Communication is a huge topic and can be considered on many different levels from a professional viewpoint. We can consider issues such as the relevance of various forms of communication between the healthcare professionals and the patient which, ultimately determines many of the parameters of treatment (and compliance).(Stewart M 1995)
We can also consider the importance of communication between healthcare professionals themselves which can cause inordinate problems for the patient if they are less than optimal. (Hogard E et al. 2006)
Firstly, communication requires a definition.
There are many attempts at trying to define the essence of communication. They all differ in detail but, in essence, they all describe a complex process of both sending and receiving messages which can be either verbal or non-verbal or, more commonly, a mixture of both. This interchange allows for an exchange of information, feelings, needs, and preferences. Typically the two protagonists in a communication exchange will encode and decode messages in a cyclic pattern. Each making an analysis and response to the preceding gambit. (Wilkinson SA et al. 1999)
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In the context of professional nursing, its purpose is generally manifold but will include the means of establishing a nurse-patient relationship, to be a tool for expressing concerns or interest in the patient’s circumstances, to elicit information relevant to the patient’s condition and to provide healthcare information. (Bugge E et al. 2006)
Implicit in the process of communication is the achievement of a shared understanding of meaning. This is validated by the process of feedback interpretation which indicates if the actual meaning of the message was interpreted as it was originally intended.
Communication can be categorised into both type and level. In a nursing-specific context, the level of communication can be defined as “Social” which is considered to be safe and non-contentious, “Structured“, which is typically utilised for situations of teaching and patient interviews and “Therapeutic” which has the characteristic of being specifically patient focussed, purposeful and generally time limited. If this is successful it develops further characteristics such as the nurse comes to regard the patient as a unique individual and begins to understand their motivations, and the patient develops a trust in the nurse. It is within this communication context that the nurse is generally able to try to provide care and, more importantly in some instances, help patient identify, resolve, or adapt to health problems. (D’Angelica M et al. 1998)
The types of communication are capable of endless subdivisions, but in broad terms, they are classified as verbal and non-verbal.
The verbal communication requires, by definition, the conscious use of the spoken or written word. The nature, grammar and syntax of the words can reflect the patient’s mental age, their education, their culture and in some cases their mental state and feelings of the moment. Certain inferences can be made from the way the words are delivered such as their choice, their tone or pace of delivery. The characteristics most favourable for efficient and effective communication are that the words should be “simple, brief, clear, well timed, relevant, adaptable, credible”. (Philipp R et al. 2005)
Non-verbal communication relies on the interpretation of facial expressions, hand gestures, and body language. This is an extremely subtle means of communication and can give credence (or otherwise) to the spoken word. In the nursing context, non-verbal communication can be manipulated to the nurse’s advantage to help to elicit information that may otherwise not have been forthcoming. It has been estimated that non-verbal communication accounts for up to 85% of information transfer between communicating adults. In the professional nursing context it requires both systematic observation and careful assessment and interpretation to derive the full meaning of what the patient wishes to convey. Most importantly, the nurse should be aware of incongruity between the verbal message and the non-verbal cues. The patient who smiles while describing a terrible pain is one such example. (Musselman C et al. 1999)
Implicit in the understanding and correct interpretation of the non-verbal cues, (and to a lesser extent the verbal ones), is an appreciation of the various environmental and circumstantial factors which can affect the process of communication. There are a number of factors that are of relevance to the clinical situation, including the culture, developmental level, physical & psychological barriers that pertain to the patient, their personal space (proxemics) and territoriality that they perceive, the roles and relationships of the people that they are speaking to, the local environment, and their personal attitudes and values and level of self esteem. (Derjung M et al. 2006)
On a personal level, I find communication skills most important in the context of the nursing report. One can experience situations where a report is given and very little real information is passed between professionals. Other situations can occur where perhaps the same length of time is taken but enormous amounts of information can be derived from a good report.
I recall one particular handover report which, despite being fairly long, left me with no clear information as to what was going on with the patients on the ward. I couldn’t recognise them as people and they were presented more as cattle. The report itself was completely task orientated and comprised little more than a list of jobs that the nurse herself had not been able to accomplish that day.
If we consider the literature on the subject we can note that the nursing report predates the Nightingale era. (Carrick P 2000). The nursing profession has evolved as have the requirements, demands and procedures employed. The nursing report is no exception to this evolution. As with any process that involves humans, there is an intrinsic variability. It is seldom perfect and its standard can vary all the way from excellent to dreadful (RCN.2003)
In consideration of comments made earlier in this essay we note that the issue of report giving is capable of considerable improvement with learning. This was demonstrated by two independent researchers who produced two seminal papers on the subject coincidentally at virtually the same time. (Ljukkonen A 1992) (Kihlgren et al 1992). In essence, their studies were a period of observation and analysis, a training period and then another period of reanalysis.
There is no merit in considering the entire paper in detail here, but the significant findings (in terms of communication) were that before the training the reports were generally:
Highly task oriented and (it was noted that) the staff often discussed the patients’ reaction in vague and general terms without imparting any specific or useful information.
The authors were also able to comment that the nursing process was seldom adhered to during the structuring of the report.
During the post training assessment the authors noted that the most significant areas of change were:
More messages were given per report after the intervention compared to the control ward and the messages with psychosocial content had doubled.
The relevance to communication issues is clear. These two studies show that communication is not necessarily innate, but is a skill that can be both learned and enhanced. Good communication equates with both efficiency and, in the case of these two studies, “less dissatisfaction and a greater team empathy between nursing colleagues which led to more collaboration between the various teams working on the ward.”
There are a number of ways in which we can approach the discussion of such topics and we shall consider a few specific different types of communication as an illustrative vehicle for discussion.
Much original and groundbreaking work in the area of communication in the healthcare setting was done by Orlando about two decades ago (Orlando I. J. 1987) who suggested that one of the core roles of the healthcare professionals (he was writing specifically about nurses at the time) was to:
“ascertain and prioritise the patient’s needs and instigate and plan appropriate help.”
Few would disagree with this comment, but it is clear that effective and precise communication between patient and nurse is essential if the patient’s needs are to be ascertained accurately in the first instance. Communication between healthcare professionals, the patient and other legitimately interested parties such as carers, is then vital if such a plan is then to be optimally implemented
The importance of communication as a skill is clearly demonstrated by the fact that it is currently included as one of the six core skills required of the modern nurse manager. (ICN 1998).
Another indicator of the importance of good communication is the fact that the majority of complaints currently made to UK Hospital Trusts can ultimately be traced back to poor communication (Richards T 1999).
Communication is an attribute and skill that is rarely intuitive. (Davies et al. 2002). There are a great many papers which demonstrate the fact that communication skills can be improved at all levels of competence with both practice and learning. (Hulsman R L et al. 1999)
A particularly comprehensive review has been recently published by Heinmann-Koch (2005) which gives an excellent analysis of the strengths and deficiencies in the communication skills of a number of healthcare professionals and the authors make a number of recommendations to address the shortcomings that they identified.
The authors quantify the essential skills of communication as “Personal insight, sensitivity, and knowledge of communication strategies”. The latter being considered vital to maximise the efficiency and effectiveness of one’s communication abilities.
If we consider the professional standing on issues of communication, we can note that the Royal College of Nursing has earmarked communication skill as a specific “competence goal” and the Royal College of Physicians have now included a specific element of assessment in communication skills in their Part II membership exam with elements of information gathering and information giving being specifically assessed. (RCP 2002)
Dacre summarises the important elements of the healthcare professional / patient interaction thus:
- The importance of reflection before a consultation in order to form a clear agenda of the overall aims of the consultation and prepare questions.
- Checking the patient’s name as an appropriate opening gambit. Starting with an open question.
- Use a mixture of open and closed questions, structuring the questions carefully, and exploring each area in full before moving on. Make sure each question is effective. Take care not to interrogate patients.
- Avoid the use of overtly medical language and check at each stage that patients have understood what is being said.
- Ensure that the healthcare professional does not push his or her own agenda.
- Allow patients time to finish speaking, using verbal and non-verbal cues to makes it clear that the healthcare professional is listening. Respond to the information that the patient has given to show that this has been heard and understood. Use careful interjections to redirect the interview if necessary.
- Avoid premature closure (finishing very quickly). There should be a summary—for example, recapping decisions which have been made, and agreement of an immediate plan for the next step.
(after Dacre J et al. 2004)
In order to explore the area of communication more fully, we will consider a number of specific instances as illustrative examples. We shall begin with the study by Coiera (E et al. 1998). The study starts with the comment:
The healthcare system seems to suffer enormous inefficiencies because of poor communication infrastructure and practices.
It then cites the Smith paper (Smith A F et al. 2005) which points out the fact that communication problems were the most common cause of preventable disability or death, and were nearly twice as common as those due to inadequate medical skill
This study took a cohort of 10 healthcare professionals working in a hospital setting and analysed all of their professionally based communications. For efficiency and content. The paper itself was both long and involved and some of the findings are only of peripheral relevance to our considerations here, so we shall confine our discussions to the parts that are relevant
The first major finding was that there was a tremendous range of topics dealt with, ranging from the clinical to the administrative. The authors comment that efficiency of communication is inversely proportional to the diversity of topics. In other words, communication in a designated clinic setting, where all of the problems are likely to have a similar thrust, is more likely to be efficient than conversations encountered in a general ward on general topics. The second general finding was that efficiency of communication was significantly impaired by the frequency of interruptions. It follows that protected time in a consultation, free from interruptions, is more likely to be an efficient communication than one that is frequently interrupted.
Interruptions were seen to be associated with a number of well recognised psychological responses including diversion of attention, forgetfulness, and errors. (Blum N J et al. 1992)
Paradoxically, the authors found that the most junior staff, (I.e. the least likely to be experienced in communication skills), were the most likely to be interrupted, while the senior staff were the least likely to have their consultations interrupted.
We have already considered a number of the factors that can influence communication and various communication strategies can be usefully employed to assist in eliciting appropriate information. Active listening is perhaps the most useful basic tool that the nurse can use. When interacting with the patient, the nurse should endeavour to utilise strategies that will facilitate both conversation and elaboration. Mechanisms such as use of broad opening statements, reflecting, open ended statements and directive questions can be strategically employed to elicit appropriate information. (Huizinga G A et al. 2005)
Many patients will not be used to expressing themselves clearly and concisely, and can be helped by techniques such as acknowledging feelings, using silence as a prompt, reflection, and stating personal observations. All of these factors can be enhanced if used alongside strategies that communicate mutual understanding. (Yedidia M J et al. 2003)
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We have presented evidence that communication is the medium of mutual understanding. We should therefore not leave this area without making comment on some strategies that the professional nurse can employ to maximise the empathetic understanding of those that she is communicating with. These strategies are important not only in the nurse / patient interaction but also in the teaching environment. Ensuring that the message is thoroughly communicated and understood requires techniques such as clarifying, validating, verbalizing implied thoughts and feelings, focusing, using closed questions and summary statements.
The converse of this argument is that the nurse should also be aware of issues that are potential barriers to communication. The absence of positive and attentive listening is a powerful disincentive to most forms of communication. The patient who perceives that they are not being listened to is not likely to produce any useful information. Other barrier behaviours include the use of reassuring clichés, giving advice, expressing approval/disapproval, requesting an explanation (asking why?), defending, belittling feelings, stereotyped comments, changing the subject. (Arora V et al. 2005)
We have devoted the majority of this examination to the spoken modes of communication, but we should not overlook that the written word is an equally important means of communicating ones thoughts to others, particularly on an interprofessional basis. In order to maximise the efficiency of communication a written report should ideally be brief, concise, comprehensive, factual, descriptive, objective, both relevant and appropriate and legally prudent. (Young B et al. 2003)
In this assessment one should draw attention to the distinction between being both brief and concise. Brief equates with shortness as undue length will allow the reader’s attention to wander, whereas being concise implies an absence of irrelevant detail thereby allowing an emphasis on what is important.
The preparation and literature review has allowed ample time for reflection on the issues raised. (Taylor, E. 2000). This has proved to be a valuable experience as some issues which I believed that I understood, became clearer and this gave me a much deeper insight into both the mechanisms and the possibilities of accurate and concise communication. Not only have the mechanisms of positive enhancement of communications become apparent but also the active removal of the barriers or impediments to communication clearly play an important role in the ability of the nurse to communication efficiently with both the patient and her healthcare colleagues.
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