Qom University of Medical Sciences Journal

Introduction
In March 2020, the World Health Organization (WHO) declared COVID-19 a pandemic. This significantly impacted global morbidity and mortality rates, overwhelming healthcare systems and leading to diverse changes in healthcare service delivery. In Iran, millions contracted COVID-19, resulting in thousands of deaths and significant economic, social, and psychological consequences. Although many countries were affected, outcomes varied considerably due to health policies, governance, and pandemic preparedness differences. Throughout the COVID-19 pandemic, nurses faced immense challenges and workloads as frontline healthcare workers. This led to occupational stress, impacting the quantity and quality of care provided. Studies in Iran revealed a high prevalence of mental health issues among healthcare workers, who were more vulnerable to negative psychological outcomes, such as anxiety, stress, and depression. 
Effective patient communication is crucial in healthcare, forming the basis of interaction with patients and their families. Communication skills encompass effectively expressing feelings and needs and achieving interpersonal goals. Poor communication skills can lead to isolation, social anxiety, depression, low self-esteem, and job loss. Communication played a vital role in managing the pandemic in healthcare settings and hospitals, although it was hampered by factors, like mask-wearing and working conditions. Previous research demonstrated the impact of communication skills on healthcare outcomes. Stronger relationships positively influence treatment outcomes. The pandemic increased physical distancing and stress, affecting the therapeutic relationship between healthcare workers and patients. It significantly altered many aspects of life, including the healthcare provider-patient relationship. Nurses faced unprecedented challenges, necessitating improved communication skills for effective crisis management and optimal patient care. COVID-19 imposed serious limitations on communication between healthcare workers and infected patients.
 Effective communication is essential in clinical settings, considering the needs of patients, families, and healthcare professionals. Communicating with critically ill COVID-19 patients, especially those who are intubated or sedated, is complex and is further complicated by the absence of family and patient emotions such as pain, fear, anxiety, and grief. The WHO emphasizes the importance of effective communication for pandemic control. Research shows that effective communication skills reduce stress, increase job satisfaction, and decrease burnout among nurses. Demographic factors, like age, gender, education level, and experience, significantly influence communication skills. Considering these demographics is crucial when designing nursing training programs to address diverse needs and preferences. This study investigated the relationship between communication skills and demographic variables among nurses at Kamkar Arab Nia Hospital in Iran from 2021 to 2022.
Methods
This cross-sectional analytical study was conducted on nurses working in the therapeutic departments of Kamkar Arab Nia Hospital in Qom, Iran, from 2021 to 2022. The required sample size of 165 participants was calculated using a formula based on a similar study, with a significance level of 0.05, σ=6.4, and d=1. A convenience sampling method was employed. Inclusion criteria included at least one year of work experience, good physical and mental health, being a registered nurse, and a willingness to participate. Exclusion criteria were not completing the questionnaire, use of psychotropic medication, and refusal to participate. Data were collected using a researcher-developed demographic questionnaire (including six questions on age, gender, marital status, etc.) and the standardized communication skills questionnaire by Julka-Anderson [21]. This questionnaire, developed in 1990 to assess communication skills, has been validated in Iran and used in numerous studies. It contains 18 questions across three domains: Verbal skills, listening skills, and feedback skills (six questions each). Using a five-point Likert scale (1=strongly disagree to 5=strongly agree), the total score ranges from 18 to 90, with 90 representing the highest communication skill score. Scores were categorized as low (<42), moderate (42-66), and high (>66). The validity and reliability of this questionnaire were reported as 0.8 in a study by Safavi et al. [22].
 Safavi et al. used Cronbach’s α to assess internal consistency reliability, obtaining a reliability coefficient of 0.8 based on data from 30 nurses. After obtaining ethical approval from the Research Department of Qom University of Medical Sciences, questionnaires were distributed to nurses in various shifts at Kamkar ArabNia Hospital. Participants were informed about the study’s objectives and assured of data confidentiality, as well as their right to withdraw at any time. Data were analyzed using SPSS software, version 26. Descriptive statistics (Mean±SD) were used to describe the data, and Spearman’s correlation coefficient and the Kruskal-Wallis test were used to analyze the data. A P<0.05 was considered statistically significant.
Results
In this study, the mean age of the participating nurses was 63.8±64.35 years. Among the 220 nurses surveyed, 39.5% were male and 60.5% were female. Demographic results showed that 30.9% of the nurses were single and 69.1% were married. The majority of nurses held the position of “nurse,” and 94.5% had a bachelor’s degree. Additionally, the employment status was predominantly formal (56.4%). Analysis of communication skills revealed that the overall mean score for nurses’ communication skills was 97.13±18.51 (out of 90 points), with the verbal domain having the highest mean score of 37.5±18.88 (out of 30 points). There was a significant relationship between job rank and the communication skills of nurses (P<0.001), with supervisors scoring higher in all areas of communication skills compared to nurses and head nurses. Furthermore, employment type and working department also showed a significant impact on communication skills (P<0.001), with contract nurses receiving lower scores in communication skills compared to formal and contractual nurses. 
Conclusion
Our study showed a significant correlation between communication skills and job rank, ward, and employment type. The score was lower among contract nurses, indicating limited clinical experience and exposure to crises. Therefore, the need for training for these nurses is crucial. The score was also lower among nurses in the emergency department, which is understandable given the extremely challenging conditions faced by emergency department nurses during the pandemic. However, supervisors had the highest scores. This is expected, as communication skills generally improve with experience and seniority. Active listening is a key characteristic of supervisors, who are expected to listen patiently and provide guidance, even if they cannot solve all the patient’s problems. Given the lower scores of communication skills and lack of preparedness among less experienced nurses during pandemics, further research on communication skill training for nurses is needed. Limitations include the lack of sample diversity, the exclusion of nurses from other healthcare facilities, and the failure to investigate the impact of psychological factors, such as stress and anxiety, on nurses’ communication skills. 
This study found a significant correlation between nurses’ communication skills and various demographic factors, such as job rank, employment type, and ward type. Supervisors scored higher than nurses and head nurses across all communication skill subscales, indicating the influence of experience and job position on communication abilities. Furthermore, nurses with contract employment scored lower on communication skills, feedback, listening, and verbal skills compared to other groups, highlighting the need for continuous training and skill enhancement for newly hired nurses. Additionally, the impact of ward type on communication skills demonstrates that nurses in different wards have varying experiences, a factor that should be considered in the design of training programs. 
Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Qom University of Medical Sciences, Qom, Iran (Code: IR.MUQ.REC.1401.124).
Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.
Authors contributions
All authors contributed equally to the conception and design of the study, data collection and analysis, interpretation of the results, and drafting of the manuscript. Each author approved the final version of the manuscript for submission.
Conflicts of interest
The authors declared no conflict of interest 
Acknowledgements
The authors would like to thank all those who participated in this study and also express their gratitude to the Vice Chancellor for Research of Qom University of Medical Sciences, Qom, Iran.