INTERPERSONAL COMMUNICATION SKILLS OF NURSE MANAGERS AND NURSING PERFORMANCE

Interpersonal communication between the nurse manager and the executing nurse is needed for the continuity and productivity of the profession, whereby one’s productivity is strongly influenced by performance. Therefore, this study aims to know the extent of the relationship between the interpersonal communication skills (leadership, communication process, motivation, and negotiation skills) of the nurse managers, (independent variable), and the performance of nurses, (dependent variable) at Tgk. Chik Ditiro Sigli Hospital and Harapan Bunda Banda Aceh Hospital in Indonesia. The population in this study were all nurses at the two hospitals consisting of 331 respondents. The results showed a significant relationship between the interpersonal communication skills of the nurse managers and the performance of the nurses at the two hospitals. The test results also showed that there was a significant difference between the interpersonal communication skills of the nurse managers and the performance of nurses at Tgk. Chik Ditiro Sigli Hospital and at Harapan Bunda Banda Aceh Hospital. The only variable that showed similarities between the two hospitals was motivation. IJMS 26 (1), 99–145 (2019)


Leadership Style
Several leadership styles greatly influence a leader's success in inspiring the behaviour of his or her subordinates. Usman (2009) stated that researchers had identified two styles of leadership: (1) task-oriented and (2) subordinate-or employee-oriented. The task-oriented style is more concerned with the completion of tasks with tight supervision to finish the task according to the leader's requirements. A good relationship with subordinates is ignored, and subordinates must work hard, be productive, and timely. In contrast, a subordinate-oriented leadership style tends to pay more attention to good relationships with subordinates, motivating them rather than closely monitoring, and more importantly, sensitive to the feelings of subordinates.
According to Ilyas (as cited in Novitasari, 2014), one of the organisational factors that affect performance is leadership. The role of leaders in organisations is to facilitate the functioning and responsibility of each of its members to remain focused. Employees generally need good leadership. Successful leaders must lead their organisations by creating a pleasant atmosphere or conditions to allow each employee to contribute totally to the work assigned. It can be done by educating members of the organisation with new skills, encouraging employees to deal with something that they are afraid of doing, also by listening to employee complaints or ideas, hopes, criticisms and suggestions. and other forms of partners or subordinates. Another aspect that is also important and must be considered by leaders is to facilitate mental and technical support for employees which will significantly determine the performance of leaders and employees.

Handling Conflict
The emergence of conflict is normal due to various perceptions, social background, education, personality, shared values, expectations, and experiences. Usman (2009, p. 22) pointed out that conflict exists as either "1) a conflict between two or more against one thing or more with fellow members of another organisation, or 2) a conflict with one's own conscience." According to Engkoswara and Komariah (2010), "conflict is any kind of antagonistic interaction between two or more parties." This conflict of interest differs in intensity depending on the means employed. Each party wants to defend the values they consider true and force others to recognise those values either subtly or roughly. Murni and Veithzal (2009) stated another definition of work conflict as the incompatibility between two or more members or groups (within an organisation/company) that must share limited resources or work activities and due to their differences in status, purpose, values and/or perception. Work conflict can also be interpreted as the behaviour of a member(s) of the organisation who are devoted to opposing another member(s). In addition, conflict can be defined as differences, disagreements, and disputes. However, it is generally understood that the organisation demands cooperation among groups because only then can the organisation move towards a higher level of effectiveness. In other words, cooperation must be fostered and developed in teamwork. Climate collaboration and functional interaction between groups often determine the effectiveness of the organisation as a whole. Siagian (2006) stated that "one of the problems that are often a barrier to the realisation of organisational effectiveness is a large number of dysfunctional personnel used to engage in unfeasible competition or competition between the various groups that should work together. It is undeniable that competition and conflict arises easily in intergroup relationships due to some factors such as goal differences, value systems, efforts and interests." Murni and Veithzal (2009, p. 14) stated that "conflict is usually caused by several factors, such as communication factors, task structure or organisation structure, personal factors to environmental factors." Moreover, Murni and Veithzal (2009, p. 8) explained that "communication factors can be a cause of conflict when members of an organisation cannot or do not want to understand and understand each other in various ways within the organisation. The occurrence of misunderstanding when communicating can also lead to conflict." The team is defined as a group with complementary skills and is committed to achieving common goals effectively and efficiently (Hunsaker, 2001).

Process of Communication
De Vito (as cited in Liliweri, 2011) said that "communication is referred to as a process to emphasise "something" that always changes or always moves. If we mention "process", then it is always connoted with "activity," or an activity that is "non-static." Liliweri (2011) expounded that "the process of communication is demonstrated by a series of stages or steps where something is changing, the people involved in the communication change their thoughts and opinions and actions. Everyone who follows the communication process will have the opportunity to be more productive in every aspect of their profession". Figure 1 explains the communication process involving five basic stages elaborated by Berlo, Chartier, Davis, Hein, Hewitt, Jonhson, Long, Prophit, Miller, and Pluckhan ( as cited in Monica, 1998).  (Monica, 1998) Once the idea is 'translated' into the selected language, the message will be transmitted by the sender through selected verbal and/or nonverbal channels. The receiver of the message, which enters the sender's channel, will receive the message and 'translates' from a language to an idea. The receiver of the information will act in response to the message delivered. The message can be saved or ignored; the receiver communicates another idea to the sender, or performs the task in response to the message.
Davis (as cited in Monica, 1998) stated emphatically that "the sender of the message must think before sending the information, this stage is very important." After the sender has a clear idea in his mind, he then selects a language that matches the idea presented. He also needs to determine which body language to use. Keep in mind that leadership and management involve recognisable strategies for all behaviours and selecting an appropriate language that is most likely to relay the messages accurately is essential. Whatever the receiver does in response to the sender's message is called feedback. Evaluating feedback is a method from the sender of a message to evaluate whether 5 thoughts and opinions and actions. Everyone who follows the communication process will have the opportunity to be more productive in every aspect of their profession". Figure 1 explains the communication process involving five basic stages elaborated by Berlo, Chartier, Davis, Hein, Hewitt, Jonhson, Long, Prophit, Miller, and Pluckhan ( as cited in Monica, 1998).

Figure 1. Communication Process (Monica, 1998)
Once the idea is 'translated' into the selected language, the message will be transmitted by the sender through selected verbal and/or non-verbal channels. The receiver of the message, which enters the sender's channel, will receive the message and 'translates' from a language to an idea. The receiver of the information will act in response to the message delivered. The message can be saved or ignored; the receiver communicates another idea to the sender, or performs the task in response to the message.
Davis (as cited in Monica, 1998) stated emphatically that "the sender of the message must think before sending the information, this stage is very important." After the sender has a clear idea in his mind, he then selects a language that matches the idea presented. He also needs to determine which body language to use. Keep in mind that leadership and management involve recognisable strategies for all behaviours and selecting an appropriate language that is most likely to relay the messages accurately is essential. Whatever the receiver does in response to the sender's message is called feedback. Evaluating feedback is a method from the sender of a message to evaluate whether the message is received following its original intent. Berlo (as cited in Usman, 2009) said that "validation is very important because humans communicate and receive messages according to their own attitude, knowledge and experience." the message is received following its original intent. Berlo (as cited in Usman, 2009) said that "validation is very important because humans communicate and receive messages according to their own attitude, knowledge and experience." Chitty (2001) defines communication as a complicated exchange between thoughts, ideas, or information, at least on two levels: verbal and non-verbal. Therefore, communication begins when two or more people are aware of each other's presence. However, what happens if the exchange of thoughts, ideas, and information does not have the same meaning for both the sender and the receiver of the message. Marquis and Huston (2010) stated that "the internal and external atmosphere also affects communication. The internal atmosphere includes the value, feelings, temperament, and level of sender and receiver strands. Weather conditions, temperature, time placement, and the atmosphere of the organisation itself is part of the external atmosphere. The external atmosphere also implies status, power, and authority as an obstacle to manager-employee communication".
Furthermore, Marquis and Huston (2010) stated that "because everyone is different, so is making decisions and looking at things differently, usually reviewing the external atmosphere is easier than the internal atmosphere. In assessing the internal mood, remember that the human mind perceives the thing to recognise. Generally, unexpected things are ignored or misunderstood. In other words, the receiver cannot communicate if the message does not match their expectation. Therefore, effective communication requires the sender to determine what the receiver sees and hears". Mikanowicz and Shank (2009) said "a sender will check each (intent/perception) of the message he sends so that the message received by the receiver has the same meaning/perception with the intent of the sender." Furthermore, Mikanowicz and Shank (2009) emphasised that "the difference in perception between sender and receiver when communicating can be suppressed only if the individual is able to see himself (self-concept) and see others as it is, this is because self-concept affects individual perception of others."

Motivation
The number and quality of work completed by managers directly reflect their motivation and the employees. Why are some managers or staff more motivated than others? What can an unmotivated manager do to influence the staff? What can the manager do to help unmotivated staff? The motivation problems facing managers are complex. To respond to unmotivated staff, managers need to understand the relationship between motivation and behaviour (Marquis & Huston, 2010). Motivation is one tool that belongs to the superior so that the subordinates will work hard and work smart as expected. Knowledge of motivation patterns helps managers understand the work attitude of their respective employees. Managers can motivate their employees in different ways according to their characteristics.
Usman (2009) pointed out that "motivation is very important for managers to improve the performance of subordinates because the performance depends on motivation, ability, and environment." Mill (as cited in Marquis & Huston, 2010) said that motivation is the "power in the individual, affecting the power or directing behaviour". Lee (as cited in Marquis & Huston, 2010) stated that "motivation, coaching and empowerment are not merely management jargon: they should be a resource you can use every day." Leaders should apply techniques, skills, and knowledge about motivational theories to help nurses achieve what they want from work. At the same time, all these individual objectives should complement organisational goals. Managers have a primary responsibility for meeting organisational goals, for example achieving acceptable levels of productivity and quality. Stoner and Freeman (1995) noted that "motivating is the management process for influencing human behaviour based on knowledge of what makes people move." Usman (2009) argued that "negotiation is a process of interaction of two or more parties whom each have a different purpose, but they try through argumentation and persuasion to find a mutually agreeable solution." Negotiation skills do not just show up. As with any other skill, this skill needs to be sharpened. Some skills need to be deepened, such as optimism, courage, tolerance, ambition, and humour (Hariwijaya, 2008).

Performance
Gaspersz (1997) stated that "performance is built of quality, and quality is composed of everything free from deficiencies or damage generated by the organisation to satisfy all elements related to the organisation both internally and externally." According to Nursalam (2014), performance can be viewed as a process or a result of work.
Performance is a process of how work takes place to achieve work. However, the work itself also shows performance. Wibowo (2008) posits that "working behaviour is seen from the work of vigorous, disciplined, and responsible individuals carrying out tasks according to established standards, have high motivation and workability and directed to the achievement of organisational goals while the work is the final process of an activity which members of the organisation is striving in achieving the goal." Based on the above opinion, it can be concluded that the performance of nurses in providing nursing care reflects their overall behaviour and abilities. Meanwhile, the work of nurses can be seen from the final process of nursing care, one of them is documenting nursing care given to the patient, which includes assessment, diagnosis, planning, implementation, and evaluation.
In addition, nurses are retiring at an accelerating rate, and it has been proposed that efforts should be made to retain nurses who are approaching retirement (Bernard Hodes Group, 2006). The ageing workforce raises performance issues from an HF/E perspective because perceptual, cognitive, and physical abilities decline with age (Sanders & McCormick, 1993).
Partly due to the nursing shortage, the nursing workforce is overloaded in terms of the number of patients that nurses oversee, the number of hours that nurses work, and the number of tasks that nurses perform. For example, many nurses work 12 hours or more per day (Houle, 2001) and often work without breaks or meals (Rogers, Hwang, & Scott, 2004). Increases in such nursing workload can increase the risk of burnout and job dissatisfaction, which may contribute to the nursing shortage (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002).
Related research on the performance of nurses was conducted by Harmiyati (2016), who concluded that the characteristics of individuals (age, sex, marital status, and education) have no relationship with the performance of nurses at public health centres (Puskesmas) while the working period is related to the performance of the Puskesmas nurses at the Puskesmas of Palembang city. A significant relationship between individual capability (knowledge, attitude, and skills) and the performance of nurses at the Palembang Public Health Centre was observed. Similarly, a significant relationship between the characteristics of the organisation (leadership, work culture, compensation, and workload) and the performance of nurses at Palembang Public Health Centre.
A nurse who has a reasonable workload will produce excellent performance, six times better compared to nurses who have poor workloads; while a nurse who has good knowledge will produce seven times better performance compared to a nurse who has less knowledge. Similarly, nurses who have a positive attitude will produce 37 times excellent performance compared to nurses who have a less positive attitude; while a nurse who has excellent skills will produce good performance six times better compared to a nurse who has fewer good skills.
A study on organisational commitment mirrored in previous literature showed a negative relationship with intention to leave. The findings of the study in a Malaysian nursing context posited that the effects of moral obligation is a mediating variable in the relationship between organisational commitment and the intention to leave among nurses who work in Malaysian public hospitals.
Therefore, factors that enable the management and employers to attain a better understanding are crucial and serve as guidelines to draft retention strategies (Omar, Mohamed Anuar, Abdul Majid, & Johari, 2012). This is reflected in one of the variables presented, the motivation factors in the context of interpersonal communication skills. The research framework was constructed to address the underlying research objectives.

Figure 2. Research framework
A nurse who has a reasonable workload will produce excellent performance, six times better compared to nurses who have poor workloads; while a nurse who has good knowledge will produce seven times better performance compared to a nurse who has less knowledge. Similarly, nurses who have a positive attitude will produce 37 times excellent performance compared to nurses who have a less positive attitude; while a nurse who has excellent skills will produce good performance six times better compared to a nurse who has fewer good skills.
A study on organisational commitment mirrored in previous literature showed a negative relationship with intention to leave. The findings of the study in a Malaysian nursing context posited that the effects of moral obligation is a mediating variable in the relationship between organisational commitment and the intention to leave among nurses who work in Malaysian public hospitals.
Therefore, factors that enable the management and employers to attain a better understanding are crucial and serve as guidelines to draft retention strategies (Omar, Mohamed Anuar, Abdul Majid, & Johari, 2012). This is reflected in one of the variables presented, the motivation factors in the context of interpersonal communication skills. The research framework was constructed to address the underlying research objectives.

Research Framework
Independent Variable Dependent Variable

Figure 2. Research Framework
Consequently, to operationalize the research framework as proposed in Figure 2, this study suggests an appropriate methodological approach. Consequently, to operationalize the research framework as proposed in Figure 2, this study suggests an appropriate methodological approach.

Methodology
This research used a cross-sectional and comparative study. The cross-sectional study is a study concerning the dynamics of correlation between risk factors and effects, by way of approach, observation or data collection at a time (point time approach) at the same time. Meanwhile, comparative research is a study that tends to compare equations and differences as a phenomenon to find what factors, or what situation causes the occurrence of a particular event (Notoatmodjo, 2012). The location of the research was at the Harapan Bunda Banda Aceh Hospital and Tgk. Chik Ditiro Sigli Hospital. The duration allocated for data collection was four months from September 2015 to December 2015. Furthermore, this study was to examine the interpersonal communication skills (leadership, communication process, motivation, and negotiation skills) of the nurse managers (independent variable) with the performance of nurses (dependent variable) in the context of selected hospitals in Indonesia. The operational definition is analysed in the following tables.  The population in this research was practitioner nurses, with 172 nurses at Tgk. Chik Ditiro Sigli Hospital and 159 nurses at Harapan Bunda Banda Aceh Hospital. The total number was 332 practitioner nurses. The reliability of a questionnaire can be ascertained by looking at the alpha value (Riwidikdo, 2010). The decision rule is conducted by comparing the value of r count with r table, whereby if the r count is greater than the r table, it is considered reliable, and if the r count is smaller than the r table, it is not reliable (Ridwan, 2005). The reliability test shows the values of all instruments of the five variables, i.e. > 0.6, which indicates that the tool is consistent and stable to use. Table 4 shows the result of the instrument reliability test using the Cronbach's alpha model. In this research, the validity test was done by first describing the concept of operational definition, distributing the questionnaire to 25 respondents of the research, and tabulating data. The result of the instrument validity test showed that all instruments of the five variables had a value of less than 0.361, which meant that all items of the instrument were considered valid.

Bivariate Analysis
A bivariate analysis was conducted on two variables that were suspected to be correlated (Notoatmodjo, 2012). In this study, the chi-square statistical test with a Confidence Level (CL) = 95 percent or significance limit (α = 0.05) was used to test the hypothesis of the relationship between the independent variables and the dependent variable and was processed by a computer. Data of each sub-variable which were inserted into the contingency table were analysed to compare between α = 0.05 with the following conditions:  (Sugiyono, 2013). In this study, the Mann-Whitney U test is used to identify differences in interpersonal communication skills of the nurse managers (in the form of leadership, communication process, motivation, negotiation), and performance of nurses at Tgk. Chik Ditiro Sigli Hospital and Harapan Bunda Banda Aceh Hospital. The two formulas used in the Mann-Whiney U test were utilised to find out which U value was smaller. The smaller U value was used for testing and comparing with U tables. According to Hypothesis Testing Criteria, Ho is accepted when the value of U is larger than U table (Sugiyono, 2013). The following are the two formulas for finding U value.
Where: n 1 = Total sample 1 U 2 = Total Rate 2 n 2 = Total sample 2 R 1 = Total Rate in Sample n 1 U 1 = Total Rate 1 R 2 = Total Rate in Sample

Analysis of Results
Tgk. Chik Ditiro Sigli Hospital is a regional general hospital located at Prof. A. Madjid Ibrahim Street, Pidie, and is owned by the Pidie District Government in Aceh, Indonesia. The demographic data of the respondents (practitioner nurses) and the nurse managers in this study include gender, age, employment, education, rank/class, and place/room. Table 5 shows the results of the data analysis presented in the form of a frequency distribution table.

gk. Chik Ditiro Sigli
Hospital is a regional general hospital located at Prof. A. Madjid brahim Street, Pidie, and is owned by the Pidie District Government in Aceh, Indonesia. The emographic data of the respondents (practitioner nurses) and the nurse managers in this tudy include gender, age, employment, education, rank/class, and place/room. Table 5 shows e results of the data analysis presented in the form of a frequency distribution (IGD); while the lowest number of respondents, 4 (2.3%) was shared equally between opthalmology and mental polyclinic.  Table 6 displays the demographic data of nurse managers at Tgk. Chik Ditiro Sigli Hospital in 2015. There were more male nurse managers as 8 respondents (61.5%) were male; 6 respondents (46.15%) were more than 40 years old; 8 respondents (61.45%) had served for more than 15 years; 8 respondents (61.5%) were undergraduates majoring in nursing and 7 respondents (53.8%) were ranked first-class junior superintendents.      Table 9 illustrates that the ability of nurse managers motivation in RSUD Tgk. Chik Ditiro Sigli by 2015, the majority is in a good category as many as 98 (57.0%) of respondents, and bad category as many as 74 (43.0%) of respondents.      Table 12 Chi-Square Tests

The Relationship Between the Leadership of Nurse Managers and Nursing Performance
Sig.

Pearson
Chi-Square 1. 0 cells (,0%) have expected count less than 5. The minimum expected count is 5,35. Data analysis to test the research hypothesis on the relationship between the communication process of nurse managers and the performance of nurses at Tgk. Chik Ditiro Sigli Hospital in 2015 was conducted using Chi-Square. The p-value analysis is 0.000 (<0.05), so H o is rejected, and H a is accepted, which means that there is a significant relationship between the communication process of the nurse managers and the nurses' performance.  1. 0 cells (,0%) have expected count less than 5. The minimum expected count is 3,58.

Profile of Harapan Bunda Banda Aceh Hospital
Harapan Bunda Banda Aceh Hospital is a private hospital located at Jl. T. Umar no. 181-211 Banda Aceh. Harapan Bunda Banda Aceh Hospital was founded by Dr. Zainal Bakri TA, on December 25, 1991. The demographic data of the respondents and the nurse managers in this study include gender, age, employment, education, and place/ room. Table 4.15 shows the distribution of the demographic data of the respondents.
The demographic data of respondents at Harapan Bunda Banda Aceh Hospital in 2015 is displayed in Table 19. The highest number in the gender category were women with 146 (91.8%) respondents; 83 (51.6%) respondents were 20-25 years old;, 83 (52.2%) respondents had served more than 5 years; 153 (96.2%) respondents had a Diploma III in nursing; the rooms with the most number of respondents came from the ICU/ ICCU and Ward 3 with 18 (11.3%) and 17 (10.7%) respondents respectively, and the lowest number of respondents was the VIP room with 5 (3.1%) respondents.  Table 20 shows the demographic data of nurse managers at Harapan Bunda Banda Aceh Hospital in 2015. Based on gender, all nurse managers here were women with a total of 16 (100%) respondents; 11 (68.7 %) respondents were 31-40 years old. There was only one (6.3%) respondent each for the youngest age category i.e. between 20 to 25 years old and more than 40 years old category; 8 (50%) respondents had served for 5-10 years; 15 (93.7%) respondents had a Diploma III in nursing while only one (6.3%) respondent had an undergraduate degree in nursing.

Results
The data on this research comprised data gathered from two hospitals which totalled 331 respondents (172 respondents from the Tgk. Chik Ditiro Sigli Hospital and 159 respondents from the Harapan Bunda Banda Aceh Hospital) using a questionnaire. The results of this study were obtained using the Mann-Whitney U test to see the difference in the interpersonal communication skills (leadership, communication process, motivation, negotiation) of the nurse managers, and the performance of nurses at two different hospitals. The test results can be seen in Table 33 as follows.  Asymp. Sig. (2-tailed) ,000 ,000 ,328 ,000 ,000 1. Grouping Variable: Hospital However, there is no difference in the motivation of nurse managers at Tgk. Chik Ditiro Sigli Hospital and Harapan Bunda Banda Aceh Hospital. In accordance with the previous statement by Mangkuprawira and Vitalaya (Yamin, 2010), "Performance is a multidimensional construction that includes many factors that influence it. These factors consist of intrinsic factors (personal/ individual) or human and extrinsic resources, i.e., leadership, system, team, and situation ". The purpose of the above leadership factors include aspects of quality managers and team leaders in providing encouragement, encouragement, direction and support work to employees.
Based on the theory and results of the above findings, it states clearly that the performance of one of the employees influenced by leadership factors. Results of research at Tgk. Chik Ditiro Sigli Hospital shows that the leadership of the nurse managers and performance of nurses is still bad. While in Harapan Bunda Banda Aceh Hospital, the results showed that the average nurse managers leadership was good as well as the performance of the nurse. The description of the poor or bad leadership of the nurse managers at Tgk. Chik Ditiro Sigli Hospital is another possibility caused by the individual factor of the nurse managers, that is, the lack of competence of the nurse managers (knowledge, attitudes, and skills) as a leader. The possible lack of competence possessed by the nurse managers as a leader is caused by not getting education and training related to the leadership provided by the hospital to the nurse managers. Based on the data that researchers had obtained at Tgk. Chik Ditiro Sigli Hospital since the period 2013 to 2015, there was no education and training related to leadership given to the nurse managers. Education and training obtained by the nurse managers have been more focused on direct nursing care actions to patients.
Robbins and Hunsaker (Bambacas & Patrickson, 2008) reviewed a large number of studies and synthesized interpersonal skills that appeared on most lists. This skill consists of three categories, that is, leadership, communication process and motivation. The interpersonal leadership skills relate to leadership styles, conflict management, meeting conditions, team building and promoting change as well as negotiation. Luthans (Novitasari, 2014) assented that "The leadership style is a way to influence other people's leadership/ subordinate such that the person is willing to do the will of leaders to achieve organizational goals although personally, it may be unpopular." Avolio (2005) examined the influence of leadership and member changes on organizational commitment. His research finds that transformational leadership is positively related to the leader-member exchange (LMX) dimension and organizational commitment. Kanste (2007) did research that aimed to explore the relationship between multidimensional leadership and fatigue among nursing staff. This study was conducted on 601 nurse and nurse managers working in different healthcare organizations. The results of this study seem to protect particularly from depersonalization. Passive laissez-faire leadership functional as an exposing factor for emotional exhaustion as well as a decreasing factor for personal accomplishment. However, the employment status and the character of work tasks affect the connection between leadership and fatigue. With all the changes and growing demand for higher quality, modern products and services, many traditional institutions all over the world face closure or difficulties in upgrading . Therefore, the hospital in this context is not excluded from future challenges to remain competitive.

Conclusion
The results showed that there was a significant relationship between interpersonal communication skills (leadership, communication process, motivation, and negotiation) of nurse managers and the performance of nurses at the two hospitals. Though management research and physical sciences are different in various aspects, there are still ways by which management research can learn from the physical sciences, allowing the issues of the real world in organisations to be addressed via systems thinking. As a suggestion for further research, it could be useful to engage qualitative research by embedding systems thinking to fathom the personal perspective in interpersonal communication skills among employees in selected hospitals. Future studies could consider the qualitative method using interviews and personal observations. As structured interviews and personal observations have led to the discovery of several key emerging themes, which may not have been uncovered as explicitly if only non-qualitative approaches were applied.