical services; neither
is it related to how much information they have. It depends,
to a large extent, on their ability to communicate with their
clients and their family members [7]. A healthcare worker
is expected to be a good communicator; otherwise, s/he is
likely to be assaulted and attacked by patients or their rela-
tives due to dissatisfaction with the health service provided
[8, 9]. Recently, health care workers have been victims of cli-
ents’ assaults and violence, whether it is verbal or nonverbal
[10, 11]. Acts of violence against healthcare workers can be
attributed to several factors including, but not limited to, long
waiting periods, dissatisfaction with prescriptions and treat-
ment methods, disagreement with doctors, verbal offenses
or negative comments, and the negative impact of certain
medications, such as recreational drugs [12]. A large bulk
of these incidents may be attributed to a lack of good com-
munication skills that is required of healthcare workers in
order to put their patients at ease before commencing their
medical and physical examination [7, 13].
Most of the previous studies have focused on the inci-
dence of workplace violence from the workers’ perspective.
This study is a leading one in Palestine as it shows the inci-
dence of workplace violence from the patients’ perspectives.
This study also aims to identify the crucial communication
skills, verbal or nonverbal, that should be incorporated in
the communications curriculum to explore how communica-
tion lapses may lead to the occurrence of violent attacks
against doctors.
2.1. Ethical Consideration. This study received official ethical
approval from the Institutional Review Board at An-Najah
National University located in Nablus/Palestine. The study
abided by “the Declaration of Helsinki (DOH).” All ethical
considerations for medical research concerning human sub-
jects were enforced. The human subject confidentiality and
rights were preserved throughout the study. Written
informed consent was provided and handed to each patient
(Appendix). The form described the study procedure, dura-
tion, benefit, and lack of any harmful intentions. Moreover,
the form indicated that all data collected would be used for
research purposes only, while any information related to
the patient would be kept confidential from all parties except
the research investigators. The patients were fully informed
that participation in the study was voluntary and that no pen-
alty would be enforced in case of nonparticipation.
2.2. Study Sample. A cross-sectional study was carried out
from November to December of the academic year
2020/2021 on patients attending hospitals seeking medical
service, e.g., clinics and laboratories, surgery operations,
and emergency rooms to investigate the doctor-patient mis-
communication as a significant factor in violence against
healthcare workers in Palestine before discharge and during
follow-up visits. A convenient nonprobability available sam-
ple took part in this study. The sample size was estimated
using the Jekel equation. The assumption of the probability
of violence against healthcare workers was 0.5 with a confi-
dence level of 95%; the estimated minimum sample size
was 384. Nevertheless, the researchers decided to increase
the sample size to 550, to decrease the standard error of the
mean and to account for the nonresponse rate. In the end,
505 participants, who were previously hospitalized in seven
hospitals with different specialties in Palestine, completed
the questionnaire and were included in the study.
2.3. Inclusion and Exclusion Criteria. The inclusion criteria
included patients or previously hospitalized patients within
six months of questionnaire administration and agreed to
participate in this study. The patients were from different
age groups, residential areas (city, camp, or village), and
levels of education. The exclusion criteria included patients
who refused to participate in the study and the doctors who
work in the medical field.
2.4. Study Instrument. A self-administered questionnaire in
Arabic was used for data collection and was distributed to
the study population. The questionnaire was made up of four
sections: sociodemographic factors including age, level of
education, gender, and place of residence, verbal miscommu-
nication section which comprised 14 items, the nonverbal
miscommunication section which was composed of 6 items,
and two questions whether a patient had ever participated
in verbal or nonverbal violence. To ensure the validity of
the study instrument, the tool was given to five experts in
the field of public health. There was an agreement among
them regarding the content of the questionnaire.
2.5. Pilot Study. A pilot study was performed on 30 individ-
uals from different age groups to determine questionnaire
wording, formatting, completeness of responses, clarity of
choices, the relevance of the statements, and the time needed
to fill the form. The questionnaire was modified accordingly.
The internal consistency of the questionnaire was measured
based on Cronbach Alpha values (0.81) before data
collection.
2.6. Statistical Analysis. All statistical analyses were con-
ducted using Statistical Package for the Social Sciences ver-
sion 22 (SPSS 22). Descriptive analyses were used for
sociodemographic characteristics. An initial univariate anal-
ysis was used to compare sociodemographic variables and
variables related to exposure to violence. Chi-Square Test
was used to determine the relationship between sociodemo-
graphic variables and verbal and nonverbal miscommunica-
tions. A p value of <0.05 was considered statistically
significant.
2 BioMed Research International
3.1. Demographic Characteristics of the Study Population.
The data were analyzed and tested for normality and found
to be normally distributed. Of the 505 patients who took part
in the study, 272 (53.9%) were males, and 233 (46.1%) were
females. The age group ≤29 years was the highest 241
(47.7%), while the age group 50-59 interval 45 (8.9%) was
the lowest. According to the level of education, the bachelor’s
degree was the highest 299 (59.2%), while the diploma was
the lowest 34 (6.7%). Based on the place of residence, 205
(49.9%) of the study population were from villages, and 48
(9.5%) of them were from camps Table 1.
3.2. The Distribution of Physical and Verbal Violence against
HealthcareWorkers. The researchers found that the total per-
centage of patients involved in physical and verbal violence
against healthcare workers was 26.8%; 7.2% were involved
in the act of physical violence; 4% of them were males while
3.2% were females, 4.2% were ≤29 years old, and 4.6% were
bachelor’s degree holders. On the other hand, 19.6% of the
study population were involved in verbal violence against
healthcare workers; 13% were males while 6.6% were females,
9.6% were less than 30 years old, and 13% were bachelor’s
degree holders (Table 2). Of the study population, 73.2%
were not involved in any act of violence against healthcare
workers.
3.3. Verbal Miscommunications in relation to Different
Demographic Factors. The ratios and correlations between
the 14 verbal miscommunication items and the different
demographic factors from the patient’s perspective are found
in Table 3. It was revealed that most of the study population
agreed that violence, physical or verbal, against healthcare
workers was due to inappropriate verbal communication
between healthcare providers and patients, based on the eval-
uated parameters (see Table 3). The reasons for violence,
either physical or verbal, against healthcare workers are
mostly because the healthcare workers: do not use simplified,
clear language when they communicate with patients and
their relatives (63.5%), do not consider patients and their rel-
atives’ level of education (77.1%), do not speak clearly when
they communicate with patients and their relatives (74.8%),
do not take into consideration the psychological state of
patients and their relatives (79.8%), do not pick the right time
to break bad news (54.9%), do not answer patients’ and rela-
tives’ questions well (75.3%), show some superiority when
communicating with patients and relatives (73.7%), do not
show sympathy and empathy when communicating with
patients and relatives (72.7%), do not focus when communi-
cating with patients and relatives (76.6%), do not use courte-
ous language when communicating with patients and
relatives (64.7%), are not competent enough to ask the right
questions when communicating with patients and relatives
(42%), do not listen attentively when communicating with
patients and relatives (72.3%), do not handle patients’ and
relatives’ complaints appropriately (71.7%), and do not ask
open-ended questions competently to enable patients and
their relatives to speak freely (68.9%).
The role of various verbal miscommunications in initiat-
ing workplace violence is found to be significantly variable
based on the patient’s characteristics. Significant differences
were found between male and female responses regarding
these items: describing the language used by healthcare
workers when dealing with patients and their families
(p < 0:05), the proper time for healthcare workers to break
bad news (p < 0:01), whether healthcare workers answer all
the questions raised by patients and their families (p < 0:05
), and whether healthcare workers communicate courteously
with patients and their families (p < 0:001) (Table 3).
Significant differences were found between the responses
of the different age groups regarding these items: healthcare
workers do not use simplified clear language (p < 0:01), do
not speak clearly when they communicate with patients and
their relatives (p < 0:05), and do not use courteous language
when communicating with patients and relatives (p < 0:01)
(Table 3). According to the level of education, a significant
difference was found regarding the item that healthcare
workers cannot handle patients’ and relatives’ complaints
appropriately (p < 0:05). There is no significant difference
between the place of residence and their answers (Table 3).
3.4. Nonverbal Miscommunications in relation to Different
Demographic Factors. The ratios and correlations between
the six nonverbal miscommunication items and the different
demographic factors from the patient’s perspective are found
in Table 4. Patients and previously hospitalized patients are
Table 1: Demographic characteristics of the study population
(n = 505).
Variable Number Percentage (%)
Gender
Male 272 53.9
Female 233 46.1
Total 505 100
Age groups (years)
≤29 241 47.7
30-39 125 24.8
40-49 94 18.6
50-59 45 8.9
Total 505 100
Level of education
Tawjihi or less 35 6.9
Diploma 34 6.7
Bachelor∗ 299 59.2
Graduated studies∗∗ 137 27.1
Total 505 100
Place of residence
City 205 40.6
Camp 48 9.5
Village 252 49.9
Total 505 100
∗undergraduate; ∗∗completed graduation.
3BioMed Research International
influenced greatly by several nonverbal miscommunications.
The reasons for violence, either physical or verbal, against
healthcare workers are mostly because the healthcare
workers: do not maintain good eye contact (66.6%), do not
smile frequently (64.5%), do not have a comfortable voice
tone (70.7%), often have a frown on their faces (47.9%), are
often seated provocatively (71.9%), and do not employ hand-
shakes properly (49.9%) (Table 4).
Significant differences were found between male and
female responses to three items: healthcare workers do not
maintain good eye contact (p < 0:05), they have a frown
when communicating with patients and their families
(p < 0:01), and they do not employ handshakes properly
(p < 0:05). Furthermore, based on the level of education, a
significant difference was found in answers regarding the
item stating that the healthcare workers are often seated pro-
vocatively (p < 0:001) (Table 4).
To the knowledge of the researchers, this is the first study in
Palestine describing the violence against healthcare workers
from the patients’ perspectives. This study revealed that
7.2% of the study population was involved in an act of phys-
ical violence against healthcare workers. Also, 19.6% of the
study population was involved in an act of verbal violence
against healthcare workers. In Palestine, violence against
healthcare workers was 20.8% nonverbal and 59.6% verbal
violence from the view of the healthcare workers [11, 14].
In another study, 35.6% of the healthcare workers in the
emergency department were exposed to nonverbal violence,
while 71.2% of them were exposed to verbal violence [14].
In Jordan, 10.4% of violence against healthcare workers was
nonverbal, while 63.5% of violence was verbal [15]. A similar
study in Saudi Arabia revealed that 5.3% of the violence
against healthcare workers was nonverbal while 39.2% was
verbal [16]. The verbal form of violence was the most domi-
nant form of violence against healthcare workers with gener-
ally high rates of violence reported from the healthcare
workers’ perspectives [15–18]. However, rare studies are
available about workplace violence in the health sector from
the patient perspective. A study conducted in China reported
that 1.5% of patients responded to medical disputes by
resorting to violence against healthcare workers. Signifi-
cantly, in the reports of violence against healthcare workers,
it was found that such assaults were more likely to be carried
out by male patients, patients with a high-income level, and
patients generally dissatisfied with life. On the other hand,
it was established that trust between the healthcare worker
and patient resulted in nonviolent resolutions of medical dis-
putes [19].
It can be observed that the percentage of violence is
greatly variable when it is studied from the perspective of
either patients or healthcare workers. These controversial
results from different perspectives in the rate of workplace
violence in the health sector affirm the need for definitive
policies regarding the definition of violence, proper reporting
strategies, and actions to control this prevalent problem with
its detrimental impact on the effectiveness of healthcare ser-
vice, medical practitioner psychology, and patient satisfac-
tion [20, 21].
The optimal health service requires effective communica-
tion between the patient and the healthcare workers, whether
in the verbal or nonverbal form [22]. This study focuses on
different parameters related to both forms of communication
between the patients and healthcare workers from the
patients’ perspective since patient satisfaction has a critical
role in the development of the healthcare sector and the
reduction of potential acts of violence against the healthcare
workers [23]. The personal interaction between healthcare
workers and patients is a pivotal requirement to achieve an
effective medical service and to avoid adverse outcomes.
Consequently, the disruption of this complex communica-
tion, either verbal or nonverbal, is a vital reason for the vio-
lence in the health sector, in addition to other
organizational, environmental, and individual factors, such
as long waiting time, the discrepancy between patients’
expectations and services received, psychiatric conditions,
and insufficient security [24, 25].
In this study, fourteen items involved in the verbal mis-
communication between the patient and the healthcare
workers have been evaluated from the patient’s perspective
(Table 3). This study revealed that most of the study popula-
tion agreed that violence, physical or verbal, against health-
care workers was due to inappropriate verbal
communication between healthcare providers and patients.
The results of this study are consistent with another recent
study in which ineffective communications, poor experience,
and other socio-behavioral problems were shown to be the
major factors contributing to workplace violence [26]. A pre-
vious study reported that effective management of workplace
violence against healthcare providers requires training
Table 2: Distribution of patients or previously hospitalized patients involved in physical or verbal violence against healthcare workers
(n = 505).
Item The total %
Gender Age groups Level of education
Male % Female % ≤29% 30-39% 40-49% 50-59% Tawj% Diplo% Ba% GS%
Individuals involved in an
act of physical violence
against healthcare workers
7.2 4 3.2 4.2 2 1 0 0.8 0.4 4.6 1.4
Individuals involved in an
act of verbal violence
against healthcare workers
19.6 13 6.6 9.6 5.4 4 0.6 1.6 1.4 13 3.6
Tawj: Tawjihi (higher secondary school); Diplo: Diploma; Ba: Bachelor; GS: Graduate studies.
4 BioMed Research International
Table 3: Verbal miscommunications in relation to different demographic factors (n = 505).
Item
Strongly
agree
(%)
Agree
(%)
I do
not
know
(%)
Disagree
(%)
Strongly
disagree
(%)
Gender
(p
value)
Age
groups
(p
value)
Level of
education
(p value)
Place of
residence
(p value)
(1) One of the reasons for violence, physical or
verbal, against healthcare workers is because
they do not use simplified, clear language
16.2 47.3 11.1 18.8 6.5 0.017∗ 0.004∗∗ 0.056 0.899
(2) One of the reasons for violence, physical or
verbal, against healthcare workers is because
they do not consider patients and their
relatives’ educational level
22.6 54.5 6.1 12.3 4.6 0.953 0.337 0.05∗ 0.921
(3) One of the reasons for violence, physical or
verbal, against healthcare workers is because
they do not speak clearly when they
communicate with patients and their relatives
21.4 52.7 8.1 14.1 3.8 0.247 0.033∗ 0.584 0.779
(4) One of the reasons for violence, physical or
verbal, against healthcare workers is because
they do not take into consideration the
psychological status of patients and their
relatives
29.9 49.9 5.9 10.7 3.6 0.753 0.914 0.097 0.135
(5) One of the reasons for violence, physical or
verbal, against healthcare workers is because
they do not pick the right time to break the bad
news
13.1 41.8 18.2 21.8 5.1 0.009∗∗ 0.643 0.648 0.706
(6) One of the reasons for violence, physical or
verbal, against healthcare workers is because
they do not answer patients and relatives’
questions well
25 50.3 8.7 11.7 4.4 0.042∗ 0.213 0.511 0.948
(7) One of the reasons for violence, physical or
verbal, against healthcare workers is because
they show some superiority when
communicating with patients and relatives
32.7 41 7.1 12.3 6.9 0.308 0.714 0.850 0.603
(8) One of the reasons for violence, physical or
verbal, against healthcare workers is because
they do not show sympathy and empathy when
communicating with patients and relatives
23.4 49.3 8.1 15.6 3.6 0.998 0.093 0.598 0.236
(9) One of the reasons for violence, physical or
verbal, against healthcare workers is because
they do not show much concentration when
communicating with patients and relatives
27.7 48.9 9.1 10.3 4 0.162 0.238 0.934 0.837
(10) One of the reasons for violence, physical or
verbal, against healthcare workers is because
they do not use courteous language when
communicating with patients and relatives
17.8 46.9 11.5 18.4 5.3 0.001∗∗ 0.003∗∗ 0.417 0.075
(11) One of the reasons for violence, physical or
verbal, against healthcare workers is because
they are not competent enough to ask the right
questions when communicating with patients
and relatives
8.1 33.9 23.4 28.9 5.7 0.159 0.316 0.288 0.432
(12) One of the reasons for violence, physical or
verbal, against healthcare workers is because
they do not listen attentively when
communicating with patients and relatives
17.4 54.9 9.3 14.1 4.4 0.536 0.428 0.797 0.974
(13) One of the reasons for violence, physical or
verbal, against healthcare workers is because
they cannot handle patients and relatives’
complaints appropriately
17 54.7 11.9 11.9 4.6 0.840 0.367 0.027∗ 0.887
5BioMed Research International
courses that aid in constructing healthcare worker-patient
relationships, improving the healthcare workers’ verbal and
nonverbal communication skills, and accurate reporting of
each violent incident [27–30].
The variables of gender, age, and level of education have
been found to influence a patient’s propensity to a violent
response to miscommunication with a healthcare worker
(Table 3). These variations have been previously identified as
Table 3: Continued.
Item
Strongly
agree
(%)
Agree
(%)
I do
not
know
(%)
Disagree
(%)
Strongly
disagree
(%)
Gender
(p
value)
Age
groups
(p
value)
Level of
education
(p value)
Place of
residence
(p value)
(14) One of the reasons for violence, physical or
verbal, against healthcare workers is because
they are not competent enough to ask open-
ended questions to enable patients and their
relatives to speak freely
17.4 51.5 13.1 14.7 3.4 0.129 0.305 0.863 0.926
∗p < 0:05, ∗∗p < 0:01, ∗∗∗p < 0:001.
Table 4: Nonverbal miscommunications in relation to different demographic factors (n = 505).
Item
Strongly
agree
Agree
I do not
know
Disagree
Strongly
disagree
Gender
(p value)
Age groups
(p value)
Level of education
(p value)
Place of residence
(p value)
(1) One of the reasons
for violence, physical
or verbal, against
healthcare workers
is because they do
not maintain good
eye contact
13.3 53.3 16.4 13.7 3.4 0.05∗ 0.079 0.065 0.140
(2) One of the reasons
for violence, physical
or verbal, against
healthcare workers
is because they do
not smile frequently
17.8 46.7 8.9 20.6 5.9 0.228 0.617 0.081 0.418
(3) One of the reasons
for violence, physical
or verbal, against
healthcare workers
is because they do
not have a comfortable
voice tone
18.8 51.9 10.3 14.7 4.4 0.195 0.210 0.076 0.402
(4) One of the reasons
for violence, physical
or verbal, against
healthcare workers
is because they often
have a frown on their
faces
11.9 36 18.4 27.5 6.1 0.003∗∗ 0.433 0.086 0.827
(5) One of the reasons
for violence, physical
or verbal, against
healthcare workers
is because they are
often seated in a
provocatively
20.8 51.1 9.9 14.1 4.2 0.107 0.377 0.001∗∗∗ 0.809
(6) One of the reasons
for violence, physical
or verbal, against
healthcare workers
is because they do
not employ
handshakes
properly
16.2 33.7 15 26.9 8.1 0.05∗ 0.481 0.494 0.497
∗p < 0:05, ∗∗p < 0:01, ∗∗∗p < 0:001.
6 BioMed Research International
risk factors contributing to workplace violence; healthcare
workers are at greater risk of assault from young male patients
with a low level of education, in addition to other societal, orga-
nizational, and patient- and doctor-related factors [31–34].
Workplace violence against healthcare workers has dele-
terious effects on the psycho-social well-being of the pro-
viders, as well as on patient management [35, 36]. As a
result, healthcare workers need to take into consideration
the patient’s variables such as age, gender, and level of educa-
tion during verbal communication to decrease any potential
for violent attacks against them. This also implies the impor-
tance of training courses for healthcare workers in proper
communications, including verbal or nonverbal skills, with
patients as a prepractical requirement [37].
By evaluating the role of six items of nonverbal commu-
nication as a reason for violence against healthcare workers
(Table 4), the patients’ gender and level of education were
found to have significant influence. The results of this study
are consistent with what was previously reported as impor-
tant but overlooked nonverbal communication lapses in
patient-doctor communication [37, 38]. Nonverbal commu-
nication can foster trust between patient and doctor [39].
Effective verbal and nonverbal communication in the work-
place is the first line of defense against violence, as good com-
munication skills will make the healthcare workers more
confident in thwarting aggressive attacks [40, 41].
In conclusion, workplace violence against healthcare workers
is an increasing problem in the health sector. As effective com-
munication is vital in achieving good healthcare, patient satis-
faction, staff confidence, and staff rights, the verbal and
nonverbal miscommunications between the patients and
healthcare workers are a serious concern because of their
adverse impact upon the integrity of the medical services.
Health care workers should take into consideration the varia-
tions in patients’ age, gender, level of education, and place of
residence in order to communicate effectively and to avoid
the possibility of violent confrontations. The improvement of
both verbal and nonverbal communication skills among
healthcare workers is recommended to foster the proper level
of trust between patients and their healthcare providers. This
requires extensive training courses as a prepractical require-
ment. Finally, it is important to develop standard policies
about the definition of workplace violence, reporting methods
and to put proper penalties in place that protect the rights of
all involved parties in the conflict.
The patients who refused to participate in the study could be
the ones who might be a greater contributor to the violence
against healthcare workers. As this research is the first of its
kind in Palestine, there are no previous studies in the area
available for the comparison of data. The geographic and
demographic variations between patients in more such stud-
ies would provide wider-ranging findings. Moreover, there
are no definitive strategies regarding workplace violence in
the health sector to use as a baseline in violence classification
and required actions.
All the utilized data to support the findings of the current
study are included in the article.
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
There is no conflict of interest to declare.
The authors would like to offer their gratitude to the Faculty
of Medicine at An-National University.
All the utilized data to support the findings of the current
study are included in the supplementary material.
(Supplementary Materials)
References
[1] N. A. CDC, “The National Institute for Occupational Safety
and Health (NIOSH),” The Journal of Infection, vol. 3, no. 3,
pp. 98–105, 2010.
[2] C. Cooper and N. Swanson, “Workplace Violence in the
Health Sector,” in State of the art, Organización Internacional
de Trabajo, Organización Mundial de la Salud, Consejo Inter-
nacional de Enfermeras Internacional de Servicios Públicos,
Geneva, 2002.
[3] M. M. LeBlanc and E. K. Kelloway, “Predictors and outcomes
of workplace violence and aggression,” Journal of Applied Psy-
chology, vol. 87, no. 3, pp. 444–453, 2002.
[4] S. F. Rasool, M. Wang, Y. Zhang, and M. Samma, “Sustainable
work performance: the roles of workplace violence and occu-
pational stress,” International journal of environmental
research and public health, vol. 17, no. 3, p. 912, 2020.
[5] G. J. Ness, A. House, and A. R. Ness, “Aggression and violent
behaviour in general practice: population based survey in the
north of England,” BMJ, vol. 320, no. 7247, pp. 1447-1448, 2000.
[6] T. Kowalenko, D. Gates, G. L. Gillespie, P. Succop, and T. K.
Mentzel, “Prospective study of violence against ED workers,”
The American Journal of Emergency Medicine, vol. 31, no. 1,
pp. 197–205, 2013.
[7] J. F. Ha and N. Longnecker, “Doctor-patient communication:
a review,” Ochsner Journal, vol. 10, no. 1, pp. 38–43, 2010.
[8] A. Bredart, C. Bouleuc, and S. Dolbeault, “Doctor-patient
communication and satisfaction with care in oncology,” Cur-
rent Opinion in Oncology, vol. 17, no. 4, pp. 351–354, 2005.
[9] T. Begum, “Doctor patient communication: a review,” Journal
of Bangladesh College of Physicians and Surgeons, vol. 32, no. 2,
pp. 84–88, 2014.
7BioMed Research International
https://downloads.hindawi.com/journals/bmri/2021/9994872.f1.zip
[10] M. A. I. Khan, H. N. Ahasan, M. S. Mahbub, M. B. Alam, M. T.
Miah, and R. D. Gupta, “Violence against doctors,” Journal of
Medicine, vol. 11, no. 2, pp. 167–169, 2010.
[11] M. Kitaneh and M. Hamdan, “Workplace violence against
physicians and nurses in Palestinian public hospitals: a cross-
sectional study,” BMC Health Services Research, vol. 12,
no. 1, pp. 1–9, 2012.
[12] G. L. Gillespie, D. M. Gates, M. Miller, and P. K. Howard,
“Workplace violence in healthcare settings: risk factors and
protective strategies,” Rehabilitation Nursing, vol. 35, no. 5,
pp. 177–184, 2010.
[13] M. C. Kapoor, “Violence against the medical profession,” Jour-
nal of anaesthesiology, clinical pharmacology, vol. 33, no. 2,
pp. 145–147, 2017.
[14] M. Hamdan, “Workplace violence towards workers in the
emergency departments of Palestinian hospitals: a cross-
sectional study,” Human Resources for Health, vol. 13, no. 1,
pp. 1–9, 2015.
[15] R. Alhamad, A. Suleiman, I. Bsisu et al., “Violence against phy-
sicians in Jordan: an analytical cross-sectional study,” PLoS
one, vol. 16, no. 1, article e0245192, 2021.
[16] N. Alharthy, M. Mutairi, A. Alsahli et al., “Workplace violence
among emergency medical services workers in Riyadh, Saudi
Arabia,” Journal of Hospital Administration, vol. 6, no. 3,
pp. 26–32, 2017.
[17] S. A. al-Maskari, I. S. al-Busaidi, andM. A. al-Maskari, “Work-
place violence against emergency department nurses in Oman:
a cross-sectional multi-institutional study,” International
Nursing Review, vol. 67, no. 2, pp. 249–257, 2020.
[18] J. Liu, Y. Gan, H. Jiang et al., “Prevalence of workplace violence
against healthcare workers: a systematic review andmeta-anal-
ysis,” Occupational and Environmental Medicine, vol. 76,
no. 12, pp. 927–937, 2019.
[19] Y. Du, W. Wang, D. J. Washburn et al., “Violence against
healthcare workers and other serious responses to medical dis-
putes in China: surveys of patients at 12 public hospitals,”
BMC Health Services Research, vol. 20, no. 1, pp. 1–10, 2020.
[20] M. J. Boyle and J. Wallis, “Working towards a definition for
workplace violence actions in the health sector,” Safety in
health, vol. 2, no. 1, pp. 1–6, 2016.
[21] F. Ghrayeb, “Workplace Violence against StaffWorking in the
Emergency Department in West Bank, Palestine,” 2017.
[22] C. Chichirez and V. Purcărea, “Interpersonal communication
in healthcare,” Journal of medicine and life, vol. 11, no. 2,
pp. 119–122, 2018.
[23] A. A. Al-Qarni, O. Z. Alsharqi, D. A. Qalai, and N. Kadi, “The
impact of marketing mix strategy on hospitals performance mea-
sured by patient satisfaction: an empirical investigation on Jeddah
private sector hospital senior managers perspective,” Interna-
tional Journal of Marketing Studies, vol. 5, no. 6, p. 210, 2013.
[24] S. Vento, F. Cainelli, and A. Vallone, “Violence against health-
care workers: a worldwide phenomenon with serious conse-
quences,” Frontiers in Public Health, vol. 8, article 570459,
p. 541, 2020.
[25] A. Raveel and B. Schoenmakers, “Interventions to prevent
aggression against doctors: a systematic review,” BMJ open,
vol. 9, no. 9, article e028465, 2019.
[26] M. M. Hossain, R. Sharma, S. Tasnim, G. M. Al Kibria,
A. Sultana, and T. Saxena, “Prevalence, Characteristics, and
Associated Factors of Workplace Violence against Healthcare
Professionals in India: A Systematic Review and Meta-Analy-
sis,” 2020, https://www.medrxiv.org/content/10.1101/2020.01
.01.20016295v1/.
[27] G. d’Ettorre, M. Mazzotta, V. Pellicani, and A. Vullo, “Prevent-
ing and managing workplace violence against healthcare
workers in emergency departments,” Acta Bio Medica: Atenei
Parmensis, vol. 89, article e028465, Supplement 4, 2018.
[28] S. Hahn, V. Hantikainen, I. Needham, G. Kok, T. Dassen, and
R. J. Halfens, “Patient and visitor violence in the general hospi-
tal, occurrence, staff interventions and consequences: a cross-
sectional survey,” Journal of Advanced Nursing, vol. 68,
no. 12, pp. 2685–2699, 2012.
[29] S. M. Adib, A. K. Al-Shatti, S. Kamal, N. El-Gerges, and M. Al-
Raqem, “Violence against nurses in healthcare facilities in
Kuwait,” International Journal of Nursing Studies, vol. 39,
no. 4, pp. 469–478, 2002.
[30] L. Sofield and S. W. Salmond, “Workplace violence: a focus on
verbal abuse and intent to leave the organization,”Orthopaedic
Nursing, vol. 22, no. 4, pp. 274–283, 2003.
[31] A. Kumari, T. Kaur, P. Ranjan, S. Chopra, S. Sarkar, and
U. Baitha, “Workplace violence against doctors: characteris-
tics, risk factors, and mitigation strategies,” Journal of post-
graduate medicine, vol. 66, no. 3, pp. 149–154, 2020.
[32] M. Kumar, M. Verma, T. Das, G. Pardeshi, J. Kishore, and
A. Padmanandan, “A study of workplace violence experienced
by doctors and associated risk factors in a tertiary care hospital
of South Delhi, India,” Journal of clinical and diagnostic
research: JCDR, vol. 10, no. 11, p. LC06, 2016.
[33] S. Dehghan-Chaloshtari and A. Ghodousi, “Factors and char-
acteristics of workplace violence against nurses: a study in
Iran,” Journal of Interpersonal Violence, vol. 35, no. 1-2,
pp. 496–509, 2020.
[34] F. Najafi, M. Fallahi-Khoshknab, F. Ahmadi, A. Dalvandi, and
M. Rahgozar, “Antecedents and consequences of workplace
violence against nurses: a qualitative study,” Journal of Clinical
Nursing, vol. 27, no. 1-2, pp. e116–e128, 2018.
[35] A. Kaur, F. Ahamed, P. Sengupta, J. Majhi, and T. Ghosh, “Pat-
tern of workplace violence against doctors practising modern
medicine and the subsequent impact on patient care, in India,”
Plos one, vol. 15, no. 9, article e0239193, 2020.
[36] X. Xie, Y. Zhao, F. An et al., “Workplace violence and its asso-
ciation with quality of life among mental health professionals
in China during the COVID-19 pandemic,” Journal of Psychi-
atric Research, vol. 135, pp. 289–293, 2021.
[37] J. W. Kee, H. S. Khoo, I. Lim, andM. Y. Koh, “Communication
skills in patient-doctor interactions: learning from patient
complaints,” Health Professions Education, vol. 4, no. 2,
pp. 97–106, 2018.
[38] B. V. Bhat and M. K. Kingsley, “Effective non-verbal commu-
nication,” in Effective Medical Communication: The A, B,C, D,
E of it, pp. 39–47, Springer, 2020.
[39] Á. Lorié, D. A. Reinero, M. Phillips, L. Zhang, and H. Riess,
“Culture and nonverbal expressions of empathy in clinical set-
tings: a systematic review,” Patient Education and Counseling,
vol. 100, no. 3, pp. 411–424, 2017.
[40] L. Locke, G. Bromley, K. A. Federspiel, and BC GB, “Patient
violence: it’s not all in a day’s work,”GNA PRESIDENT’SMES-
SAGE, vol. 79, no. 1, p. 18, 2018.
[41] M. Baby, C. Gale, and N. Swain, “Communication skills train-
ing in the management of patient aggression and violence in
healthcare,” Aggression and Violent Behavior, vol. 39, pp. 67–
82, 2018.
8 BioMed Research International
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- Breaching the Bridge: An Investigation into Doctor-Patient Miscommunication as a Significant Factor in the Violence against Healthcare Workers in Palestine
1. Introduction
2. Materials and Methods
2.1. Ethical Consideration
2.2. Study Sample
2.3. Inclusion and Exclusion Criteria
2.4. Study Instrument
2.5. Pilot Study
2.6. Statistical Analysis
3. Results
3.1. Demographic Characteristics of the Study Population
3.2. The Distribution of Physical and Verbal Violence against Healthcare Workers
3.3. Verbal Miscommunications in relation to Different Demographic Factors
3.4. Nonverbal Miscommunications in relation to Different Demographic Factors
4. Discussion
5. Conclusion and Recommendations
6. Limitations of the Study
Data Availability
Disclosure
Conflicts of Interest
Acknowledgments
Supplementary Materials
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