This essay will explore the importance of communication in nursing; define communication and look at the different modes of communication and barriers to communication. A reflective model will be used to describe how communication impacted on care delivery in practice. Although each person will bring their own experience of ways to communicate, it will discuss how student nurses can develop their skills that will assist them to ensure excellent communication and also how qualified nurses continue to learn communication throughout their profession.
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Baillie, (2009) indicate that It is predominantly imperative for a nurse to have and develop effective communication skills. A nurse will have contact with a wide range of individuals during nursing; this includes the patient and their relatives and also members of the healthcare team. (Thompson 2003, cited in Baillie 2009) suggests that communication is not only needed whilst transferring information from one person to another, it plays a significant role in relationships.
Kenworthy et al. (2002) indicates that Communication comprises of three fundamental factors; the sender, the receiver and the message. Successful communication can be defined when the receiver is able to interpret the senders message whilst reflecting on their thoughts and feelings and the message received is almost accurate to that of the sender. There are various modes of communication that a nurse may use. For example, face to face contact, telephone calls, emails and letters. (Kenworthy et al. 2002)
Daniels et al. (2010) explain that communication has two parts; a verbal and a non verbal message. Verbal communication is associated with speech and usually heard through the persons ears, however paraverbal cues for example, pitch, speech, inflection and volume can be associated with verbal messages changing the word meaning. Different cultures may find spoken language to be problematic to understand because paraverbal cues may differ from one culture to another. However, paraverbal cues such as a happy friendly smile or crying with grief are associated with different cultures and may help with a cultural barrier. (Daniels et al. 2010) The way in which a nurse speaks and the tone of voice can be very reassuring to a patient, however a patient can also misinterpret the tone as being demeaning or they may even become frightened. Another very important factor suggested by Corner and Bailey (2008) is the way in which a nurse may choose words ensuring that a patient will understand and not be confused with any medical jargon.
A nurse requires excellent awareness of communication theories whilst giving verbal handovers in both hospital and community settings. A report will only become effective during handover if the nurse has a confident attitude, along with good verbal and non verbal skills creating an ideal environment for communication between the healthcare team to ensure continuity of care.(Thurgood [no date] )
Nurses are responsible for maintaining confidentiality. (NMC, 2008) Confidentiality is imperative in a therapeutic relationship with information only being shared between appropriate people. (Sundeen et al. 1998)
Nonverbal communication is made up of all types of communication, with the exception of total verbal communication. Nonverbal communication is usually observed through the eyes however, other senses in the body can compliment this. (Kenworthy, 2002) Nonverbal aspects of a message can include kinesis, facial expression, gesture, touch, movement, body language and eye contact. (Baillie, 2009) Nonverbal communication can be divided in three ways; sign, action and object. Sign nonverbal communication can include hand gestures and sign language, action nonverbal communication can include how you move around, involving body movements that do not offer precise signals. Object nonverbal communication can include furnishings, hairstyles and clothing. (Sundeen et al. 1998)
Written communication is certainly a significant method of communication and is crucial in a healthcare setting. The (NMC, 2008) states that it is imperative that all records are kept clear and accurate. This must include all information on assessments, discussions, treatment and the effect of them. Unfortunately, (Bailie, 2009) points out that written communication is an area that is often ignored, stating that good written communication is vital to protect the patients’ welfare, encouraging high standards of continuity and clinical care, ensuring healthcare team members receive accurate information.
Bailie, (2009) suggests that there are different barriers that may prevent a nurse from communicating that may influence the development of a therapeutic relationship, arguing that Physical barriers may possibly include the surrounding environment, a patient who is in need of pain management or any speech, hearing or visual problems. Bailie, (2009) indicates that psychological barriers may include the emotional needs such as anxiety or personality issues such as a person being introvert or having different beliefs and social barriers can be caused if a person feels that their own social status is categorised by hierarchy, religious or culture beliefs.
Students are encouraged to keep reflective journals of experiences whilst on clinical placements. Reflective journals enable students to learn from their experiences, enhancing their communication development. However, education should be a lifelong experience in that qualified nurses are also encouraged to keep journals. Journals are known as reflective practice and studies have shown that using these can lead to better practice. (Sully & Dallas, 2005)
I now plan to use Gibbs’ model of reflection (1988). This model of reflection is simple to follow for a first piece of reflective writing (please see appendix 1). The patient who has been used in this scenario will be referred to as Mr Jones. The reason for not using the patient’s real name is to respect the patient’s confidentiality. (NMC, 2008)
On my second day of placement Mr Jones was transferred to the ward from the Accident and Emergency Department. During handover the nurse explained that Mr Jones had been referred from his general practitioner since he was complaining of pain in the throat area. As previously mentioned, Thurgood, [no date] states that a handover will only be successful if the nurse has good verbal and non verbal skills. Mr Jones general practitioner was also concerned as he had not eaten anything and drank very little over the previous two days. Past medical history revealed that Mr Jones had been diagnosed with mouth and throat cancer three months ago and was currently receiving chemotherapy treatment at another hospital. However, the nurse described that Mr Jones had become quite angry at times and that he removed his venflon out of his arm and refused fluids.
My mentor asked if I would assist her whilst taking Mr Jones observations. The observations involved taking the patients temperature, pulse, respiration and blood pressure. Comparisons were then compared to the patient baseline and plotted on a chart. Baillie, (2009) suggests that all nurses who observe patients should have the necessary skills and knowledge to understand the measurements and take appropriate action.
The medical team decided that the way forward with medical treatment was by firstly ensuring that sufficient fluids were given to Mr Jones. The doctor asked Mr Jones for consent to insert a venflon in his hand whilst explaining the importance of fluids in the body, yet he kept shaking his head. The (NMC, 2008) states that we must gain consent before any treatment and respect the patient’s choice. The doctors decided that they would prescribe Mr Jones a supplement drink. (Cancerhelp) suggests that Supplement drinks can be used if a patient has a poor appetite and not able to take in enough nourishment into the body. The medical team decided that the nurses on the ward should encourage Mr Jones with oral fluids over the following twenty four hours and assess from there. Mr Jones became quite angry with the doctors and started pushing his arms away, prompting them to leave.
Once the medical team had left I volunteered to sit down with Mr Jones as he appeared to be quite upset. I introduced myself as a student nurse. Mr Jones seemed a very pleasant man however, I soon realised that Mr Jones found it very difficult responding to my questions due to his speech. Mr Jones became more upset and at this point he started to cry, I reached out for a tissue and passed it to Mr Jones, I also held his hand to comfort him. As mentioned previously, Bailie, (2009) suggests that non verbal communication such as touch can be reassuring to the patient. I felt quite nervous at this point, being a student and not experienced, I was not sure what to talk about next, so I stood up and told Mr Jones that I would be back in a minute. I walked to the toilet and became upset, I felt absolutely useless not knowing what to do and more so, to see a grown man similar to my own dads age crying. I put a small amount of cold water over my face and wiped my eyes before I went back on the ward to prevent people from seeing that I had been upset.
I spoke to my mentor and discussed with her that I thought Mr Jones was struggling to communicate with me as his speech was very poor and how upset he had become. (Maguire 1978, cited in Hanson 1994) states that a patient with cancer may find it difficult to communicate to show any worries that they might have. My mentor explained to me that speech more often does become deteriorated when people have mouth or throat types of cancer. I asked my mentor how she felt if I offered Mr Jones a pen and notepad to enable him to write things down or if that at any time he felt he could not communicate by speech comfortably. Baillie, (2009) indicates that speech problems can cause a physical barrier to a patient. My mentor said that she thought it was a good idea and that I could try if I wanted to.
I returned to the bay and found that Mr Jones had pulled the curtains around his bed. I can understand that Mr Jones wanted privacy from the other patients and maybe staff as he was clearly upset. I popped my head around the curtain, smiled at Mr Jones and asked if he was happy for me to come and sit down with him. Mr Jones smiled and started tapping on the chair, gesturing for me to sit down. I sat down and asked Mr Jones if he found it difficult to communicate with his speech and he nodded. Speech disorder, (2009) suggests that Cancer of the throat can cause loss of the individual’s voice and speaking ability. This can be problematic for a patient who would normally use verbal communication. I then continued to show Mr Jones that I had brought a note pad and pen, offering for him to use if he wanted. Mr Jones smiled at me and wrote down “thank you”. Mr Jones then started to open up, writing down that he felt secluded and on times felt patronised by the doctors because he used to live in Pakistan. I reassured Mr Jones and asked why he did he feel this way, he replied by saying that he was confused, there with things he did not understand, the doctors do not listen, he was very scared of dying and asked me if he going to die. Corner & Bailey (2008) indicate that doctors prefer to use closed questions as opposed to open questions, concentrating on the biomedical model and not the emotional needs of the patient. I explained to Mr Jones that I would ask a member of the team to come along and have a chat with him and try to answer the questions that I felt I could not answer being a student nurse. At this point I asked Mr Jones if he would like to have a sip of water and he gave me the thumbs up. I felt really good with myself at this point, I was not experienced however, I had encouraged the patient to drink a small amount of water.
I then discussed this with my mentor who agreed that this patient absolutely needed to be able to understand what the medical team were explaining to him and equally important that the medical team must listen to the needs of the patient. Corner and Bailey (2008) argue that it is important for a patient to have a balanced relationship, along with good doctor-patient communication to enable a patient to have faith in their professional opinion. My mentor asked me to be present with her, whilst she had a chat with Mr Jones and I agreed. My mentor came down to the patient’s level to ensure good eye contact and allowing the patient to answer many open questions, to enable us to get a good understanding of how he was feeling. Wiggens (2006) suggests that open questions will gain an enhanced assessment of the patient, allowing them to speak freely. Mr Jones felt much more at ease once my mentor had finished explaining the importance of fluid and nutritional intake that the body needs. Mr Jones was able to write down on the notepad any questions that he felt had been unanswered and anything that he wished to have a better understanding of. Gurrero, (1998) suggest that nurses must be willing to use other means of communication aids, for example white boards, writing pads and pens.
The hospital had kept a food chart for Mr Jones since he had been admitted into hospital, clearly showing a very minimal amount of fluid intake and no nutritional intake. My mentor decided to show this to Mr Jones, fortunately he understood and consented to have a new venflon put back in his arm. Mr Jones continued to write down that he felt he was unable to swallow properly and that he would prefer to have fluids this way. My mentor phoned the doctor to come to the ward and Mr Jones happily consented.
I felt totally powerless when seeing the frustration that Mr Jones showed towards the medical team during his first assessment on the ward. I could see that there was nothing that the medical team could do to encourage Mr Jones to have the venflon put back in. I believe that because of the breakdown in communication from the doctor, Mr Jones became very distressed. As previously mentioned Corner and Bailey (2008) argue that a doctor-patient relationship is needed for good communication. I felt very inexperienced and accepted the fact that the medical staff knew what they were doing however, I hoped that the doctors would have done something more, even though I understood that the patient had a right to say no to any form of medical treatment that was offered. I was concerned that Mr Jones would die if he did not eat or drink. The other nurses on the ward did not seem to be as anxious to the situation as me. This resulted in me becoming quite distressed over the whole situation, even questioning myself if nursing was for me.
I discussed how I felt with my mentor and this left me feeling very positive. My mentor was a very experienced nurse who explained that nurses quite often find themselves in similar situations and most definitely feel the same way as I do. My mentor said that she felt I had done everything that I could have done with the patient and especially how I noticed that the patient was feeling angry and frustrated because he was having difficulties communicating. I found that my lack of confidence as a student nurse left me not knowing what to do if a patient is refusing treatment, eating and drinking. When Mrs Jones came to see her husband during visiting time, she told me that her husband had told her that he felt much happier that he now understood what was going on. Mrs Jones also said that the note pad was a fantastic idea for her husband to write things down and be able to communicate.
If the situation arose again with a patient who has mouth or throat cancer, I would certainly ask during handover how well can the patient communicate, to ensure a good environment is created for the healthcare team and the patient.
To conclude, I believe that there is nothing else that I could have done to help Mr Jones. However, I do believe that during the handover it would have been beneficial for everyone involved in the care of Mr Jones to be made aware of his difficulties with verbal communication. Nurses certainly need to communicate effectively with patients to provide safe and effective care, taking into consideration that there is difference and diversity and looking at every individual needs. Nurses who work with different cultures have a duty to learn the differences in cultural behaviour and patterns within these groups to prevent a cultural barrier. Listening, along with smiling at appropriate times, showing a positive and genuine interest towards the patient, and have good eye contact will help to prevent barriers in communication. Another important factor is the way in which a nurse positions themselves when talking to a patient. If a patient is sitting, it may be appropriate for a nurse to come down to their level as not to seem to be standing over them, as this could be very disturbing and disrespectful to some patients. Touch and gestures can also go a long way into reassuring a patient. Just by touching a patients arm if they are upset and frightened can mean a lot to a patient. Along with this goes body language and showing respect that will hopefully continue to trust.
Baillie, L., (2009). Developing Practical Adult Nursing Skills. 3rd ed. London: Edward Arnold (Publishers) Ltd.
Cancerhelp,(2009).Coping with cancer [online]. Available at: http://www.cancerhelp.org.uk/coping-with-cancer/coping-physically/diet/managing/weight/high-calorie-drinks (accessed 13.01.2009)
Corner, J., & Bailey, C., (2008).Cancer Nursing. Oxford: Blackwell Publishing Limited.
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Nursing and Midwifery Council, (2008) The NMC code of professional conduct: standards for conduct, performance and ethics. London: Nursing and Midwifery Council.
Speech disorder, (2009). Cancer cause speech disorder [online] Available at: http://www.speechdisorder.co.uk/cancer-cause-speech-disorder.html (accessed 13.01.2009)
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