The aim of this essay is to explore the concept of communication within nursing. Communication is often seen as a verbal act, however, this essay will explore the various other means in which people communicate, and attempt to apply them to a clinical setting. It will also explain how important communication is when establishing the nurse, patient relationship, and how bad communication skills can result in a breakdown in that relationship. Finally, a reflection will be written on an aspect of communication that took place during a clinical placement. This will be used to highlight how ‘good’ or ‘bad’ communication techniques can impact upon the patient and hence inhibit or aid the rehabilitation process.
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Over recent years, the role of a nurse has changed considerably. According to Kenworthy et al (2002) the nurse no longer treats a patient who is ill, but treats the person who happens to have an illness. Nursing has taken on a more holistic approach, and patients are seen more as whole beings (Jones 1998). Not only are their medical histories examined, but their social being and their lifestyle are taken into consideration when planning and implementing treatment (Kenworthy et al. 2002). The Nursing and Midwifery Council (NMC) Code of Professional Conduct (2008) specifies that nurses should treat patients as individuals and make their care their primary concern. This should be carried out whilst respecting their dignity and treating them as individuals. The code goes on to state, that a nurse should; ‘act as an advocate for those in their care, helping them to access relevant health and social care, information and support (NMC 2008 p.1).
In order for a nurse to understand the patient ‘holistically,’ they will need to collect and analyse a huge amount of data. This begins with the initial assessment, and signals the beginning of the nursing process. (Palmer & Kaur, 2005). According to Roper, et al (1983), cited in Aggleton & Chalmers (2000) nursing should be centred on the patient’s twelve activities of daily living. This involves asking in depth questions concerning the patient’s normal behaviours and habits in relation to such activities as elimination, sleep, work and play. By talking to the patient and obtaining the information required, the nurse should aim to build a therapeutic relationship between themselves and the patient. During this period, the nurse should attempt to gain the trust of her patient by making them feel comfortable, safe and at ease (Sheldon 2005). This stage of the nurse, patient relationship is crucial, and depends wholly on the communication abilities of the nurse in question.
In order for an assessment to be successfully completed, the nurse should be conscious of the types of questions used. The use of open ended questions can allow a patient to elaborate on their feelings, and prevent ‘yes’ or ‘no’ answers. However, when precise information is required the use of closed questions may be more appropriate (Sully & Dallas 2005). Stuart & Laraia (2001), cited in Riley (2004) argue that a therapeutic relationship can be facilitated by communication, but at times can act as a barrier to the relationship. Renwick (1992) cited in Arnold & Boggs (2003) concur, suggesting that nurses should ask an appropriate number of questions in order to collect relevant data , yet too many questions could cause the patient to feel as if they are being cross-examined. According to Sheldon, (2005), a nurse should view communication as a clinical skill, and endeavour to constantly build on their expertise throughout their career.
Communication in its simplest term, is the social interaction of people. It involves the sending and receiving of messages, which can either be verbal or non-verbal (Anderson, 1990). According to Riley (2004) firstly, the sender has to encode the message that he or she wishes to send. This message is then conveyed to the receiver through means of speech, sight, and touch. It is then necessary for the receiver to decode the message, and encode a return message.
Speech is often seen as the main component of communication. However, it is important for health professionals to remember, that not all words have the same meaning for everyone. Even if a patient does understand what the nurse is saying, the non verbal actions that accompany the words spoken, can completely change the meaning of the message (Arnold & Boggs, 2003)
Therefore, other elements apart from speech need to be taken into consideration when decoding and encoding messages. According to Argyle (1988) and Ekman & Friesen (1987), cited in Kenworthy et al (2002), facial expression can reveal volumes with regards to the emotional state of the receiver or sender. They recognised six fundamental emotions, which are identifiable across all cultures, by the movement of facial muscles; happiness, anger, surprise, fear, disgust and sadness. If a patient were undergoing an embarrassing procedure and the nurse caring for them showed signs of embarrassment or distaste via their facial muscles, this could make an unpleasant situation even more humiliating for the patient concerned. Stanton (1990) argues that an individual’s body language can often display a much stronger message than their verbal communication, and can become open to misinterpretation. It is therefore necessary for health professionals to consider their non-verbal techniques of communication in order to avoid such misunderstandings.
A further aspect of communications that a nurse should be conscious of is paralanguage. This includes the characteristics that run alongside language, for instance, pitch, volume, tone, accent and speed of speech. (Kenworthy et al 2002). It is entirely possible for the sender to ‘encode’ one thing, only for the receiver to ‘decode’ quite another. For instance, if a nurse is giving a patient instruction on how to take their medication, with a loud tone, and is pronouncing her words very slowly,
the patient may feel as if they are being patronised. This could ultimately lead to a breakdown in communication, and hence the patient’s quality of care could become compromised.
In conclusion, it is of the utmost importance that a nurse is able to build a trusting relationship with the patient, this will form the basis of the patient’s treatment and rehabilitation. The nurse’s communication ability is paramount and they must be fully aware of, and take into account the verbal and non-verbal aspects of communication. The nurse must also be aware of the diversity of client’s, and treat them with sensitivity and respect. This will create a mutual understanding between nurse and patient, which will ultimately aid the rehabilitation process.
The second part of this assignment will reflect on an incident that took place during a clinical setting. It will be used to demonstrate a further understanding of the importance of communication within nursing.
Reflection on Practice
Reflective practice has been identified and acknowledged as an essential tool within the healthcare profession. According to Jasper (2003), the ability to reflect upon one’s experiences is the starting point for relating theory to practice. The reflective process requires the individual to be self aware, and able to analyse their actions, thoughts and feelings, and if necessary, bring about positive change (Bulman & Schutz 2004).
For the purposes of this reflection I will use the Gibbs’ reflective cycle (see Appendix 1). This model sets out a series of structured questions, which will help guide me through the reflective process
In accordance with the Nursing and Midwifery Code of Conduct (2008) patient confidentiality will be maintained throughout this reflective account. Therefore, the patient involved will be referred to by the pseudonym of Rose.
Description: What Happened?
My first clinical placement was on an elective surgery ward. Rose, a 70 year old woman was suffering from primary osteoarthritis of the right hip. This is a degenerative, non-inflammatory condition, which affects the hyaline cartilage of the synovial joints (Manley and Bellman 2003). Due to her continuing pain and decreased mobility, she had agreed to undergo a total right hip arthroplasty. According to O’Brien et al (1997a) arthroplasty, is the most common, and successful treatment for osteoarthritis of the hip.
Rose was on her second, post operative day and was having trouble opening her bowels. The nurses caring for her were aware of this, and she had been given a laxative the previous evening. She was very reluctant to get out of bed and walk to the toilet herself, as she was afraid of the pain, and the fact that she may dislocate her hip. A staff nurse and I, had placed a bed pan underneath Rose several times that morning, but she had been unable to open her bowels. According to (Heberer and Marx 1995) constipation after surgery is quite commonplace, this can be due to the drugs taken after surgery to combat pain. Each time the staff nurse and I had assisted Rose, she had become very frustrated and angry.
Later that afternoon Rose’s buzzer went off, she explained that she had a strong feeling that her bowels were about to open. I could tell by Rose’s facial expression that she was indeed desperate to open her bowels. The other two nurses on duty that day were busy with two post operative patients. I realised, that I would have to choose between waiting for another staff member to assist me, or allowing Rose to soil herself and her bed. I was aware that this would be very embarrassing and humiliating for her, I was also aware of the Code of Conduct (NMC 2008) that emphasises the fact that nurses should act in the best interests of the patient. I was also reluctant to attempt this alone, as Rose had become somewhat angry during previous attempts.
Feelings: What were you thinking?
Even though I had previously assisted qualified staff in placing Rose on a bedpan, I was rather apprehensive about tackling this procedure unsupervised. As no help seemed to be arriving, I realised that I had to make a decision. Not only was Rose becoming increasingly desperate, she was also becoming irate and impatient.
I decided, that in order to adhere to the Code of Conduct (NMC, 2008) I would have to try and help Rose to the best of my ability, alone. I was very nervous, not only was I worried that I would not get her on the bedpan in time; I was also concerned that I would not be able to cope with her demeanour, if this happened. I did not feel experienced enough in my communication skills to be able to carry this out, whilst at the same time, attempting to place her on the bed pan.
I explained to Rose that I was going to place the bedpan underneath her; I also explained that I was a student nurse and that I was still learning. Above Rose there was an over bed pole hoist (monkey bar) that she was able to use to pull herself up, whilst I placed the bed pan underneath her. Whilst Rose was pulling herself up she was making a lot of noise due to the strain of using her upper body, and the pain of her hip. I tried to encourage her with a calm voice, however I was aware that my tone of voice was rising because I felt panicked. This in turn caused Rose to become even more agitated. This was making me even more apprehensive, and I began to feel flustered and very inexperienced. It was very difficult to sit rose squarely on the bedpan as she was lying flat, I was very worried that she would completely miss it and soil the bedding. Not only would this be very humiliating and uncomfortable for her, but it would make me feel very incompetent as a nurse. During this time I felt very inexperienced, and doubtful as to whether I would make a very good nurse at all.
Eventually Rose managed to open her bowels, it was extremely loose and had an offensive smell. I was very worried that I would not be able to remain professional due to the sight and smell of the faeces. I was aware that this could be detrimental to Rose’s self esteem and could cause a barrier within the nurse, patient relationship. Whist wiping Rose, it was clear that she was very embarrassed. I too felt embarrassed, and endeavoured to keep talking to her until I had finished. Even though I had tried to hide my embarrassment, I was very concerned that Rose had been aware of it. This made me feel frustrated and annoyed with myself.
Evaluation: What was good and bad about the situation?
I feel that my lack of communication skills during an embarrassing situation were evident during the procedure. Rose was embarrassed enough, without me adding to her discomfort by showing my awkwardness. Although I managed to check my facial expressions whilst Rose was defecating for signs of distaste, I failed to check them for signs of embarrassment whilst wiping her.
Despite my inexperience, I feel that I made the right choice when I decided to place Rose on the bed pan myself. I was aware that I had limitations as a student nurse, however, I felt that it was in Rose’s best interests for me to go ahead unaided. The whole situation would have been made a lot worse if Rose had defecated in the bed. She would have felt very humiliated and embarrassed and her feelings of lost independence would have escalated.
Analysis: What sense can you make of the situation?
On reflection I feel that I pre-judged Rose. Every time I had dealt with her over the previous two days she had appeared very demanding and short tempered. However, when everything had been cleared away, I sat with Rose and we talked for a while. Through the use of open questions I began to understand why Rose came across as difficult. Sully (2005), suggests that the use of open ended questions allows the patients to elaborate their feelings, and closed questions should only be used in instances when ‘yes’ or ‘no’ answers are required. I discovered that Rose was a very nice lady, who was simply embarrassed and frightened by her lack of mobility and independence. She explained that previous to her hip problems she had played golf on a regular basis, and that she was very worried that she would not be able to resume this pastime. According to Kennedy Sheldon (2004) anger in patients is often a reaction to fear and anxiety, particularly in cases where there is lack of independence. After our conversation, I felt that I had a greater understanding of Rose. Although I knew Rose was in pain, and appreciated her embarrassment, I had viewed her as an impatient, demanding lady. Rogers (1951), cited in Kennedy Sheldon (2004) suggest, that the manner in which a person responds to illness, is an individual response to their change of circumstances. He goes further, and states that it is the responsibility of the nurse to treat the patient as an individual, devoid of any prejudice, and with unconditional positive regard. (ibid). Smith & Hart (1994), cited in Hollinworth et al (2005) concur, stating that nurses should refrain from being judgemental and should never label patients as being ‘difficult’ or ‘demanding’ following a particular episode of anger. On reflection this is exactly what I did. Due to Rose’s frustration during earlier attempts to place her on the bed pan, I had perceived her as a demanding and bad tempered lady, this had led to me feeling very apprehensive about dealing with her. On reflection, I realise that I made assumptions about Rose’s personality that were not true.
During the procedure I had attempted to calm Rose down by talking to her. However, I had allowed the tone of my voice to rise because I felt flustered. Ellis et al (2003), suggest that the tone and pitch of a sender’s voice can give clues to the receiver about the mood, and mind state of the sender. Jack & Smith (2007), argue that the actual tone of the voice used, can have more of an impact that the actual words spoken. This can lead to a total misinterpretation of the message being conveyed and could ultimately lead to a breakdown in the nurse, patient relationship (ibid). Even though I was encouraging Rose, the tone and level of my voice could have been perceived as impatient. This would have caused Rose to become even more agitated, during what was an embarrassing and humiliating time for her.
During the procedure I had also underestimated how my facial expression could be perceived by Rose. Although I had been conscious of not displaying signs of distaste whilst Rose was defecating, I had failed not to show signs of my embarrassment whilst wiping her afterwards. Arnold and Boggs (2003) argue that if the verbal message fails to match the non-verbal message, then the non-verbal aspects will take precedent. Therefore, even though I was telling Rose that everything was fine; my face was conveying quite clearly that I was very embarrassed. On reflection, I can see that this must have been very humiliating for Rose, as she was normally a very independent lady who was used to dealing with her elimination needs herself.
Conclusion:
This situation, has taught me the importance of building a therapeutic, trusting relationship with patients. It is essential that the nurse knows the person as a whole in order to treat them as individuals. If I had been aware of how independent and active Rose had previously been, then I would have been far better equipped to deal with her.
I have also been made more aware of the dangers of pre-judging patients. I had labelled Rose as a bad tempered lady, and had failed to understand her reasons for this behaviour. This experience has shown me the importance of questioning and listening to patients in order to see them as ‘whole beings’.
My experience has shown me, how lack of communication skills can cause barriers within the nurse patient relationship. It is very important to not only be aware of what you are saying, but to also be aware of non-verbal communication techniques that run alongside language.
Action Plan
My encounter with Rose has shown me how inexperienced I am with regards to communication with patients. I realise the importance of continually striving to enhance my skills, in order to progress as a student nurse. During subsequent placements, I will take the opportunity to practice my communication techniques, bearing in mind that communication is not only about conversing with the patient verbally, but also about being aware of facial expressions, paralanguage and the ability to listen attentively. In future I will be acutely aware of the importance of not pre-judging or labelling patients, but will endeavour to treat them respectfully and as individuals.
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Overall Conclusion
In conclusion, good communication skills are essential in order for a nurse to provide the best level of care. For a nurse to be able to establish a trusting relationship with the patient, they must first have a mutual understanding. This understanding can only be achieved if the nurse is able to communicate effectively, being aware, not only of the words being used, but also of the non-verbal traits that run alongside those words. The nurse also needs to be aware of the patient’s non-verbal cues. Many patients will show signs of frustration or anger because they are frightened, it is important that the nurse is able to read these signs and investigate them further. For a nurse to successfully practice, it is essential that they continually practice, develop and enhance their communication skills throughout their career.
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