Communication is a process and has many aspects to it. Communication is a dynamic process by which information is shared between individuals (Sheldon 2005). This process requires three components (Linear model Appendix figure 1.1), the sender, the receiver and the message (Alder 2003). Communication would not be possible if any of these components are absent. While Peate (2006) has suggested that communication is done every day through a linear process, Spouse (2008) argues that it is not so simple and does not follow such a linear process. He explains that due to messages being sent at the same time through verbal and non- verbal avenues, it is expected the receiver is able to understand the way this is communicated.
Effective communication need’s knowledge of good verbal and non-verbal communication techniques and the possible barriers that may affect good communication. The Nursing and Midwifery council (2008) states that a nurse has effective communication skills before they can register as it’s seen as an essential part of a nurse’s delivery of care. (WAG 2003)
Reflecting on communication in practice will also enforce the theory behind communication and allow a nurse to look at bad and good communication in different situations. This will then enforce the use of good communication techniques in a variety of situations allowing for a more interpersonal and therapeutic nurse patient relationship.
This assignment discusses health care communication and why it is important in nursing by:
Exploring verbal and non-verbal communication and possible barriers
By exploring the fundamentals of care set out by the Welsh assembly and the nurse and midwifery council’s code of conduct a better understanding of the importance of communication is gained.
Reflecting in practice using a scenario from a community posting.
Verbal communication comes in the form of spoken language; it can be formal or informal in its delivery. Verbal Language is one of the main ways in which we communicate and is a good way to gather information through a question (an integral part of communication) and answer process (Berry 2007; Hawkins and Power 1999). Therefore verbal communication in nursing should be seen as a primary process and a powerful tool in the assessment of a patient.
There are two main types of questioning, open-ended questions or closed questions (Stevenson 2004). Open-ended questions tend to warrant more than a one word response and generally start with what, who, where, when, why and how. It invites the patient to talk more around their condition and how they may be feeling and provoke a more detailed assessment to be obtained (Stevenson 2004). The use open-ended questions make the patient feel they have the attention of the nurse and they are being listened too (Grover 2005). It allows for a psychological focus to be given, this feeling of interest in all aspects of the patients care allows for a therapeutic relationship to develop (Dougherty 2008).
Closed questions looks for very specific information about the patient (Dougherty 2008). They are very good at ascertaining factual information in a short space of time (Baillie 2005).
There are two types of closed questions: the focused and the multiple – choice questions. Focused questions tend to acquire information about a particular clinical situation (e.g. asking a patient who is been prescribed Ibuprofen, are you asthmatic?) whereas multiple choice questions tend to be more based on the nurse’s understanding of the condition being assessed. It can be used as a tool to help the patient describe for example the pain they feel e.g. is the pain dull, sharp, throbbing etc (Stevenson 2004).
For verbal communication to be effective, good listening skills are essential. Sharing information, concerns and feelings becomes difficult, if the person being spoken to doesn’t look interested (Andrews 2001). Good active listening can lead to a better understanding of the patients most recent health issues (Sheldon 2005). Poor listening could be as a result of message overload, physical noise, poor effort and psychological noise. Therefore being prepared to listen and putting the effort and time are essential in a nurse’s role (Grover 2005).
This type of communication does not involve spoken language and can sometimes be more effective than words that are spoken. About 60 – 65 per cent of communication between people is through non – verbal behaviours and that these behaviours can give clues to feelings and emotions the patient may be experiencing (Foley 2010, p. 38). Non-verbal communication adds depth to speech; to re affirm verbal communication; to control the flow of communication; to convey emotions; to help define relationships and a way of giving feedback. The integration between verbal language and paralanguage (vocal), can affect communication received (Spouse 2008)
Berry (2007, pg18) highlights the depth of verbal language due to the use of paralinguistic language. The way we ask a question, the tone, and pitch, volume and speed all have an integral part to play in non – verbal communication. In his opinion, personality is shown in the way that paralanguage is used as well as adding depth of meaning in the presentation of the message been communicated.
Foley (2010) identifies studies where language has no real prevalence in getting across emotional feelings, in the majority of cases the person understands the emotion even if they don’t understand what is being said. Paralanguage therefore is an important tool in identifying the emotional state of a patient.
Non-verbal actions (kinesis) can communicate messages, such as body language, touch, gestures, facial expressions and eye contact. By using the universal facial expressions of emotion, our face can show many emotions without verbally saying how we feel (Foley 2010) refer to Appendix table 2. For example, we raise our eye brows when surprised, or open our eyes wider when shocked.
First impressions are vital for effective interaction; by remembering to smile with your eyes as well as your mouth can communicate an approachable person who is open. This can help to reassure a patient who is showing signs of anxiety (Mason 2010).
BARRIERS TO COMMUNICATION
An understanding of barriers in communication is also very important. The Welsh Assembly’s fundamentals of care (2003) showed that many of the problems associated with health and social care was due to failures in communication. These barriers may be the messenger portraying a judgmental or power attitude. Dickson (1999) suggested that social class can be a barrier to communication, feeling inferior to the nurse may distort the message being received, making communication difficult to maintain.
Environmental barriers such as a busy ward and a stressed nurse could influence effective communication. This can greatly reduce the level of empathy and communication given as suggested by Endacott (2009).
People with learning disabilities come up against barriers in communicating their needs, due to their inability to communicate verbally, or unable to understand complex new information. This leads to a breakdown in communication and their health care needs being met (Turnbull 2010).
Timby (2005) stresses that when effectively communicating with patients the law as well as the NMC (2008) guidelines for consent and confidentiality must be adhered to. This also takes into account handing over to other professionals. He suggests that a patient’s rights to autonomy should be upheld and respected without any influence or intimidation, regardless of age, religion, gender or race. The use of communication in practice is essential and reflecting on past experience helps for a better understanding of communication, good and bad.
Reflecting on my experience while on placement in a G.P with a practice nurse in south Wales Valley’s, has helped me understand and gain practical knowledge in communicating effectively in nursing practice. The duration was for one week and includes appointments in several clinics to do with C.O.P.D (Chronic obstructive pulmonary disease). I will be reflecting upon one appointment using the Gibbs’s reflective cycle (1988).
Due to confidentiality (NMC, 2008) the patient will be referred to as Mrs A.E. The Nurse called Mrs A.E to come to the appointment room. I could see she was anxious through her body language (palm trembling and sweaty, fidgety, calm and rapid speech). The nurse asked her to sit down. The nurse gained consent for me to sit in on her review (NMC, 2008).
The review started with a basic questionnaire the nurse had pre generated on the computer. It was a fairly closed questionnaire around her breathing including how it was, when it was laboured. Questions were also asked around her medication and how she was taking her pumps. Reflecting on these questions, I feel the questions did not leave much opportunity for Mrs A.E to say anything else apart from the answer to that question. The nurse controlled the communication flow. The Nurse did not have much eye contact with the patient and was facing the computer rather than her patient. I wondered if the nurse had notice the anxious non-verbal communication signs. The patient seemed almost on the verge of tears, I wasn’t sure if this was anxiety, distress from being unwell, or she was unhappy about something else. I felt quite sorry for her as all her body language communicated to me that she was not happy. She had her arms crossed across her body (an indication of comforting herself) and she did not smile. She also looked very tense and uncomfortable.
The Nurse went on with the general assessment and did the lung test and I took the blood pressure and pulse, gaining consent first as required by the NMC. Once all the questions had been answered on the computer the Nurse turned to face Mrs A.E and I noticed she had eye contact with her and had her body slightly tilted toward the patient (non verbal communication). The Nurse gave her information on why her asthma may be a bit worse at the moment and gave her clear and appropriate information on how she can make manage her COPD at this time of year. The Nurse gave her lots of guidance on the use of her three different pumps, and got her to repeat back to her the instructions, to make sure she understood. I could feel the patient getting more at ease as the communication progressed and also on the confirmation that she understood the instruction. The Nurse knew this patient well and then set the rest of the time talking to the patient about any other concerns she had and how she was feeling in herself, using a more open question technique.
The nurse used her active listening skills and allowed the patient to talk about her problems and gave her empathy at her situation as well and some solutions to think about. She gave the patient information of a support group that helped build up confidence in people with chronic conditions and helped them deal with the emotional side of their condition.
After the patient had gone, my mentor explained that the patient was a regular to the clinic, she had many known anxiety issues which weren’t helped by her chronic asthma.
Through-out the beginning of the review I felt very awkward. I thought, because I was sitting in on the review, may have been the reason the lady had not said why she seemed so anxious and upset. I also felt the nurse was not reacting to the sign of anxiety from Mrs A.E and this made me feel uncomfortable. I felt like I wanted to ask her if she was ok, but felt that I couldn’t interrupt the review. However by the end of the review I felt a lot better about how it had gone. I did feel that by building up a relationship with the patients allowed the nurse to understand the communication needs of the patient and also allowed her to use the time she had effectively. She used empathy in her approach to the lady and actively listened to her. I understand that the start of the review was about getting the facts of the condition using a lot of closed questions, whereas the later part of the review was a more open questions and non verbal communication approach, allowing the patient to speak about any concerns and feelings about those questions asked earlier.
Effectively using closed questions allow for a lot of information to be gathered in a short space of time, and can be specific to the patients review needs. These pre-generated questionnaires are good at acquiring the information needed by the G.P. and also for good record keeping which are essential in the continuity of care delivered to the patient (NMC 2008). It can also protect the nurse from any litigation issues.
The use of open and closed questions also allowed for the review to explore the thoughts and feelings of the patient, thus allowing for empathy from the nurse and is considered a vital part of the counselling relationship (Chowdhry, 2010 pg. 22).
However the use of the computer screen facing away from the patient, did not allow for good non-verbal communication skills to be used. The lack of eye contact from the nurse may have exacerbated the anxiety felt by the patient. Hayward (1975, p. 50) summarised in research that anxiety highlighted an uncertainty about illness or future problems. This link to anxiety was also linked to increased pain.
Nazarko (2009) points out, it is imperative that a person has the full attention of the nurse when they are communicating. He states that being aware of one’s own non-verbal behaviours, such as posture and eye contact can have an effect on how communication is received by the patient.
As evident in the reflection, the patient at the beginning of the review was anxious, upset and worried. By the end of the review her body language had significantly changed. The patient looked and felt a lot better in herself and had a better understanding of how her condition was affecting her and understood how to manage it. However if this information was badly communicated, the patients anxiety could have been prolonged (Hayward, 1975). This also links back to the need to understand medical conditions so that communication is channelled to the patients’ needs at the time. The fundamentals of care set out by the Welsh Assembly Government (2003), states that communication is of upmost importance in the effectiveness of care given by nurses. By looking at all the fundamentals of communication and the effect on patient care we can understand and recognise that the communication in this reflection was good communication in practice.
The closed questions were used at the beginning of the review, had their advantages. They allowed the nurse to focus the on the specific clinical facts needed. The start of the review used mainly closed questions to get all the clinical facts needed to be recorded, such as Personal information, Spirometry results, blood pressure, drug management of COPD (Robinson, 2010). The structured approach allows the nurse to evaluate using measurable outcomes and thus interventions adjusted accordingly (Dougherty, 2008). The closed question approach allows the consultation to be shortened if time is an issue. However the disadvantage of this as identified by Berry (2007) is that important information may be missed. The use of closed questions on a computer screen hindered the use of non-verbal communication. Not allowing for eye contact, which is an important aspect of effective communication.
The use of open questions in the review allowed the patient to express how they were feeling about their condition or any other worries. The nurse used active listening skills, communicated in her non-verbal behaviour. It gave the opportunity to the patient to ask for advice on any worries they might have. The use of open questions can provoke a long and sometimes not totally relevant response (Baillie, 2005), using up valuable time.
Eye contact is another important part of communication in the reflective scenario. The eye contact at the start of the review was limited. The nurse made slight eye contact when asking the closed questions, but made none when given the answer. This may have contributed to the patient’s anxious state. However, the eye contact given during the open questions section. At this stage, there were several eye contacts between the nurse and patient and information was given and understood. The value of eye contact in communication is invaluable and has great effect at reducing symptoms of anxiety (Dougherty 2008).
The use of communication in this COPD review was very structured. The use of closed questions helped to structure the consultation and acquire lots of information from the patient. The open questions allowed for the patient to express any feeling or concerns. The nurse used verbal and non-verbal communication methods, to obtain information about the patient; assess any needs and communicate back to the patient, within the time period. However in my opinion, if the computer screen was moved closer to the patient during the closed question section, better interaction could have been established from the beginning. It would also allow the nurse to look at the patient when asking the questions leading to a more therapeutic relationship, whilst still obtaining and recording a large amount of information.
Therefore, the use of effective communication skills as seen in this review along with a person centred approach can significantly increase better treatment and care given to the patient (Spouse, 2008) and thus signifies good communication in practice.
The goal of the plan is to increasing patient participation in the use of the computer as an interactive tool. By allowing the patient to see what is on the screen and being written, allows the patient to feel more involved in the assessment and takes away any feeling of inferiority from social class difference.
In attempt to achieving these goals, the following steps would be taken:
Set up a team to investigate the issue which could involve nursing staffs or other hospital staffs.
Drawing up a feedback questionnaire, to investigate how patients feel about the closed questions on the computer, including a section on how they would feel if they were allowed to look at the screen.
Collation, analysis and review of the results of the feedback
Identify barriers to the implementation of the plan (e.g. willingness of nurses to this change).
Inform the NMC on the issues and the findings from the feedback questionnaire.
Implementation of the plan.
Set up a monitoring and evaluation team to see if the plan is being implemented appropriately.
This assignment has looked at communication and its importance in nursing practice. Communication is thus an important process involving the interaction between one or more persons using verbal and non-verbal methods. Understanding the barriers to communication contributes significantly to how effective a nurse communicates in practice. The use of questioning in nursing has been a valuable tool in assessing a patient and obtaining information. However the way this is done can have an effect on the development of empathy, trust, genuineness and respect, between the nurse and the patient. It is imperative for nurses to however reflect on their communication in practice to further improve the therapeutic relationship between them and the patient as has been identified as essential in the delivery of care (WAG 2003).
Alder, RB. Rodman, G. 2003. Understanding human communication: (8th edition). USA: Oxford university press
Andrews, C. Smith, J. 2001. Medical Nursing: (11th edition) London: Harcourt Publishers limited
Berry, D. 2007. Basic forms of communication. In: Payne, S. Horn, S. ed. Health communication theory and practice. England: Open university press.
Chowdhry, S. 2010. Exploring the concept of empathy in nursing: can lead to abuse of patient trust. Nursing times 160(42), pp. 22-25
Dickson, D. 1999. Barriers to communication. In: Long, A. ed. Interaction for practice in community nursing. England: Macmillian press LTD, pp. 84-132
Dougherty, L. Lister, S. ed. 2008. The royal marsden hospital manual of clinical nursing procedures. Student edition. 7th ed. Italy: Wiley-Blackwell
Egan, G. 1990. The skilled helper: A systematic approach to effective helping. 4th ed. California: Brooks /Cole
Ekman, p. Friesen, WV. 1975. Unmasking the face. Englewood cliffs, NJ: prentice-hall INC
Endacott, R. Jevon, P. Cooper, S. 2009. Clinical Nursing Skills Core and Advanced. Oxford : Oxford University Press.
Foley, GN. 2010. Non-verbal communication in psychotherapy. Psychiatry (Edgemont) 7(6) pp. 38-44
Gibbs, G. 1988. Learning by doing: a guide to teaching and learning methods. Oxford: Oxford further education unit.
Grover, SM. 2005. Shaping effective communication skills and therapeutic relationship at work. Aaohn journal 53(4) pp.177-182
Hawkins, K. Power, C. 1999. Gender differences in questions asked during small decision-making group discussions, small group research.(30) pg.235-256
Hayward, J. 1975. Information – A prescription against pain. London: Royal college of nursing. p. 50
Marie- Claire Mason 2010. Effective interaction: Nursing Standard 24(31) p 25.
Nazarko, L. 2009. Advanced communication skills. British journal of healthcare assistants. 3 (09) pp 449-452
Nursing and Midwifery Council (NMC)2008. The Code: Standards of conduct, performance and ethics for nurses and midwives. London. NMC
Peate, I. 2006. Becoming a nurse in the 21st century. England: Wiley and Son
Robinson, T. 2010. Empowering people to self-manage COPD with management plans and hand held records. Nursing times. 106(38) pp. 12-14
Sale, J. Neal, NM. 2005. The nurses approach: self-awareness and communication. In Ballie, L. ed. Developing practical nursing skills. 2nd ed. London: Oxford university press. Pg. 33-57
Sheldon, L. 2005. Communication for nurses: Talking with patients. London: Jones and Bartlett publishers.
Spouse, J. Cook, M. Cox, C. 2008. Common foundation studies in nursing (4th edition). London: Churchill livingstone.
Stevenson C, Grieves M, Stein – Parbury J. 2004. Patient and Person: Empowering Interpersonal relationships in Nursing London. Elsevier Limited.
Timby, BK. 2005. Fundemental Nursing Skills and Concepts Philadelphia. Lippincott Williams and Wilkins
Turnbull J, Chapman ,S. 2010. Supporting Choice in Health Care for People with Learning Disabilities. Nursing Standard 24 (22) pp 50 – 55
Welsh Assembly Government 2003. Fundamentals of Care Guidance for Health and Social Care Staff Cardiff: WAG