Importance of Communication in Nursing

Importance of Communication in Nursing INTRODUCTION 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), 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 needs 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 are seen as an essential part of a nurses 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 councils code of conduct a better understanding of the importance of communication is gained. Reflecting in practice using a scenario from my community posting. VERBAL COMMUNICATION Verbal communication comes in the form of spoken language; it can be formal or informal in its delivery. Verbal Language is one of the primary 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. 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 nurses 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 is essential. Difficulty in sharing information, concerns or feelings could arise if the person you are communicating with thinks you are not being attentive and interested in what they are saying (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 nurses role (Grover 2005). NON-VERBAL COMMUNICATION 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 functions as a replacement for speech; to re affirm verbal communication; to control the flow of communication; to convey emotions; to help define relationships and also a way of giving feedback. The integration between verbal language and paralanguage (vocal), can affect communication received (Spouse 2008) Berry (2007) 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 dont 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 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 The understanding of the barriers to communication is also very important for effective communication and taken into consideration could result in a failure in communication. The Welsh Assemblys 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 by distorting the message being given and received as would be the case if the patients feel they occupy an inferior status thus making communication difficult and awkward. 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 patients 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. REFLECTION Reflecting on my experience while on placement in a G.P with a practice nurse in south Wales Valleys, 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 and diabetes. I will be reflecting upon one of such appointments using the Gibbss reflective cycle (1988). Description 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 that the way the questions did not leave much opportunity for Mrs A.E to say anything else apart from the answer to that question and 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 wasnt sure if this was anxiety or distress from being unwell, barrier of social class or if the lady 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 timidity) 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 herself more comfortable. 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 she had given to make sure she understood. I could feel the patient getting more at easy 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 f eeling 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. Feelings After the patient had gone, my mentor explained that the patient was a known regular patient to the clinic, that she had many anxiety issues which werent 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 couldnt 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 abo ut any concerns and feelings about those questions asked earlier. Evaluation 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. 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) in a summary of research into anxiety noted uncertainty about illness or future problems was linked to anxiety and therefore linked to 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 ones 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. Whereas, bad communication would have caused more stress and aggression (Nursing standard 34 (30) 2010). 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 a good communication in practice. Analysis 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 to be recorded. 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. The use of Egan (1990, p. 46) acronym SOLER allowed the nurse to focus on the skill of actively listening. 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 patients 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). Reflection conclusion 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. Action Plan 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. CONCLUSION This assignment has looked at communication and its importance in nursing practice. Communication is thus an iterative 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). REFERENCES 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. Cited 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) pg 22-25 Dickson, D. 1999. Barriers to communication. Cited 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 edition. Italy: Wiley-Blackwell Egan, G. 1990. The skilled helper: A systematic approach to effective helping. (4th edition). 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) pg. 38-44 Gibbs, G. 1988. Learning by doing: a guide to teaching and learning methods. Oxford: Oxford futher education unit. Grover, SM. 2005. Shaping effective communication skills and therapeutic relationship at work. Aaohn journal 53 (4) pg. 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. Pg. 50 Marie- Claire Mason (2010) Effective interaction: Nursing Standard 24 (31) pp 25. Nazarko, L. 2009. Advanced communication skills. British journal of healthcare assistants. 3 (09) pg 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 nursein 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) pg. 12-14 Sale, J. Neal, NM. 2005. The nurses approach: self-awareness and communication. Cited in Ballie, L. ed. Developing practical nursing skills (2nd edition). 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) pg 50 55 Welsh Assembly Government (2003) Fundamentals of Care Guidance for Health and Social Care Staff Cardiff: WAG Importance of Communication in Nursing Importance of Communication in Nursing Communication in nursing Introduction Communication in nursing is vital to quality and safe nursing care (Judd, 2013). There is evidence that continues to show that breakdowns in communication can be responsible for many medication errors, unnecessary health care costs and inadequate care to the patient (Judd, 2013). Several reports exist from the Institute of Medicine that stress the importance of good communication and its link to providing safe and reliable care (Judd, 2013). (Smith Pressman, 2010). However, even nurses with the best communication skills can be challenged by difficult situations such as life threatening threatening illness or injury, complicated family relationships, and mental health issues, to symptoms such as unrelieved pain and nausea. How a nurse may respond during these situations depends on many factors. Each nurse brings their own history, culture, experience, and personality to a situation. Communication in the workplace can either be horizontal among workers at the same hierarchical level, vertical among workers in different hierarchical levels or diagonal amongst different workers in different hierarchical levels. All these kinds of communication are crucial in the work environment because work needs to be done and goals need to be met. A communication channel is made up of three components made up of the sender of the message (encoder), the channel of sending the message and the receiver of the message (decoder) (Anderson, 2013). For effective communication to be achieved, the encoder and the decoder must be able to understand one another. This paper will discuss some strategies which could be implemented to improve both written and verbal communication between nurses, health professionals and between patients and the health care team. Communication, a fundamental aspect of nursing, is a complex, continual transactional process that occurs between persons by which information, feelings, and meaning are conveyed through verbal and non verbal messages (Peereboom, 2012). It is crucial for nurses to identify communication strategies that should be put into consideration every time they are involved in conversations involving their line of practice. This is because clear and accurate communication strategies enable them to identify effective patterns in their interactions and in teaching themselves to improve their patient education techniques. Handover communication between practitioners may at times seclude crucial information and is even prone to misinterpretation. Such communication breakups and challenges can lead to intense mishaps in the continuity of health care, incorrect treatment, and potential harm to the patient in general (Memoire, 2007). Simple strategies can easily impart critical information just by eye sight. For instance, nurses are able to communicate critical patient status issues like allergies and fall risk with color-coded patient identification wrist bands or stickers on their medical records, a seat belt or flag attached to a wheel chair, or any other objects which are easily identifiable by all medical practitioners (Joint contribution resources, 2005). The use of local jargon can also be avoided when making professional conversations because some words may portray a meaning that was not intended or is not readily understood by a large number of people. Assimilation of the ISBAR tool is a strategy that has been really helpful in enhancing communication in the healthcare sector when used. Identifying yourself (I), availability of the situation (S), background (B), assessment (A), and recommendations (R) facilitates communication allowing each health practitioner to receive and give important information in a format that satisfies numerous communication styles and needs (Dixon et al., 2006). This tool should be adopted by everyone to improve communication is because this technique utilizes the use of one common language for passing on critical information without leaving out anything. Another strategy that can be used to improve communication in healthcare centers is the Crew Resource Management technique which is both a communication and team building technique (ECRI, 2009). This strategy trains members of the healthcare sector to assert themselves respectively and be attentive when they are being spoken to and also encourages them to make use of briefings. Briefings are direct communications between physicians, nurses or other caregivers acting on patient status which includes sharing of important information at critical times, such as before the start of a procedure, at the change of shift and during normal patient rounds (ECRI, 2009). COMMUNICATION BETWEEN PATIENTS AND THE HEALTH CARE TEAM One stratergy that can be used to improve communication between patients and the health care team is the use of ‘The World Health Organization Surgical Safety Checklist’. This checklist is to be used in operating suites to ensure everyone involved with the patient including the patient understands what procedure they are having ad gives prompts to tick off so important information is not missed during handovers leading to reduced inpatient complications and death (Department of Health, 2010). In addition to the patient, their family members or next of kin can also be included in the rounds further increasing the opportunity for direct dialogue which reduces the development of complications which arise as a result of miscommunication in the form of home care. It is important to note that if personal care by the family of the patient is not provided as requested by the medical practitioner, cohesive care is not accomplished and the opportunity to achieve patient care goals will not be met (O’Leary et al., 2010). Joint commission reports also indicate that health practitioners should also encourage patients to actively participate in their own care as a strategy to enhance communicational barriers (Stein, 2006). Successful interactions are always co-constructed, involving a constant interplay among the two parties. When the patient and the healthcare provider are comfortable with one another communicating becomes easy and more effective in the sense that the healthcar e provider will be able to solve the needs of the patient. COMMUNICATION BETWEEN HEALTH CARE DISCIPLINES Communication between medical practitioners can greatly influence the general patients care outcomes. Medical practitioners are in the frontline to investigate and identify communication challenges and try to implement solutions that fit their line of duty. Some further research is also being carried out to evaluate potential solutions and more successful options (Rosenstein, 2005). Creating a collaborative relationship between nurses and other medical practitioners is also another strategy that can help reduce communicational barriers and thus improve the general treatment of patients (Arora, 2005). With regard to Schmalenberg and Kramer (2005), â€Å"MD/ RN collaboration is reflected in reduced patient mortality, fewer transfers back to the ICU, reduced costs, decreased length of stay in hospitals, higher nurse autonym, retention, nurse-perceived high quality care, and nurse job satisfaction†. Larabee (2006) also found out that positive relationships between medical practitioners were a major contributing factor to improved nursing job satisfaction and retention. Positive collegial relationships therefore result from good communication, mutual acceptance and understanding, use of persuasion rather than coercion, and a balance of reason and emotion when working with others (College of Nurses of Ontario, 2009, pg. 7). COMMUNICATION BETWEEN NURSES A number of strategies have been set up to address communication issues among nurses. For instance, the implementation of unit based care teams places nurses and people like physicians close to one another thus increasing the chances of communicating effectively (Gordon et al, 2011). The introduction of compulsory bed rounds is also another strategy that has enabled nurses to reduce communication barriers and promote effective communication thus creating patient health satisfaction and general health care providers satisfaction in their duties. The continuous flow of interruptions and multiple patient handoffs affect the ability of nurses and physicians to connect effectively, and establish a trusting and collegial relationship (Tschannen et al., 2011). The fact that the working environment of nurses and other medical practitioners is rather different also induces a number of communication barriers with regard to the intensity of activities on a normal working day (Burns, 2011).this could be improv4d by†¦ Communication challenges are recognized when set goals or achievements are not met or when there is great employee turnover. Technological advances have opened up communication across boundaries of different countries meaning that people with different languages, behaviors and culture interact with one another (Krizan, 2010).In the health care sector in particular, the most pertinent communication barrier is the inability for colleagues to interact physically as they are separated in different departments (Vignam, 2013). This lack of interaction minimizes the ability for team members to collaborate wholly in the sense that the ability to analyze body language and create a sense of energy among team members is null. This can be improved by†¦ Barriers Barriers to communication that exist are the use of machinery and equipment that might malfunction and deliver the message later than expected thus reducing the urgency of information. In addition to this, these machines are not able to express aspects of speech such as tone thus making them a true barrier to effective communication. Language is also a major communication barrier in the case where colleagues do not speak the same language or where they have difficulty in articulating clearly in one common language. The use of local idioms, jargon and acronyms further complicates language and kills communication among team members who find certain words ambiguous (Lingard, 2005). A patient in a hospital setting usually sees more than one health care practitioner and specialist during their stay (Memoire, 2007). Handover communication between practitioners may at times seclude crucial information and is even prone to misinterpretation. By improving communication among healthcare professionals the delivery of patient care improves and is saferStrong and effective nursing care is enriched and strengthened by good communication (2) In Victoria, the direct cost of medical errors in public hospitals is estimated at half a billion dollars annually [1]. Today, healthcare is evermore complex and diverse, and improving communication among healthcare professionals is likely to support the safe delivery of patient care. References Anderson, P., 2013. Technical communication, cengage learning, Canada Arora V, Johnson J, Lovinger D. (2005) Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care Burns, K. (2011). Nurse-physician rounds: A collaborative approach to improving communication, efficiencies, and perception of care. MEDSURG Nursing Dixon, J., Larison, K., Zabari, M. (2006). Skilled communication: Making it real. AACN Advanced Critical Care College of nurses of Ontario. (2009), conflict prevention and management, Toronto, ON ECRI. (2009), Healthcare risk control, 5200 butler pike, Plymouth meeting, PA 19462-1298, USA Fernandez, R., Tran, D., Johnson, M., Jones, S. (2010).Interdisciplinary communication in general medical and surgical wards using two different models of nursing care delivery. Journal Of Nursing Management Gordon, M., Melvin, P., Graham, D., Fifer, E., Chiang, V., Sectish, T., Landrigan, C. (2011). Unit-based care teams and the frequency and quality of physician-nurse communications. Archives of Pediatric Adolescent Medicine Joint commission resources. (2005), issues and strategies for nurse leaders: meeting hospital challenges today, joint commission resources, Inc, USA Krizan, A., Merrier, P., Logan, J., Williams, K., 2010. Business communication: Business communication series, Mason: USA: Cengage learning Larabee, L., Janney, M., Ostrow, C. Withrow, M. Hobbs, G. Burant, C. (2007), predicting registered nurse job satisfaction and intent to leave, journal of nursing Lingard L, Espin S, Rubin B. (2005) Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR. Qual Saf Health Care Memoire, A. (2007), communicating during patient hand over, patient safety solutions, vol 1 O’Leary, K., Thompson, J., Landler, M., Kulkarni, N., Hawiley, C., Jeon, J.Williams, M. (2010). Patterns of nurse-physician communication and agreement on the plan of care. Quality and Safety in Healthcare Peereboom, K. (2012), facilitating goals of care discussions for patients with life limiting disease- communication strategies for nurses, journal of hospice and palliative care Rosenstein AH, ODaniel M. (2005). Disruptive behavior clinical outcomes: Perceptions of nurses and physicians.American Journal of Nursing Stein JS. (2006) Improving patient safety communication. Presented at: Philadelphia Area Society for Healthcare Risk Management; Mar 16; ECRI Institute, Plymouth Meeting (PA). Schmalenberg, C. Kramer, M., King, C. (2005), excellence through evidence: securing collegial nurse physician relationships, journal of nursing administration Schmalenberg, C., Kramer, M. (2009). Nurse-physician relationships in hospitals: 20,000 nurses tell their story. Critical Care Nurse Vigman, S., 2013. Global challenges: communication and culture: people issues in a global environment, workforce solutions review Department of Health 2010 Promoting effective communication among healthcare professionals to improve patient safety 1-1-7 Retrieved from http://www.health.vic.gov.au/qualitycouncil/downloads/communication_paper_120710.pdf http://www.health.vic.gov.au/qualitycoun http://www.health.vic.gov.au/qualitycouncil/downloads/communication_paPromoting effective co Importance of Communication in Nursing Importance of Communication in Nursing 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) 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 â€Å"Social† which is considered to be safe and non-contentious, â€Å"Structuredâ€Å", which is typically utilised for situations of teaching and patient interviews and â€Å"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. (DAngelica 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 â€Å"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, â€Å"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: â€Å"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 â€Å"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 â€Å"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) 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 clichà ©s, 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. Conclusions. 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. References Arora V, J Johnson, D Lovinger, H J Humphrey, and D O Meltzer 2005 Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis Qual. Saf. Health Care, Dec 2005 ; 14 : 401 407. Blum N J, Lieu T A. 1992  Interrupted care: the effects of paging on paediatric resident activities. Am J Dis Child 1992 ; 146 : 806-808 Bugge E and I. 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