When we are talking about communication among Gaza nurses during the work, we are talking about a very vital issue, because as human being we use all types of communication (verbal and nonverbal) in all sides of our life. If we talk to any person, we send our message as we want or need, but are we sure that the message was understood correctly? Sometimes we don’t care the condition our message received with its full meanings or not. Other times there are some gaps and challenges we don’t give them any attention facing us when we send our messages.  This may happened in the normal life, but when we speak about patients the problem could be more vital.

The nurses are one of the most important team who deal with patients, and because of the nature of this job they owe to communicate with others (doctors, physiotherapists, laboratory, X-ray….est.). During the day and night time the nurses stay in the hospitals and clinics to provide nursing and medical services to patients. It is very essential to evaluate the communication process and to see if there are any gaps or challenges in the process of communication among nurses in Gaza.

Overall aim of the study

The aim of this study was to describe Gaza nurses perceptions, attitudes, opinions, impressions and experiences about communication gaps and challenges among Gaza nurses. The study aims to highlight the main strength and weakness points of the nursing communication process during work.

Purpose of the study

The purpose of this study is to describe nurses’ perceptions, opinions, impressions, and experiences about verbal and non verbal communication among Gaza nurses in the health organizations.

In addition to identify the factors which affect the communication process?

Objectives of the Study

  1. To assess nurses perception, opinions, impressions, and experiences about the communication process used.
  2. To identify the gaps and challenges which affect the communication process.
  3. To identify the degree of mutual support between the nurses and their colleagues in the same profession.
  4. To identify the role of the easy communication in the development and advancement of the nursing profession relations in Gaza and Palestine.
  5. To conclude recommendation for Gaza nurses in order to improve the communication process.

Justification of the study

Around the world, the doctors are the most categories from the medical professions who take the major attention from the decision makers in the health ministries or other related ministry, especially in the third world countries.  Most researches which were done all over the world take the side of the doctor nurse relationship.  On the other hand there are inadequate research studies which highlight nurse to nurse relationship, role of the nurses in providing health care to patients, and gaps challenges and problems they faced.  Communication is one of the important tools which the nurses are using; we are in need to describe the gaps and challenges which face communication process through Gaza nurses.

In Arab countries around Palestine (Egypt, Jordan, Lebanon) there is no enough studies highlight this problem. In Israel the author found some studies deal with this topic. In Palestinian National Authority (PNA) there is no previous study take concerning this subject... 

Hypothesis of the study

The hypothesis assumes that

"There is a positive relationship between the academic level and verbal and non verbal communication among nurses in Gaza health organizations".

Null hypothesis of the study.

"There is a negative relationship between the academic level and verbal and non verbal communication among nurses in Gaza health organizations".


Palestine is suited on the eastern coast on the Mediterranean Sea in the Middle East. Lebanon boards it on the north and Syria and Jordan on the east and by Egypt and Mediterranean Sea on the west (MoH 1998).  Palestine has an important geographic and strategic location. Palestinian National Authority territories comprise two areas separated geographically: West Bank (WB) and Gaza Strip (GS). West Bank lies within an area of 5,800 square kilometer west of the Jordanian river. It has been under Israeli Military Occupation, together with East Jerusalem since June 1967. West Bank is divided into four geographical regions. The Northern area includes the districts of Nablus, Jenin and Tulkarem, the center includes the districts of Ramallah and Jerusalem, the south includes Bethlehem, Al-Khaliel district, and the sparsely populated Jordan valley including Jericho (MoH 2003).

Gaza strip is a narrow piece of land lying on the coast of the Mediterranean Sea (Annex, 2). Its position on the crossroads from Africa to Asia made it a target for occupiers and conquerors over the centuries. The last of these was Israel who occupied Gaza strip from Egyptians in 1967 (MoH 2003). The Gaza Strip goes along with the Mediterranean Sea between Israel and Egypt. It is about 360 square kilometer.  Its length from Rafah in the south to Beit Hanoon in the north measures 50 kilometer long and (5-12) kilometer wide. The Strip administratively divided into five governorates, North, Gaza, Midzone, Khanyounis and Rafah. It has four towns, fourteen villages and eight refugee camps (MoH 2000).

 Israel take a decision from one side to evacuated Gaza strip from the Israeli militaries, settlements  and citizens.

Human Resources in the Health Care System

In Palestine, the health providers (MoH, NGOs, UNRWA and MMS) employ 16,935 permanent employees, 8.882 in WB (52.4%) and 8.053 in GS (47.6%) out of them 9,069 (53.6%) are working in MoH, 5,632 (33.2%) working in NGOs, 1,157 (6.8%) working in UNRWA and 1,077 (6.4%) working in MMS (MoH 2004).

Out of total employees there are 11,933 (70.5%) health professional. They are distributed by specialty as 3,093 physicians, 293 dentists, and 329 pharmacists with ratio per 10,000 populations of 8.3, 0.8 and 0.9 respectively. In addition to 4,905 nurses, 574 midwives, and 2,739 paramedical, with ratio per 10,000 population 13.1, 1.5 and 7.3 respectively. The MoH employ 9,069 permanent employees in year 2004, with ratio of 24.3 per 10,000 population out of them 6,005 (66.2%) are health professional. There are 1,722 physicians with ratio 4.6 per 10,000 populations.

Nursing in Palestine

The nursing profession has grown significantly in the past recent years in Palestine. Now there is advanced technology used to provide the advanced health care consistent with these development nurses needs to be qualified, efficient and effective. Specialty nursing education future plan for nurses/midwives need to concentrate on fields with least available such as oncology, health education, women health, management, orthopedic, rehabilitation etc (MoH, MoHE and WA 2001). Nursing has grown significantly in the past recent years in Palestine. It has become an extremely important component in Health Care System, taking to fact that nurses represent the majority group among all health care professionals. Therefore, the increased awareness of the Palestinian nurses, together with the feasibility to promoting and developing the nursing profession, has seen in the last years. 

The total number of employed nurses in Palestine 5910 at the end of 2003, out of which 2524 are working in MoH (42.7%), 1602 in NGOs (27.1%), 944 in UNRWA (16%) and 840 in Military Medical Services (14.2%) (MoH 2003, 127).


Literature Review

Introduction: This chapter reviews the literature about the nursing communication, and factors that affect nurse's perceptions about nursing communication. It starts with the different definitions of communication, nursing, perceptions of communication, gaps and challenges of communication, communication and mutual support between co-workers, conflict of communication, and communication with high management.

Definitions of communication

A) "Communication is the interchange of information between at least two persons".  (Lippincott & Raven 1996)
B) The process by which information and feelings are shared by people through the exchange of verbal and non-verbal messages amongst team members.
C) "Any act by which one person gives to or receives from another person information about that person's needs, desires, perceptions, knowledge, or affective states. The act of  communication may be an intentional or unintentional, it may involve conventional or unconventional signals, additionally, it may take linguistic or nonlinguistic forms, and may occur through spoken or other modes." (National Joint Committee for the Communicative Needs of Persons with Severe Disabilities, 1992)
Definition of nursing
Researches have defined nursing as the act of utilizing the environment of the client to assess him in his recovery process. (Nightingale, 1992).
Others, have looked at nursing as the diagnosis and treatment of human different responses to actual or potential health problem (American Nurses Association ,1980)

Perception of communication

According to, (Federal Bulletin Law (FBI) Law Enforcement Bulletin,  Sept, 2002) tell us that managers can use open-ended questions usually beginning with how, when, where, and what that employees cannot answer with merely a yes or no to stimulate conversation. Managers should avoid "why" questions because employees can perceive such inquiries as judgmental or confrontational, resulting in their becoming defensive. Open-ended questions, designed to elicit information without asking numerous questions, include "Can you tell me more about that?" and "Could you help me better understand by explaining that further?" Such questions focus on what the employee thinks and feel. 

Gaps and challenges of communication.
Hunter, Scott in, (Credit & Financial Management Review 2003) said about acknowledging co-workers that "everyone craves positive attention, for most individuals live with a sense of insufficiency and of their own shortcomings. Look for opportunities to acknowledge coworkers. What positive impact are they making on the company? Acknowledge people for doing a good job, for making a deadline, for keeping their promises. Acknowledge them for their appearance, for the way they manage their workload, or for the way they treat others. Always remember to keep it authentic and sincere, and look for and find numerous opportunities to thank people for the many large and small contributions that they make to the company". Then how long our managers are committed by these concepts, I think little of the managers who do that. 
Conflict of communication.
(Journal of nurses in staff development 2001) said that the ability to communicate effectively with a multidisciplinary team in an assertive manner to resolve conflict, motivate others, and delegate tasks is a prerequisite skill to promote a harmonious working environment. Acquisition of this skill is often a combination of inherent attributes and learned experiences. 
Communication and mutual support between co-workers.
Handover is a complex system based on several sound socio-technical principles and the value of this nurse-to-nurse communication should be acknowledged. The multiple functions highlight the knowledge and expertise currently hidden within handover, which could be promoted in terms of nursing professionalism. 
Communication with high management
( FBI Law Enforcement Bulletin 2002) showed the amount of time managers spend on investigating and resolving work-related personnel problems can be staggering. These problems run the gamut from equal employment opportunity complaints, job performance issues, and personality conflicts to lack of productivity and negative attitudes, regardless of the problem, the end result, and the mission, always suffers. In a majority of instances, these personnel problems share a common thread--poor or no communication between managers and employees. Managers significantly can minimize personnel problems and create a productive and harmonious work environment by using effective communication techniques. Certain leadership styles are more compatible with particular organizational models (Paware & Eastman 1997). 
Conceptual frameworkIn this chapter the researcher build on a model which contains most of the communication concepts, which have been incorporated into his conceptual framework. Attention is paid keeping these concepts open and flexible to accommodate the diversity of the Palestinian situation. Conceptual models attempt at organizing and donating a symbol representing of conceptualization of the phenomena with minimal use words (Burns & Grove, 1977). Framework is the conceptual groundwork of the study and use to guide and direct the research process and to make research findings more meaningful and generalizable. Additionally, framework is efficient mechanisms for drawing together and summarizing accumulating facts as shown in the figure (3.1)      

Basic dimensions of the communication process

(James L. 1985) defined Communication as "the exchange of information between a sender and a receiver, and the inference (perception) of meaning between the individuals involved. ". Analysis of this exchange reveals that communication is a two-way process consisting of respectively linked elements.

Managers analyze their own communication patterns as well as design communication programs that fit organizational needs.

The author choose the perceptual model because the clearness of the  flowchart of this model.  And it can illustrate the main cornerstones of the communication process, especially the goal of the study is to discover the gaps and challenges of communication among Gaza nurses.       

Abu Hassan communication model

The author develop a model of communication among nurses which consist of the five factors from Likert scale, if we can increase the perception of communication, the mutual support reduce the gaps and challenges, the conflict of communication and improve the communication with high management. Communication process sure will be better and the service the nursing care will improved either.     

Figure 3.1

Abu Hassan model of communication


Study design

 The design of this study is descriptive analytic design using quantitative and qualitative design. This design would be useful for descriptive analysis of study construct. It is less expensive than other design and enables the researcher to meet the study objectives in a short time (Coggen et al. 1993, 18). It is suitable in term of time, people, money, and resources and it is relatively practical and easily managed (Holm and Liewellyn 1986, 36). It's also, provide detailed information and stimulate further research or studies.

Study Population

The target population consists of all nurses who were working in nursing fields either in government, UNRWA, and NGOs sectors. The total number of nurses who have been working in the nursing fields in the governmental, nongovernmental, and UNRWA, health institutions at the end of 30/ 7/2005 were about 1890 nurses in the Gaza Strip. This number was obtained according to records of all those health institutions, there is a documented letters sent from Al Quds university to the managers of those institutions regarding the number and the names of there employees.

Study Setting

This study was carried out at different health institutions in the Gaza Strip including governmental hospitals, primary health care (PHC), UNRWA clinics, and non governmental organizations (NGOs) hospitals (El Wafa Medical Rehabilitation Hospital, Al Aowda Hospital, Ahliy Araby Hospital, Patient Friend Society, Palestinian Red Crescent Society).

Sample Size

The sample size was calculated using the Eipinfo statistical program. To calculate the desired sample size the author proposed that the population size was 1890 nurse, the desired precision was 0.5 the expected prevalence was 50% and the design effect was 1.0 The sample size equal 400 subjects, twenty questionnaires added the total size of the sample 420subjects.

Sampling Procedures

Systematic random probability method used to select the sample. Systematic random sample serves to fairly represent all members of the population from which they are selected (Bell 1995, 32). Every subject name was given a serial number, and then the researcher randomly selected the starting number and chose every fifth number. The sampling interval (k) was (5).


Validity is defined as "the extent to which a measuring instrument measures what is supposed to measure" (Mark 1996). When the instruments measure what are designed for, this considered being of great importance for their reliability. The researcher administered different types of validity as follow:

Content validity

Content validity is defined as "the extent to which a test reflects the variable it seeks to measure" (Holm and Liewehyn 1986). It's conducted before data collection by the help of experts to ensure relevancy, clarity and completeness. Content validity is a subjective estimate of measurement based on judgment rather than statistical analysis. In order to validate the instrument used, the designed questionnaire with covering letter, title and objectives of the study were sent to 13 experts from different backgrounds including researchers, managers, experts in management field and experts in health organization work. The experts were asked to estimate the relevance, clarity and completeness of each item; some questions were modified with the help of the supervisor. A total of 13 items were considered in the final design for the first part, 82 items for the second part "questions of the scale", 11 items for the third part (closed ended  questions)  and the 5 open ended questions followed them.


Reliability is the degree of consistency, which measures the attribute it is supposed to measure (Cronbach 1951). Reliability refers to the consistency or stability of measurement (Holm and Liewellyn 1986). In this study Cronbachs Alpha coefficient was used for the internal consistency was.

The reliability coefficient for the study instrument as a whole was (.7884). Cronbachs Alpha was computed for the instruments sub-scales table (1)


Results and discussion

Distribution of the study population by the age.

As shown in Figure (5.2), about 44% of study population were lies in the age group from  (33-44) years, where the youngest age group (21-32) years represents only 39%, this group showed high significant while 17% of the study population lies in the age group from (>44) years. However the mean age of study population was 35.94, standard deviation SD ± 8.80 years. As shown in table (4.5) the age group from 21-32 showed high significant in communication, this is a result that they are new employed in the health organization, and they are not yet feel the frustration which the other nurses complain of, either reflects the effort of the nursing educational college in improving communication by including it in the nursing  curriculum.      

Distribution of the study population by Address

As depicted in Figure (4.5), shows that (27.3%) were residing in Middle district, (22.4%) in Gaza district, then about (21.9%) in Rafah district  (19.4%) in North district, and (13.2%) in Khan younis district .

The mean of address is 2.91 with SD ±1.4

This distribution is corresponded with the natural distribution of the nurses according to their address, because the middle district have four major refugees camps, and the people who lives in this area of Gaza strip have relatively low income, so they cannot spend money for their sons education. Also the nursing have better opportunity to be employed than other jobs. The majority of the nurses are working in Gaza city, where the most major health organizations are available.

Distribution of the study population by marital statu

Figure (5.5), shows that the majority of respondents were married (82%), while single subjects represented (15.6%) and the least small categories were those who divorced or widowed which represented (2.4%) of the study population.

The mean was 1.86 while SD ±.40

This results are corresponded with the age group of the sample which revealed that 39% of the population of the study are between the age of 21-32, which either congruent with our culture which obligate males to marry after they got a job.

Distribution of the study by population average income

Figure (7.5), shows that slightly more than third of the study population (35.8%) having monthly salary less than 1700 New Israel Shekel (NIS), (39.6%) from 1701-2200 NIS, and (24.6%) more than 2200 NIS.

The median average monthly income was 2000 NIS, and SD ± 701.2 NIS.

This explain the low monthly income among nurses in Gaza, which make the nurse always search for another job to improve their income which consume their energy and attention and that will affected negatively in  communicate with their co-workers correctly.  


Distribution of the study by population place of graduation

Figure (9.5), shows that (30.3%) were graduated from Palestine college of nursing, more than one fourth (27.3%) of the study sample were graduated from Islamic university, (11.5%) from Faluga nursing institute, (15.8%) from Shifa nursing school, and (15%) were from other school of nursing.

The mean of graduation is 2.6 with SD ± 1.41.

And this is congruence with the situation in Gaza which affected by Israeli occupation.




Distribution of  the study population by date of employment, current position, years of experience, years in current position.

            Variables                                         No.                            %              

                        <1995                                                  162                              44.2%

                        1996-2000                                           102                              27.9%

                        >2000                                                  102                              27.9% Title of current position          

                        Staff nurse                                           196                              53.6%

                        LPN nurse                                           93                                25.4%

                   Head nurse                                               58                                15.8%

                     Supervisor                                              19                                5.2%

Years of experience

                        <8                                                        139                              38%

                        8.1-15                                                 98                                 26.8%

                        >15                                                      129                              35.2%

 Years in current position

                        <2.5                                                     71                                19.4%

                        2.6-7                                                    118                              32.2%

                        >7                                                        177                              48.4% 


The distribution of the participant from the sample shows that about (44.2%) of them were employed before year 1995, (27.9%) between (1996-2000), (27.9%) after the year of 2000.

The mean of date of employment is 1.83 with SD ±..834.

This result indicates that the Israeli occupation was imposed restricted roles to employ nurses in the governmental places. In the same time the MOH in the period of (PNA) employed more than half of the nurses in the period of 1996-2000.   


The distribution of title of current position shows that more than half of the participant are staff nurses (SN) (53.6%), (25.4%) are licensed  practical nurses (LPN), (15.8%) are head nurses, and (5.2%) supervisors. The mean of title of current position is 2.99 and SD ±.78. Which reflects the willing of Gaza nurses to improve their academic level.


Concerning  years of experience in current position there are (19.4%) of the subjects have an experience less than two and half years, (32.2%) between 2.6-7 years, and (48.4%) with more than seven years.

The median of  total experience is 7 years and SD ± 7.78.

This result is congruent with the result of date of employment and title of current position,


Factor analysis and related sub-scale dimensions


Varimax rotated principle factor analysis was used to identify nurse's perceptions.

Factor analysis extracted five components, factor loading over 0.5 were selected. The extracted factors were  perception of communication, gaps and challenges of communication, communication skills and mutual support between co-workers, conflict of communication, and communication with high level management.

Factor name

No. of Item


Standard deviation


perception of communication





Gaps and challenges of communication





communication skills and mutual support between co-workers





conflict of communication





communication with high level management






Overall perceptions






Table (5.3) shows that factor one and two consist of 18 items  with mean (3.3617 & 3.5184) and the SD and variance (.2897- .8391 & .3259- .1062)  respectively, 13 items  for factor three with mean (3.4491) the SD and variance (.3020 -.0913), while factor four 9 items the mean (3.0106) the SD and variance (.4395- .1931), and 8 item for factor 5 the mean (3.1892), the SD and variance (.5130 - .2632). The total items of  overall perceptions is 66 with mean (3.3058) and the SD and variance (.2550- .6510).

Distribution of the study population by studying communication in the nursing curriculum




As depicted in Figure (5.11), about (72.7%) of the subjects were studying communication in the nursing curriculum, while (37.3%) of subjects were not studying communication in the nursing curriculum with mean of  1.273, while the SD ±.446.

There is no real communication courses presented in all school of nursing curriculum because of that we are in need to establish the first step toward this in order to improve the communication process among Gaza nurses.

Distribution of the study population by studying communication in special course




As depicted in Figure (5.12), about (31.4%) were studying communication in special course, while, (68.6%) of subjects were not studying communication in special course with mean 1.685, while the SD ±.464

It means to the nursing managers in Gaza did not care or oriented about the importance of communication among nurses, and it's influence to improve patients bed side care.

Distribution of the study population by challenges facing correct communication according to nurses' opinion.


مربع نص: percent




As depicted in Figure (5.17), showed that the question the challenges which face the correct communication among co-workers were related to the nature of the work (62.8%), (49.7%) to the co- workers, while (45.1%) were think that the problem of communication is related to the nursing management and (45.1%) were think that the problem of communication is related to the public.

We should educate the nurses and managers about the most common challenges that facing correct communication in order to overcome all problems facing Gaza nurses 

Qualitative findings.

The second part of questionnaires is followed by open ended questions relevant to perceptions towards the communication among Gaza nurses during work. The respondents had a large number of opinions, so the researcher ranks some relevant answers in a descending order according to its important and most answers repeated in all questionnaires.



In response to the question about some facts delay the communication among co-workers during the work.

  • Bad nursing management and have the right person in the right place.
  • Variance of, age, years experience, gender, and qualification among co- workers.
  • The nature of work (night shift), low ratio of nurses in the shift, partiality in duty distribution, increase work load, and unclear job description are the main problems.
  • Send and receive the message in inaccurate manner, misunderstanding, and type of communication methods.
  • The high rush of public,  and phone calls
  • Careless, low cooperation, relations, mood status, and bad personal and social relations among co-workers.


In response to the question about some facts to ease the communication among co-workers during the work.

  • Cooperation, job satisfaction, and group decision making between co-workers.
  • Age and gender coordination.
  • Availability of clear hierarchy.
  • Good feedback, positive critique, report writing.
  • Good listening, clear message.
  • Mutual social support during crisis. increase of respect and trust among co-workers.
  • Modern and electronic communication facilities.


In response to the question about the nurse own experience; please list the weakest elements in the communication process during the work.

  • Political affiliations affect communication and relationship among co-workers.
  • Work over load.
  • The routine of writing reports.
  • Criticism by higher managers at the front of others.


Conclusion and Recommendation


The sample size was 420 participants, with 87.1% response rate. The majority of participants were males 46%, married 82%, working in hospitals and governmental sector 65%. The highest percent of participant were lived in middle district and they constituted 27.3% followed by Gaza district 22.4%.

Study population was of different nursing posts and titles as: regular staff nurses were 53.6% while LPN nurses 25.4% and the supervisors only 5.2%.

While the age group between 21-32 shows statistically significance of perception of communication (0.009).  The study reveals that females shows high level of perception of perception of communication, gaps and challenges of communication, and communication skills and mutual support between co-workers than males, while males shows high level of communication with high level management. Also the study reveals that who reside in Gaza district shows higher level of perception of obstacles than other districts, while northern district shows high level with communication with high level management. The study reveals that who work in NGOS shows high level of perception and obstacles, while the nurses who work in governmental primary health care (PHC) shows high level with communication with high level management.

The nurses who graduate from IUG show high level of perception of communication, ,  while those who from IUG & PCN shows high level of gaps and challenges of communication, and who graduate from PCN shows high level with other sub dimensions.

Those who have master degree showed high level with gaps and challenges of communication, while those who have two year diploma shows high level with other sub dimensions.

The study reveled that those who employed after year 2000 show high level of perception of communication while those who employed between year 1996-2000 shows high level with other sub dimensions.

The study reveled that those who revived from 1701 to 2200 NIS show high level of  perception of communication and communication with high level management while those who received <1700 NIS shows high level with other sub dimensions.

The study reveled that those who are <2.5 years in current position show high level of perception of communication, conflict of communication, and communication with high level management, while those who are in current position between 2.6-7 years shows high level with gaps and challenges of communication and who are >7 years in current position shows high level of communication skills and mutual support between co-workers.



  • Integrate communication topic in the main nursing curriculum.


  • Construct special courses, workshops, concern the communication process for managers and nurses.
  • Construct direct relationship between the first line employees and the high managers, resolve the conflicts between managers and nurses.
  • Construct a clear hierarchy.
  • Construct social committee in every health organization to strength social relations between Gaza nurses.
  • Improve work circumstances, Reduce time duty, reduce public ratio during duty time, regulate visiting time.
  • Mutual respect and support.
  • Strength the roll of nursing association.

Limitation of the study.

§  Unusual political difficulties to reach some member.

§  Political situation that faced the author which led to delay in receive the last of nurses names who work in the ministry of health.

§  Limited resources such as educational materials, journals, books and internet.

§  Incorporation of nursing director in the ministry of health with the researcher.

Further researches

§  Other study concerning communication between nurse and doctors.

§  Other study concerning communication between nurse and patients.

§  Other study concerning communication between doctors and patient.





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