This assignment will critically analyse the concept of communication within nursing. A concept is said to be ‘a label given to an observed phenomenon’ (Bell, 2009, P46-51). Cutcliffe and McKenna, (2005, P3) suggested that concepts are ‘the building blocks of a theory’, Mcewan and Willis, (2007, P52) supports this and writes ‘concepts are the equivalent to bricks in a wall’. Concept analysis is the means of examining phenomena and is important to nursing as the results of an analysis can often be transferred in to practice to improve standards of care and patient experience (Biley and Maggs, 1996, P237). The analytical framework devised by Walker and Avant (2005, P65) will be used to structure this analysis and identify the uses, attributes, antecedents and consequences of communication. Following a framework when carrying out a concept analysis, enables the writer to thoroughly examine the concept in a logical manor. In order to complete stage five and six of the framework model cases must be devised. The model and contrary case used in this assignment are based on completely fictitious characters therefore to comply with university and Nursing and Midwifery Council (NMC) code of conduct guidelines consent was not needed (NMC,2008).
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The concept of communication was chosen for this analysis as it is an essential aspect of the nurse’s role and is also a contemporary issue in nursing practice that will always remain current. Long (1999, P73) and Cutcliffe and Mckenna (2005, P54) report that during a hospital admission patients will interact more with the nurse, than they do with any other member of the multi disciplinary team (MDT). Current practise sees nurses using constant communication with patients and their families, other professionals and all members of the MDT To adhere to the Nursing and Midwifery Council (NMC) code of conduct nurses must do this effectively (NMC, 2008).
The benefits of effective communication in nursing have been researched for many years by Dougherty and Lister (2007, P52), Kihlgren et al (2003, P1-13), Boore (1978, P29) and Hayward (1975, P73) and all suggest that the way in which a nurse interacts and communicates with their patients can have an impact on recovery time and can also greatly affect the patient’s experience and the standard of care given. Past experiences on placement always resulted in the nurse mentor commenting on the good communication skills and nurse patient relationships formed by the writer. It was felt that these relationships seemed to form naturally, so doing an analysis of communication would help develop and underpin an understanding of the theory that is influencing practise.
There has been a number of analytical frameworks constructed to guide concept analysis, as previously stated the framework devised by Walker and Avant (2005, P65) (Appendix 1) will structure this analysis. The framework was chosen over those of Rodgers (1989, P330-335), Morse (1995, P31-46 and Wilson (1963, P65), as it was felt that it was clear and simplistic enough for the novice analyser to follow, however it still ensured a systematic, thorough examination of the concept. The framework by Walker and Avant (2005, P65) is a modification of Wilson (1963, P65) and consists of eight stages that should be followed. The first stage of the framework is to identify a concept.
Concepts can be described as ‘concrete’ or ‘abstract’. Concrete concepts are considered to be measurable, unlike abstract concepts which are related to feelings, phenomena and understanding (Chinn and Kramer, 1995, P54). Communication is an abstract concept as it can mean many different things to the individual. Effective communication in nursing would develop a positive concept, however communication carried out ineffectively will quickly turn the concept negative (Mcewan and Willis, 2007, P52). Dunne (2005, P57-64) defines communication as ‘the process by which information, meanings and feelings are shared by persons through the exchange of verbal and non verbal messages’, for the communication to be effective both parties must understand the messages sent and come to a mutual understanding of the message. . The oxford dictionary (2008, P91) defines communication as ‘the means of sending or receiving a message’. Following a comprehensive search of the literature a definition of communication in the context of nursing could not be sought. Communication is normally carried out in two forms either verbal communication; which uses spoken or written words or non-verbal communication which involves the use of gestures, touch and facial expressions. (Berman, 2008, P461).
The importance of effective communication in healthcare is recognised in ‘The NHS Plan’ (2000). ‘The NHS plan’ highlights the need for development and improvement of communication skills within health care professionals and states that from ‘2002 it will be a pre-condition of qualification that students have demonstrated competence in communication with patients’ and at the point of registration individuals should ‘have the ability to recognise their communication skills limitations in practise and be committed to personnel development in this area’ (DoH, 2000, NMC, 2008).
Walker and Avant (2005, P65) consider that once a concept has been identified, the next stage is to outline the aims of the analysis. The aims of this analysis are to explore and unpick the theory of communication within nursing and identify and explore the uses, attributes, antecedents, consequences and empirical referents of communication in nursing. Model and contrary cases will be devised to demonstrate understanding of the concept.
The third stage of Walker and Avant’s (2005, P65) framework is to determine the uses of the concept. ‘Communication is one of the most fundamental human aspects of daily living’ (Holm, 2006, P493-504) and has many uses in nursing. One of which is to aid the development of nurse patient relationships. The NMC code of professional conduct states that nurses must always act in a way that is in the best interests of the patient, making the care of people your first concern, treating them as individuals and respecting their dignity. In order to do this nurse’s must make every effort to get to know their patients on a holistic individual basis; this is facilitated by the development of therapeutic relationships (NMC, 2008, Timmins, 2007, P395-399). Berman (2008, P472) defines a therapeutic relationship as, ‘an intellectual and emotional bond between nurse and patient, where the main focus is always to benefit the patient’. Current research and literature suggests that the main components of building therapeutic relationships are active listening, attending and responding, all of which are factors of communication (Dunne, 2005, P57-64).
The use of effective communication is also vital when informing patients of options or treatments relating to their care. When nurses are competent in using effective communication, they are able to provide patients with enough knowledge to enable them to make an informed choice regarding the care they receive. (NMC, 2008, DoH, 2006). Many recent government initiatives including Making a difference (1999), Essence of care (2001) and Your health, your choice, your care (2006), all set out benchmark criteria for the improvement of patient care and experiences. Effective communication is at the heart of all these plans and benchmarks will not be met without the use of effective communication.
Current research and literature also shows that the use of effective communication between MDT’s is vital for the delivery of safe, high quality patient centred care. Information should be passed between MDT professionals clearly and accurately as effective teamwork will enhance continuity of care, minimise the risk of patient harm and improve patient outcomes (Leonard et al, 2004, P85-90, Xyrichis and Ream, 2007, P 323 – 241). Effective team working has been highlighted as one of the most important factors in producing good outcomes for all involved healthcare, effective communication is paramount in ensuring this is achieved. As it has been reported that 70-80% of healthcare errors are caused by poor team understanding and communication (Xyrichis and Ream, 2007, P232-241, Schaefer et al, 2004, p221-225, Leonard et al, 2004, P85-90).
Walker and Avant (2005, P65) also suggest that ‘consideration is given to how the concept is used in different disciplines’. Outside of nursing the use of communication is extensive and again one of the main activities of daily living. The media is said to be the most powerful tool for communication and can penetrate into all aspects of social experience worldwide (Baudrillard, 1994, P 601). Advances in recent years have also seen the use of the internet rise, in which worldwide communications can be achieved in minutes. Verbal communications have also been reported as the best method of advertising (Hasan, 2009, P12-15, Goldenberg et al, 2001, P 211-223). Also in all aspects of life body language can be considered one of the truest forms of communication and must never be overlooked.
To ensure a thorough literature search was carried out for stage four of the framework, which is determine the attributes, a number of hand searches and electronic data bases searches were carried out. To ensure the search was comprehensive and located only valid current literature the search was not limited to nursing literature, as Walker and Avant (2005, P65) suggest searching only nursing literature may bias the analysis. Mckenna (1997, P62) writes it is better to examine fewer attributes that really illustrate the concept than cover a number of attributes that only vaguely characterize the concept. After fully engaging in the literature the common themes that kept occurring were, active listening, the use of the situation, background, assessment and recommendation framework (SBAR) when communicating patient information between the MDT and the power of non verbal communication, i.e. body language.
Sundeen et al (1994, P118) writes that active listening is a technique which is most effective in communications and will greatly enhance the nurse patient relationship and patient experience. Active listening is the behaviour of listening, whilst observing without interrupting. Active listening uses all the senses as opposed to passive listening which uses only the ear. Often in nurse patient communications there will be silences, research shows that nurses will often jump in and fill the silences, but by doing this nurses are preventing the patient from continuing their conversation. Stickley and Freshwater (2006, P12-18) considers that silences should not be filled by nurses as they are a reflection point for the patient and silences encourage patients to continue to talk. Nurses should demonstrate active listening thorough their body language with the use of eye contact, nodding and gestures to show an attitude of care and interest, thus encouraging the patient to talk. Active listening involves paying attention to the total message both verbal and non verbal and noting whether the two forms of communication are congruent. Sometimes what patients say is not really how they are feeling and nurses need to develop the skills to identify this through the patient’s body language (Berman, 2008, P468, White, 2000, P127).
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Research has suggested that patients and their families may refrain from speaking to the nurse, through fear that the nurse is too busy or not willing to listen (Dunne, 2005, P57-64, Cynthia, 2001, P24-27). Patients frequently want to share their concerns with nurses but may not come forward and say so. Hunt and Meerabeau (1993, P115-123) agrees with this but also highlights that nurses should be aware that some patients may not wish to have in depth emotional conversations with nurses and may want to keep conversations simple and nurses should detect and respect this. A nurse who hasn’t actively listened to their patient will have not fully understood the message that the patient is giving them and therefore will not act appropriately resulting in poor patient care and non adherence to professional bodies policies (Alcagno, 2008, P333-336, NMC, 2008). A recent study by Barrere (2007, P114-122) shows that nurses who didn’t actively listen to their patients often made mistakes and missed important clues on how the patient was feeling.
Another attribute to communication that was repeatedly discussed in the literature was non verbal communication (NVC). Words are powerful things and can stimulate or shut down a conversation, however body language and tone of voice will override any spoken words (Calcagno, 2008, P333-336). Current literature suggests that only 7% of communication is interpreted from the words used, and the rest is from body language. Bush (2001, P39) repeats this and writes that ‘80% of the message being communicated is taken from body language’. Berman (2008, P461) agrees with this and writes ‘non verbal communication can often tell others how a person is feeling rather than what is being said’ and suggests this is because non verbal communication is controlled less consciously than verbal communication in which people have to think about and choose what words they use. Dougherty and Lister (2004, P17) also agree and suggest that nurses should always be self aware, as their body language, ‘facial expressions, tone of voice, eye contact and posture’ can have a great influence on the message that is being communicated. To communicate effectively with patients nurses should be positioned at the patient’s eye level, using gestures to show that they are interested in, listening to and understand what the patient is saying. Active listening extends to all aspects of the nurses role, as not listening effectively to colleagues can result in patient harm and even fatalities (Denham et al, 2008, P148-161).
Another common theme discussed in the literature regarding communication within the MDT, was the use of SBAR. Although originally developed in the United States (US) for use by the military SBAR is now being used in nursing nationwide. SBAR is an abbreviation for the framework, situation, background, assessment and recommendation (appendix 2). Mentally following the SBAR framework enables nurses to communicate patient information with other healthcare professionals systematically and consistently, thus promoting safe practice and continuity of care, both of which are crucial to the patient and the healthcare team (Challand, 2009). Continuity of care cannot be achieved without a successful handover of information between professionals (Pithier, 2005, P1090-1093, NMC, 2008,). Wong et al (2008, P9) defines a handover as ‘the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis. Messam (2009, P190-196) states the nurse shift change handover is an essential and complex component of nursing. Conveying accurate precise information in the handover through the use of SBAR is vital to safe practice, as the aim of the handover is to accurately exchange information regarding patients and their care from the nurses leaving shift to the team starting shift and any omissions or errors made can lead to dangerous or even fatal consequences. Pithier (2005, P1090-1093) and Leonard et al, (2004, P85-90) support this and write how nurse handovers are paramount to care and will be more effective if structured by the SBAR framework.
Stage five of Walker and Avant’s framework states that model cases should be constructed to aid and demonstrate understanding of the concept. Model cases are example of the concept in its best form and contain all of the defining attributes (Xyrichis and Ream, 2008, P232-241). Bill is a 64 year old gentleman who has recently been admitted to the orthopaedic ward of a local hospital for an elective hip replacement. The nurse observes Bill sitting in his chair looking worried and withdrawn; the nurse goes over to Bill and quietly asks him if he is alright. Bill says he is ok but the nurse is aware that although Bill says he is fine his body language is not congruent. The nurse places her hand on Bill’s shoulder and asks him if he is sure, or if there is anything he wants to discuss. Bill sighs and explains to the nurse he is very worried about the surgery and how he will be afterwards. The nurse sits attentively at Bills level showing that she is interested and actively listening to what Bill has to say. The nurse then talks Bill through the procedure and rehabilitation process following the surgery. The nurse also suggests Bill may benefit from speaking to patients who have been in the same situation and asks Bill if he would like to do this. Bill agrees that this may help him feel easier about the situation. The nurse does as planned and arranges for John to talk to Bill, after Bill’s encounter with John the nurse speaks to Bill again to clarify Bills understanding and confirm if talking to John has helped and if there is anything else she can do for him. Bill states he feels much better and thanks the nurse for her time and care and starts preparing for the operation feeling more informed and prepared for the surgery.
The sixth stage of Walker and Avant’s (2005, P65) framework is to identify additional cases, it is suggested that a borderline, related or contrary case is constructed. A contrary case is said to be an example of the concept in its worst form and would include few if any of the defining attributes (Mandzuk and McMillan, 2005, P12-18, Xyrichis and Ream, 2008, P232-241). Bill is a 64 year old gentleman who has recently been admitted to the orthopaedic ward of a local hospital for an elective hip replacement, whilst the nurse is in Bill’s room he tells her how he is very anxious about the surgery. Without making eye contact with Bill the nurse says you will be fine it is a routine procedure we do them every day and walks out of the room. Leaving Bill alone, anxious and feeling like he has no support.
The seventh Stage of the framework is to identify the antecedents and consequences of the concept. Antecedents are defined as the ‘elements necessary to the formation of the concept and include professional knowledge, responsibility, sensitivity and reflection’ (Andberg et al, 2007, pg 640). Rodgers (1989, P334) agrees and states ‘the antecedents of a concept are the events or phenomena that are generally found to precede an instance of the concept’. In order for nurse patient communication to commence there must be a nurse-patient encounter, within this encounter there is a need for messages, information and feelings to be transported. In relation to MDT working, there must multiple members with information to convey, whilst keeping patient welfare the common focus. Pinto, (2000, P20) agrees and writes that in order for communication to take place there must be a sender, a recipient and messages to convey.
The consequences of a concept are said to be ‘events which occur as a result of the occurrence of the concept (Rodgers, 1989, P334). Andberg et al ( 2007, pg 637) writes that when identifying the consequences of a concept all the effects, good or bad should be considered. Communication in nursing can produce a very positive outcome for all involved when carried out effectively. Effective communication fosters the development of therapeutic relationships between nurse’s and their patients. Following the development of a therapeutic relationship through the use of effective communication nurses can reassure their patients, enable patients to gain a better understanding of their illness and empower patients to voice their opinions and concerns regarding the treatment and care they receive (Collins, 2009,P24-26, NMC,2008, Rowe, 1999, P37-40) Effective communication will also strongly influence the patients perceptions of the quality of care that they have received and will impact on their overall satisfaction with health care services (Shaw and Wilson, 2009). In agreement with this Collins (2009, P24-26) writes ‘without exception patients experiences are influenced by how care is communicated and delivered’.
In contrast when carried out ineffectively communication has been shown to be the leading cause of inadvertent patient harm and clinical errors (Leonard et al, 2004, P85-90, Pincock, 2004, P1136, Gardezi et al, 2009, P1390-1391, Sutclifee et al, 2004, P186-194, Ghandi, 2005, P353-358). In the Every Complaint Matters (2008-2009) report produced by The Parliamentary and Health Service ombudsman it is stated that a large percentage of complaints against the NHS are a result of communication breakdown between healthcare professional and patients. Chant et al (2002, P12-21) suggests that one of the most fundamental barriers to effective communication in practice is the clinical environments policies and practices. This is supported by a qualitative study of patient experiences by McCabe (2004, P41-49) which stated that patients felt that ‘nurses were often to task orientated’ and only approached patients to carry out administrative or functional tasks. Chant et al (2002, P12-21) also writes that students often steered away from chatting with patients through fear of appearing lazy and not looking busy. To enable nurses to have more time to spend communicating with patients the national initiative ‘The Productive Ward was devised by the NHS Institute for innovation and improvement (NHSI). The initiative aims to ‘motivate ward teams to review the way in which activities are undertaken in the workplace’, with the goal of removing wasted time and creating time to provide more direct patient centered care (Bloodworth, 2009, NHSI, 2007)..
The final stage of Walker and Avant’s concept analysis framework is to identify empirical referents. Empirical referents are said to be ‘measures that are taken in order to observe whether the concept is present’ (Walker and Avant, 2005, P65). As communication is an abstract concept that is largely subjective to the individuals thoughts and experiences it can often be hard to measure. To assist the NHS in evaluating their performance patient and public involvement (PPI) forums and patient advice and liaisons service (PALS) has been developed to enable patients to get ‘their views and opinions of the care they have received fed back into the NHS’, to promote changes in practice and improve standards of care (DOH, 2003). Analysing qualitative research can also help gain an understanding of patient’s perceptions of the communication and care they feel they have received (Matiti and Sharman, 1999, P32-35).
Using Walker and Avant’s Framework to examine the uses, attributes, antecedents and consequences of communication has enabled a thorough examination of the concept. It is felt that conducting this analysis has enhanced understanding of the concept and its influences on practice, the knowledge gained through this analysis will be used to guide future practice and improve on an already established skill. It can be seen from this concept analysis that effective communication is at the heart of nursing and is a fundamental skill. The level of communication between healthcare professionals and patient’s will greatly affect nurse patient relationships and the patients perceptions of the nursing care received, this in turn will have a huge impact on how nurses and healthcare services are perceived as a whole by society. Effective communication is crucial for the delivery of patient centred; high quality care and many government initiatives have been published to guide healthcare professionals in the delivery of this. However despite this it can unfortunately be seen that the NHS still receives a large number of complaints from patients who feel they have received poor communication which resulted in inadequate care. Failing patients through a breakdown in communications would also result in non compliance of the NMC code of professional conduct. As communication is a learnt skill nurses constantly need to strive to improve their skills and work within current initiatives and guidelines. Complying with this will enable standards of care to improve and in time society will have an improved perception of the NHS and the care and services it provides.
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