Effective Communication Skills for Nursing Practice: A Review

 

Dr. V. Indra

 

ABSTRACT:

Communication is central to nursing care especially in the setting of a progressive disease, which will end in the patient’s death. This article outlines a variety of communication strategies designed to enhance nurses’ communication skills to discuss goals of care and treatment options with patients throughout their disease trajectory. These strategies are tools that can be especially helpful when treatment focus shifts from cure to comfort and quality of remaining life. The function of communication is to reduce uncertainty and to provide a basis for action. Clumsy communication can cause harm, “paralyze” action, and destroy the patient-nurse relationship. The described strategies are designed to decrease the likelihood of such outcomes.

 

 

INTRODUCTION:

Communication can be defined as a process during which information is shared through the exchange of verbal and non-verbal messages, and where people create a relationship by interacting with each other. Communication is integral to the nurse-patient relationship and is one of the six fundamental values of nursing identified in the government’s strategy to deliver high-quality, compassionate care for patients. The policy document Compassion in Practice states that ‘communication is central to successful caring relationships and to effective team working’. The Nursing and Midwifery Council highlights the importance of communication in its code of conduct, stating that nurses must meet people’s language and communication needs and “share with people, in a way they can understand, the information they want or need to know about their health”.

 

Effective communication helps vulnerable patients to cope with and make better decisions about their care and treatment. However, maintaining effective communication in busy healthcare environments where patients are vulnerable and staffs are frequently stressed requires advanced interpersonal skills, as well as an awareness of self and others.

 

“Communication forms the foundation of all nursing care yet strangely, it is an area of nursing which has often been taken for granted or underestimated”. Responsible nursing is not simply the ability to successfully carry out a series of routine procedures–be they taking a blood sample, dressing a wound or administering medication. Neither is it about treating the patient purely on a physical level. Nursing is a holistic process, taking into consideration not only the psychological, but any socio-cultural, environmental and politico-economic features of a disease and its treatment, not to mention the impact on patients and their families. From a communication perspective, the following functions, as outlined by the Nursing Code of Practice (NMC): respecting confidentiality; sharing, in a way they can understand, information people want or need to know about their health; accurate record keeping, reinforce the fact that effective spoken and written skills are essential to the toolkit of the responsible nurse and therefore should be integral to any course in this field [1].

 

EFFECTIVE COMMUNICATION:

However, as with many things in life, it is often a question of perception. According to Timmins (2007) ‘Statistics show that [native speaker] nurses often rate their communication skills higher than their patients.’ So what constitutes effective communication skills in this particular context? Theorists from the field of nursing communications highlight the need for comprehensible pronunciation, active listening skills, non-verbal communication and the ability to bridge professional and lay language. To this skill-base I would also add written communication. In addition, cultural awareness, which, inextricably linked with language, plays a very important role in achieving effective communication in the healthcare environment [2].

 

Having established the professional outcomes, it is important to then consider how these might translate into the teaching of English to non-native speaker nurses.

·        Improving verbal communication skills is about enhancing the ability to use effective strategies to repair or avoid possible breakdown in communication; encouraging the use of patient-friendly language and familiarizing the nurse with language (euphemisms, and colloquialisms) commonly used by patients. Patient education is an important aspect of the nurse’s role and learners should be familiar with the language used in patient educational leaflets and websites. Communication with other healthcare professionals also requires a certain level of comfort when employing medical terminology.

 

·        It is often the nonverbal cues (or signs) or the paralinguistic elements of speech rather than what is actually said that betray true feelings and emotions. Developing non-verbal skills therefore means increasing an awareness of body language, enabling nurses to better read and interpret their patients' physical and emotional signs (expressions of anger, melancholy, etc.), while simultaneously mirroring their own verbal communication.

 

·        Employing active listening skills helps to ensure a successful interaction through techniques that facilitate discussion (leaning slightly forward, using sounds of encouragement), demonstrating that the nurse is truly listening and assimilating the information provided by the patient in order to arrive at an eventual nursing diagnosis.

 

·        Voice management not only refers to accurate pronunciation, essential in ensuring safe practice, Voice management not only refers to accurate pronunciation, essential in ensuring safe practice, but also relates to appropriate pitch and intonation, which help towards establishing and maintaining rapport with the patient. If a nurse’s tone of voice fails to match the lexical input, then efforts to employ the correct phrase to reassure or empathize with the patient are wasted. This aspect of voice management is especially pertinent when dealing with native speaker patients, where tolerance of inappropriate intonation patterns may be lower.

 

·        Cultural awareness requires a widening of understanding not only of cultural issues in their broadest sense (professional, local, medical and ethical) but also the impact of the nurses own cultural background on their interactions with both patients and colleagues. It is becoming increasingly accepted that training nurses in cultural sensitivity is vital to their level of competency in the host country.

 

·        Much of the written communication carried out by nurses is formulaic–filling in charts and documents. What is necessary therefore in terms of written communication is clarity and coherence, as well as accurate spelling, as is a knowledge of accepted medical terminology, abbreviations and acronyms, all of which are vital in avoiding potential fatalities [3].

 

EFFECTIVE COMMUNCIATION SKILLS:

Skills that assist in keeping the focus on the patient and/or career:

·      Looking and listening for cues.

·      Asking open questions. For example: ‘How are you?’

·      Asking open directive questions. For example: ‘How are you since I last saw you?’

·      Asking open questions about feelings.

·      Exploring cues. For example: ‘You said you are not with it, can you tell me more about that?’

·      Using pauses and silence.

·      Using minimal prompts.

·      Screening. For example: asking the question ‘Is there something else?’ before continuing with the discussion.

·      Clarifying. For example: asking the question ‘You said you are not with it, from what you say, it sounds like it is hard to concentrate?’

 

Skills that demonstrate listening:

·      Reflecting

·      Acknowledging

·      Summarizing

·      Empathizing

·      Making educated guesses

·      Paraphrasing

·      Checking

 

Skills that assist with information giving:

·      Checking what information the person knows already.

·      Giving small amounts of information at a time, using clear terms and avoiding jargon.

·      Avoiding detail unless it is requested–do not assume people want to know.

·      Checking understanding using an open question. For example: ‘I’ve gone through some difficult information, what sense have you made of it?’

·      Pausing and waiting for a response to what you have said before moving on.

·      Checking, with sensitivity, the effect of the information you have given on the patient or career.

 

For example: ‘There has been a lot of information to take in today, how are you feeling?’[4]

 

IMPORTANCE OF COMMUNICATION IN NURSING:

Effective communication in nursing is important not only because accurate diagnosis and treatment depend on it but also because communication emerges as a significant factor in patient satisfaction surveys.

 

The following are the identified factors relating to patient’s role in nurse-patient communication, highlighting the importance of communication. These were:

1.    Nurses need good interviewing skills to enable accurate problem identification.

2.    Attending to the patient as an individual rather than a collection of symptoms increases the importance of psychosocial factors (and hence communication) in nursing.

3.    Research shows beneficial effects of giving information e.g. for increasing compliance with drug and treatment regimes or for reduction in stress, pain and anxiety.

4.    Patient satisfaction surveys show that poor communication and lack of information are significant areas of complaint.

 

In addition to these four factors, 2 more factors add-up:

5.    High quality nursing care (reflected in positive clinical outcomes) is characterized by effective communication.

6.    Communication itself actually constitutes the care or nursing action in some instances [5].

 

 

NURSE-PATIENT RELATIONSHIP:

There is an increasing recognition that quality nursing care depends on establishing a collaborative nurse/patient relationship. Establishing such a relationship is achieved through effective communication. The connection between quality nursing care through the role of communication in building and maintaining relationships is explained: “talk can be used as a strategic resource to establish, maintain repair and terminate relationships.” Thus the quality of nursing care is enhanced when nurses and patients can negotiate a mutually acceptable agreement on the goals of the encounter.

 

Both the nurse and the patient perceive that the quality of care increases when the nurse pays attention to the patient’s concerns, anticipates and meets needs, and informs the patient of the expected course of events. Gunther and Alligood give a slightly different emphasis “Individualized care necessitates knowing the patient so that the nurse can assist in applying information to that patient's unique life situation." and elaborate by quoting Luker, Austin, Caress, and Hallett: "Knowing the patient is an essential antecedent for the provision of good quality care". Hence, “Communication establishes the nurse-patient relationship that is directly linked to good nursing practice.”

 

It must be noted that while these views on the desirability of partnership or collaboration seem widely accepted, not all nurses agree. Waterworth and Luker ask whether some patients might be more concerned with pleasing the nurse than with participating in decisions regarding their care. In their view the nurse may unwittingly coerce patients into a collaborative role. Another challenge to the idea of collaboration comes from Candlin who explains “patients (and some nurses too) frequently believe that in sickness people want to be ‘cared for’ and have the weight of decision-making taken from them.”[6]

 

ATTRIBUTES OF AN EFFECTIVE NURSE COMMUNICATOR:

A number of research works discuss, either directly or indirectly, the attributes of an effective nurse communicator. Most of the attributes mentioned can be allocated to one of three categories

·      Repertoire of communicative skills

·      Professional philosophy

·      Maturity [7].

 

The verbal skills nurses need are described as “a repertoire of interaction techniques, observing and listening, reinforcing and encouraging, questioning, responding, and giving information.”. She elaborates on specific questioning techniques, for instance using closed and open questions. “Closed questions can be useful when it is necessary to collect facts quickly. They can also focus the conversation but, when used habitually, can act as an inhibiting force on the development of the interaction.” Norton and Talerico talk about ‘communication strategies’ for example being clear, avoiding euphemisms, spelling out the goals and expectations of treatment and being specific when using words such as ‘hope’ and ‘better’.

 

On the other hand, ‘being clear’ is not always a requirement for effective communication. Vague, ambiguous or woolly language has definite usefulness in particular situations for example in diplomatic politeness or in moderating a sea of precision. An example of the latter might be in a description of how steroids work. To say that steroids provide a general sense of well-being is often more helpful than a detailed description of steroid physiology. Vague, ambiguous language is evident in the data of this study.

 

Ambiguity is a feature associated with the multiple goals of much professional activity. In their classic work entitled “How are you?” Negotiating phatic communion Coupland and Robinson analyze responses to this question when posed to elderly people at the outset of interviews about their medical experiences. Asking “How are you?” in a medical context allows the patient to respond with social chat or medical information [8].

 

BARRIERS TO EFFECTIVE COMMUNICATION:

Patient and career barriers:

1.    Environment–Noise, lack of privacy, no control over who is present or not present (staff or relatives).

2.    Fear and anxiety–Related to being judged, being weak, or breaking down and crying.

3.    Other barriers–Difficulty explaining feelings (no emotional language to explain feelings), being strong for someone else, or communication cues being blocked by healthcare professionals [9].

 

Healthcare professional barriers:

1.    Environment–High workload, lack of time, lack of support, staff conflict, lack of privacy or lack of referral pathway.

2.    Fear and anxiety–Related to making the patient more distressed by talking and/or asking difficult questions.

3.    Other barriers–Not having the skills or strategies to cope with difficult reactions, questions and/or emotions. Thinking ‘it is not my role’, and ‘the patient is bound to be upset’ [10].

 

CONCLUSION:

It is widely accepted that building and maintaining a good patient relationship is an essential aspect of the treatment and healing process and that effective communication skills are key to achieving this. It also goes without saying that patients spend more time communicating with nurses than with any other healthcare professional. Emphasis placed on the therapeutic nature of medicine means that, possibly more than any other learner, non-native speaker nurses have a very real need to communicate effectively from day one.

 

REFERENCES:

1      Menon M., Migrant Nurses: Cross-cultural understanding or misunderstanding? Australian Nursing (1992), Churchill Livingstone

2      Candlin, S. (2000). New dynamics in the nurse-patient relationship. In S. Sarangi, and M. Coulthard, (Eds.), Discourse and social life (pp. 230-245). Harlow, UK: Pearson Education Limited.

3      Cartwright, S. (1988). The Report of the Cervical Cancer Inquiry. Auckland: Government Print.

4      Roper N. et al, The Roper-Logan-Tierney Model of Nursing: Based on activities of living (2000), Churchill Livingstone.

5      Bourhis, R., Roth, S., and MacQueen, G. (1989). Communication in the hospital setting: A survey of everyday language use amongst patients, nurses and doctors. Social Science and Medicine, 28 (4), 339-346.

6      Brown, S. J. (1995). An interviewing style for nursing assessment. Journal of Advanced Nursing, 21, 340-343.

7      Scanlon W.J., Nursing Workforce: Recruitment and retention of nurses and nurse aides is a growing concern (2001), U.S. General Accounting Office, http://www.gao.gov/new.items/d01750t.pdf

8      Borland S., 90% of Hospitals Fail to Check on Nurses’ English Before Letting Them Work on Wards, Daily Mail (2012)

9      Editorial Desk, Errors That Kill Patients, The New York Times (2002)

10    McCabe C, Timmins F. Communication Skills for Nursing Practice, Palgrave MacMillan (2006)

 

 

 

 

Received on 13.03.2018           Modified on 16.04.2018

Accepted on 29.05.2018       © AandV Publications all right reserved