Course #453

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Hours
2
$18.95

Course Material Valid Through
February 2023

Communication Strategies

Disclosures

Description

Authors: Lia Ludlam, BS, Excerpts written by Carolyn Mikanowicz, RN, PhD and Antoinette Gmeiner, RN, PhD

The goal of this course is to provide health care professionals with a comprehensive overview of communication strategies that will assist in their daily work and personal environments. Various types and models of communication are discussed as well as practical strategies for improving interpersonal relationships.

Learning outcomes include:

  • Recognize how communication impacts care outcomes
  • Be able to use proper terminology to discuss the various components of communication
  • Recognize how other's perceptions affect the way they communicate and adjust your communication style accordingly

Criteria for Successful Completion

After reading the material, complete the online evaluation. If you have a Florida nursing license or an electrology license you must also complete the multiple choice test online with a score of 70% or better. Upon completion of the requirements you may immediately print your CE certificate of completion.

Accreditation

  • American Nurses Credentialing Center's Commission on Accreditation (ANCC)
  • California Board of Registered Nursing Provider No. CEP 1704.
  • This course has been approved by the Florida Board of Nursing No. 50-1408.
  • Kentucky Board of Nursing Provider No. 7­0031

Conflicts of Interest

No conflict of interest exists for any individual in a position to control the content of the educational activity.

Expiration Date

This course expires February 5, 2023.

About the Authors

Lia Ludlam, BS, Ms. Ludlam is a medical, science and technical writer based in Texas. She has written articles for BYU Magazine and BYU's College of Physical and Mathematical Sciences. Previously, she worked as a researcher in lab investigating neurodegenerative disease. She holds bachelor's degree in Genetics and Biotechnology from Brigham Young University and is pursuing a master's degree in Nutrition.

Excerpts written by Carolyn Mikanowicz, RN, PhD. Dr. Mikanowicz is a retired registered nurse and professor emeritis who served in the Health Professions Department and as Program Director for the Master's in Health and Human Services at Youngstown State University.

Excerpts written by Antoinette Gmeiner, RN, PhD Dr. Gmeiner is a joint CEO of a business and life coaching company. Dr. Gmeiner completed her Ph.D. at the former Rand Afrikaans University in South Africa. She has varied experience in the field of psychiatric mental health nursing – as advanced practitioner in private practice, as consultant in the field of mental health and as lecturer in psychiatric mental health nursing.

Purpose and Goals

The goal of this course is to provide health care professionals with a comprehensive overview of communication strategies that will assist in their daily work and personal environments. Various types and models of communication are discussed as well as practical strategies for improving interpersonal relationships.

Learning Outcomes

  1. Recognize how communication impacts care outcomes
  2. Be able to use proper terminology to discuss the various components of communication
  3. Recognize how other's perceptions affect the way they communicate and adjust your communication style accordingly
  4. Speak with a balance of assertiveness, respect, and clarity
  5. Be able to more deeply understand others when they speak through enhanced listening skills
  6. Create clear and informative written documents
  7. Handle conflict constructively

Introduction

Communication is an everyday activity that is so completely intertwined with human life that we sometimes overlook its pervasiveness, importance, and complexity. Every aspect of our daily lives is affected by our communication with others, including people we don't even know. This course is designed to help you better understand communication in all of its aspects—its complexities, its powers, its limitations, and its possibilities.

Communication also helps us to construct new meanings from the stories in our lives. Through communication, we reach some understanding of each other, learn to like, influence and trust each other, begin and terminate relationships, and learn more about ourselves and how others perceive us.

The ultimate goal of good communication in the healthcare field is, of course, delivering the best care possible for the patient. As a nurse, your ability to communicate plays a crucial role in delivering quality healthcare. In 2014, JONA, The Journal of Nursing Administration reported a study that concluded nurse shift reports and nurse handovers were two of the most significant processes to improve patient safety and avoid medical errors. Beyond nurse-to-nurse communication, the way a nurse communicates with the patient, the doctor, and the medical community at large also have dramatic impacts on care quality.

By developing an understanding of a variety of communication theories, you can be more discriminating in your personal communication. This widening of perception will enable you to go beyond habitual thinking and to become increasingly adaptable, flexible, and sophisticated in terms of your approach to communication and make you a better healthcare provider.

Definition of Communication

Communication is a system of operations that includes language, gestures or symbols to convey intended meaning and sharing of experience.

The word communication is derived from the Latin "communico'', from "communis" or the word "common." It means to share, to impart, to take part in, to join, to unite or to connect. Communication, therefore, is a dynamic social interaction involving exchange of ideas or feelings between two or more people, making it probably the most significant of all human behaviors and the foundation of all relationships. It is said that all behavior is communication and all communication affects behavior.

Communication is a key tool in the delivery of health care services. In the medical community, it can be described as a process for sharing information using a set of common rules. Communication among doctors, nurses, and patients can:

  • Improve treatment
  • Protect the patient
  • Improve the patient experience
  • Resolve conflict and improve relationships
  • Increase awareness of a health issue, problem, or solution
  • Demonstrate skill and competence
  • Increase demand for health services
  • Inform or reinforce knowledge, attitudes, or behavior

Communication Types

Different kinds of communication in a healthcare setting include:

  • Intrapersonal communication—communication with oneself: inner thoughts, beliefs, feelings, and inner talk about health issues that influence the individual's health-directed behaviors.
  • Interpersonal communication—nurse-nurse, nurse-doctor, and nurse-client interactions.
  • Small group communication—interaction in small professional-professional and professional-client settings
  • Organizational communication—communication among the hospital administration and staff
  • Public communication—presentations, speeches, and public addresses made by individuals on health-related topics
  • Mass communication—widespread communications to healthcare professionals and/or the general public about health-related topics

The concepts and suggestions in this course are designed to apply to all kinds of communication scenarios for nurses.

Other Key Terms

Understanding the basic components of communication can help us to develop more effective communication skills:

The message is what is said and its corresponding nonverbal communication. The words, body language, tone, pitch, and loudness are all part of the message sent.

The speaker/source is the person sending the message. The sender controls not only the message itself but also manipulates the tools involved.

The listener/receiver is the person at whom the message is aimed. The listener should provide the speaker with feedback: a reaction that indicates attentiveness, understanding and the feelings of the receiver. Feedback includes clarification of misunderstood statements.

The channel is the means through which the message is delivered. Mediums include face-to-face conversation, phone calls, doctor's notes, memos, and emails.

Interference occurs when a listener fails to hear the message because of external influences (such as background noise) or internal influences (such as having something else on the mind).

The context is the time, place, and situation in which an interaction occurs. It also includes the social, relational, and cultural relationship between the participants.

Selected Models

Researchers have developed many models to explain the underlying structure of the communication process. Three of these models include:

  1. Linear Model
  2. Interactive Model
  3. Transactional Model

Linear Model

One of the earliest models of communication was designed by Claude Shannon and Warren Weaver. Known as the Shannon-Weaver model or the Linear Model, this model gives a simplified explanation of communication as a one-way street, similar to the way a telephone signal works.

In the linear model, a source selects information that is formulated into a message. This message is transmitted by a signal through a channel, which encodes the signal so that it can be received by a receiver. The receiver interprets the message and sends it to a destination. Sometimes, "noise" can disturb or otherwise influence messages as they are being transmitted. (Figure 1)

 
linear model of communication

Linear Communication Model (1949)

Figure 1

This model is too simple to describe most human conversations, but it's a great description of the written communication used in healthcare such as memos, blogs, manuals, emails, prescriptions, or doctor's notes.

For example, a doctor (the source) knows what prescription a patient needs. The doctor types the prescription (the message), often encoding the message using symbols (the channel). This message is intended for the pharmacist (the receiver) who can decode the message and properly fill the prescription for the patient (the destination).

Interactive Model

To better account for the complex nature of a human conversation, the Interactive Model adds two new elements to the Linear Model: feedback and context.

Feedback is the response of the receiver that lets the speaker know how their message is being received. For example, does the receiver understand? Are they interested? Do they agree? In fact, including feedback in the communication model allows the speaker and receiver in the interaction to alternate roles—by giving feedback, the receiver becomes a speaker as well.

Context is the circumstances surrounding an interaction. Examples include the physical surroundings, such as the lighting, noise level, and setting (is it at a work party? In the hallway before a patient goes into surgery? In a room alone with a patient?). Context can also include the psychological state of the people in the interaction. Are they stressed? Excited? Frustrated? Do they feel love for each other? People will communicate differently in different contexts.

 
interactive model of communication

Interactive Communication Model

Figure 2

Transactional Model

The Transactional Model adds two more degrees of complexity: simultaneous message-sending/message-receiving and outside context.

Unlike the Interactive Model, which describes a clear alternation between roles for the speaker and listener, the Transactional Model describes everyone in the interaction as simultaneously sending and receiving messages. In fact, the model drops the terms "source" and "receiver" and simply designates all parties in an interaction as "communicators." Communicators simultaneously send and receive messages through every exchange. This allows both parties to adapt their messages part-way through sending them and means that it is impossible to ever not communicate.

A good communicator can pick up on the feedback from other people and change the way they are sending their message so that it is better received. Good communicators also send clear feedback about how they are receiving messages.

Additionally, this model broadens the definition of "context" to include social norms, relationship history, and the culture of each participants. The Interactive model includes context, but limits the definition of context to the immediate environment surrounding the conversation. The Transactional model accounts for the context of what is going on outside of the interaction.

Examples of this broader context include societal norms such as the tone of speaking or the amount of touch that is appropriate between a nurse and a patient or between two people. Context also includes relationship history, such as how long people have known each other. Lastly, the cultural backgrounds of the communicators affect their world views and how they interpret each other's body language and other language cues.

One interesting sub-model within the Transactional Model is Leary's Reflective Model, in which every communication occurs along two dimensions: a dominance-submission scale and a hate-love scale. When individuals interact, each message has a dominant-submissive quality and a hate-love quality. (**Figure 2**) A communicator responds to messages based on the perceived message they receive.

 
interactive model of communication

Leary's Reflective Model (1955)

Figure 3

Leary states that two rules govern the function of these dimensions.

Rule 1: Dominant or submissive behavior usually stimulates the opposite behavior in others. More explicitly, individuals who act dominantly usually stimulate the person they are interacting with to act submissively, and vice versa.

Rule 2: Hateful or loving behavior usually stimulates the same behavior from others.

Leary states that these responses toward others are involuntary and immediate in interpersonal situations.

Variables That Influence Communication

Perception is the way a person interprets the world around them. A person selects, organizes, and interprets messages based on their needs, values, beliefs, and culture. This makes perception highly personal and internal.

To effectively communicate, we must realize that we are all different in the way we perceive the world and use this understanding as a guide to our communication with others.

–Tony Robbins

To be a good communicator, you need to realize that perceptions differ and alter your communication style to account for the different perceptions of the people with whom you are speaking. Some great ways to understand what another person perceives include:

  • asking questions to understand their past experiences, values, and beliefs
  • asking for feedback
  • comparing your perceptions
  • checking that the message you sent was the message they received.

Experience

Our perceptions are shaped by our past experiences. It can be hard for us to see others' points of view when they don't match what we've learned from our experience, but that doesn't mean that the other point of view isn't valid.

Sometimes, a nurse or a patient will be averse to a certain procedure or process because of a negative experience with that procedure for them or someone they know. Try to help them see that if data shows that a procedure is safe, it's safe to perform.

Culture

Culture is a certain way of life, developed and shared by a group of people and passed down from generation to generation. It is made up of many complex elements such as religious and political systems, language, clothing, buildings, art, and music. Your values, the way you dress, the food you eat, your relationships with parents and friends, your marriage, your job, and the languages you speak are all profoundly linked to your culture.

Communication is culture-bound in the sense that each culture teaches people how to communicate through speech, clothing, jewelry, hand gestures, physical touch, facial expression, the use of silence, eye contact, body language, and the degree to which emotion is expressed. The use of each of those communication tools varies from culture to culture.

How people communicate with others that come from different cultures is of critical importance in comprehensive healthcare practice. People from different cultures use different models to understand health and healthcare. For example, in Western culture, medical personal often speak of getting healthy as "fighting" sickness, as if sickness were a battle. In other cultures, such as the Hmong culture, health is something that grows within the body like the way a crop grows in a field. It needs proper care and nutrients in order to flourish.

Also remember that culture is an individual matter—each person has their own unique culture. It can be tempting to assume that two people of the same ethnicity or background have identical beliefs and values, but this isn't the case. Think of the differences in culture even between your immediate family and your relatives' families. There are probably some similarities, but there are also probably some significant differences in tastes, beliefs, and priorities. Get to know each person as if you were getting to know a new culture.

Try to be sensitive toward possible differences by implementing some of the following principles in transcultural communication:

  • Be sensitive toward other cultures and be curious, not an "expert." Be aware that your frame of reference might simply be different than others, not better. This will help you to learn from people.
  • Ask questions to better understanding the points of view of others.
  • Be honest and mindful and admit your shortcomings.
  • Be accepting.
  • Do not be secretive.
  • Search for commonalities.

Values

Values are an important component of culture. A value is something on which people place worth and importance, and people place worth and importance on different things. Values determine what we think is right or wrong, important or meaningless, beautiful or ugly.

Values can be based on moral or religious systems. Some values are acquired through interacting with others such as parents, teachers, siblings, a peer group, and media figures.

Our daily roles also influence our values. In any one day, a person can be a student, sibling, parent, nurse, citizen, consultant, artist, teammate, or teacher and change what they value in each role.

Sometimes differing values can act as a filter for communication and can lead to misunderstanding and misinterpretation. For example, one nurse might value efficiency the most, while another prioritizes patient connection. If the two nurses try to make decisions together without first seeking to understand each other's values, they might become very frustrated. When both understand what the other nurse values, it is easier to make a decision.

It is important therefore, to be aware and sensitive to other value systems when communicating and to not impose your own value system on others.

Communication Techniques

Assertiveness: A Case Study

"I work with a lot of new nurses and in my opinion, assertiveness is one of the hardest skills to obtain but also one of the most valuable. I have watched new nurses who are extremely shy and insecure in their ability to communicate in the healthcare field. The thing they don't understand is that most everyone feels this way, a little unsure of themselves. But the nurse who is assertive will reap the most respect and receive the results he or she wants more quickly. Patients will respond with more trust. Physicians will respond more receptively. And your other co-workers will respond with more attention.

I remember watching a new nurse who had a patient who was struggling with shortness of breath. The patient was very overweight and had pneumonia so no one was very surprised, but this nurse didn't feel quite right about it. The first time she contacted the doctor she mumbled and said things like "I'm not sure but..." Or "I really could be totally wrong..." in such a self-deprecating way that the doctor ignored her concerns. The patient continued to struggle and the nurse decided to contact the physician again.

This time she spoke with me before making the call and we discussed what she planned to say. She role-played it with me until she could confidently convey her message. She called the doctor back and didn't stumble over her words at all. The physician listened to her because she was able to clearly express herself and present her concerns in a direct manner. The doctor ordered a CT scan and identified a Pulmonary Embolism on top of the pneumonia that had to be treated in an entirely different way. Because this nurse was assertive, she provided the best care for her patient and expedited care for something that might have been ignored and created increased problems."

Adelynn S, RN, Utah

This section will take an in-depth look at some important communication techniques in these areas:

  • Speaking
  • Listening
  • Writing
  • Handling Conflict

Effective Speaking

Assertiveness

Assertive behavior means to stand up for your own rights without violating the rights of others. Communicating assertively is the use of honest, direct communication that maintains and defends one's rights in a positive way. You must be able to express your opinion and take responsibility for what you say and do.

What does assertive communication look like?

  • Clearly and calmly expressing your opinions
  • Using direct language
  • Taking initiative to tackle problems
  • Having strong posture that indicates control and confidence: straight back, relaxed shoulders, direct eye contact

What are the advantages of being assertive?

  • Your needs and beliefs are represented
  • You feel more confident
  • You accept responsibility
  • You can accomplish tasks faster
  • You have fewer miscommunications
  • You will manage conflict more effectively
  • You are less likely to worry and dwell on negative emotions
  • You will be seen by others as competent
  • You will maintain better interpersonal relationships

Respect

The word respect has multiple definitions. In one sense, it means "due regard for the feelings, wishes, rights, or traditions of others"—that is, respect is a way of treating all people with consideration, merited simply on the fact that they were born. Being assertive should always be balanced with respecting others in this way.

Respect can also mean "a feeling of deep admiration for someone or something elicited by their abilities, qualities, or achievements." This type of respect must be earned.

Both types of respect improve communication. You should show the first kind of respect to all people. Being treated with consideration makes people feel valued and therefore more open to working with you. You can show respect by doing some of the following:

  • Take care not to invalidate a client's experience by moralizing or dismissing the feelings of others. (For example, saying "Don't worry, time heals all wounds" when a patient has recently lost a loved one or saying "It's not that bad" when a patient complains of symptoms.)
  • Give clients as much privacy as possible during any form of treatment.
  • Minimize experiences that humiliate patients and strip them of their sense of identity. Help them to stay in control of their own lives as long as possible.
  • Be honest with clients about treatments, privileges, length of stay and so forth.
  • Be on time for appointments.
  • Treat your client's room and belongings as their private property.

At the same time, you should try to earn the second kind of respect by becoming the most competent nurse you can. People trust and listen better to people they respect. Here are some ways to earn respect:

  • Respect others
  • Thoroughly learn nursing techniques and procedures
  • Admit to mistakes quickly
  • Be proactive about resolving problems
  • Stick to high moral standards

Genuineness

Genuineness is the ability to be real and honest with yourself and others. Often, people will respond better to your genuine personality rather than an affected one. Being "real" with people will help them trust you more and give more credibility to your message. You should always try to be pleasant and courteous with people, but you don't have to pretend be something you are not.

Another aspect of genuineness is telling people the truth even when it might not be good news. Never try to sugarcoat a diagnosis or a prognosis—studies show that people would rather hear the hard truth than to hear you beat around the bush.

"I" Statements

"I" statements are statements that focus on your personal experience rather than on other people's actions.

Here's a good example of an "I" statement:

"I feel frustrated when there's noise when I'm trying to study."

versus "You make a lot of noise and it frustrates me."

"You" statements might indicate to others that you are judging their motives or attacking them. If people feel judged or attacked, they will often become defensive. Instead, "I" statements keep the focus on your actions and are less affrontive to other people.

Vocabulary

Many of the words you use have connotations associated with them. Connotation is a meaning or emotion associated with a word beyond its literal definition. For example, the word "cloudy" literally refers to a large collection of liquid particles in the sky, but when you hear the word "cloudy" it might stir up emotions of being depressed, bored, or even cozy, or awestruck depending on your personal experience with clouds. Using words with strong connotations might impact how a patient feels. You should never sugarcoat the information you give a patient, but you should be sensitive to how the words you use make them feel.

Improve the exactness of your communication through learning correct medical vocabulary terms and acronyms. It might require regular research on your part, but the use of precise terminology is important in ensuring accurate communication between healthcare professionals.

Using Body Language

The study of body movement and facial expressions as a means of communication is called kinesics.

Facial expressions and gestures enhance communication. For instance, if you smile warmly while greeting someone, you can help them feel more comfortable in your presence. Be aware of the messages your body position and facial expressions are sending when you speak to others.

An important aspect of kinesics is maintaining adequate eye contact to convey caring, attention, warmth, and confidence. You'll need to learn a balance between too much eye contact and too little. Staring at the client without ever breaking eye contact can make the client feel uncomfortable, and minimal eye contact may indicate that you are bored, timid, not listening, or not interested. Finding a good balance may take some practice.

Touch

Physical touch can be a connecting force between people and is often a necessary part of nursing. However, touch can also be easily misinterpreted as having a sexual or a threatening intent. Before touching a patient, always ask their permission first and be sensitive to the patient's response as you are touching them.

Leaving communication channels open

One component of effective speaking is providing your listener regular opportunities to speak as well. A listener might get so distracted trying to interrupt you to share an important piece of information that they stop absorbing your message. In addition, people who get frustrated tend to stop being receptive. Also, after hearing the other person's input, you might realize that you need to change your message or that you don't even need to have the conversation at all.

Great ways to give your listener channels to express themselves include:

  • Occasionally leave brief pauses of silence while you are speaking, allowing the other person to speak if they need to.
  • Check in regularly during the conversation with questions such as "What are your thoughts on this?" or "Do you have any questions?"
  • Make help accessible. Give other people ways to contact you in case they have concerns after the conversation has ended, and make sure to respond to people in a timely manner.

Asking Questions

The single biggest problem in communication is the illusion that it has taken place."

-- origin unknown, often attributed to George Bernard Shaw

You can make sure that your message is being received correctly by asking questions to check for comprehension. Usually this involves more than simply asking your listener if they understood—they might not know that they don't understand!

You might ask questions such as the following:

  • "I want to make sure I explained that well. Can you tell me what you understood from what I said?"
  • "Can you walk me through your plan of what you're going to do now?"
  • "Do you know what to do in this situation?"
  • "When a patient has ________ condition, what is the first thing you should do?"
  • "Could you explain it back to me so I know you understood?"
  • "What are your thoughts about that?"

Be careful to not sound patronizing when asking these kinds of questions. Usually a condescending tone can be avoided by explaining to your listener why you are asking follow-up questions. Place the focus of the question on making sure that you explained the concept in an understandable way rather than expressing doubt that the listener understood.

Sometimes, even more effective than telling someone what to do is asking a question that allows them to figure out the answer on their own. People are more likely to follow through on an action if the action is their idea.

  • "What do you think would be a good solution to this problem?"

4.2 Effective Listening

An effective listener is as actively involved in the conversation as the speaker—in fact, listening well often requires more effort and concentration than speaking.

It's a common human tendency to assume we know what a person is saying or feeling without getting all the information first. It's also difficult to listen without trying to think about what you are going to say next, but good listening can drastically improve your communication experience: The speaker will feel less defensive, more satisfied with the communication, and might be more willing to listen to your side. And who knows? You might even end up changing your point of view after carefully listening to the opinions of those around you.

Refraining from Unfair Judgment

Judging occurs when one person makes assumptions about the motives, character, or intelligence of the other person. If someone feels unfairly judged, they might withdraw from the discussion, which will extinguish open communication. Judgmental responses can be damaging to relationships since the judged person feels they have to defend her/his opinion, belief, or behavior, placing them in a position of resistance.

Some judgment is necessary when making decisions but be careful that you have enough information to make a correct judgement before acting on it. Also, remember that you can assess behaviors of other people, but it is much harder to accurately assess the motives or character behind their actions. It is generally when people feel that their motives, character, or intelligence are questioned that they withdraw.

Listen carefully to the other person's point of view—is it valid or true? Could you learn from what they are saying?

Sending feedback

You can help a speaker feel comfortable and understood by sending obvious feedback. Feedback might include:

  • Nodding and eye contact to show that you are listening
  • Paraphrasing the speaker's point to show that you understood
  • Verbalizing agreement or disagreement
  • Pausing to ask clarifying questions to show that you care about understanding correctly.

Reading body language

A speaker's nonverbal communication can reveal as much as or more than the words they use, since body language can be harder to control than the word choice.

A good listener will be alert to:

  • Posture. If the speaker has an open body position (that is, if their arms are down or they are leaning towards you), they are probably feeling comfortable and ready for open communication. However, folded arms over the chest or learning away from you may indicate that the individual may be feeling defensive. This person may need space or reassurance.
  • Gestures. Watch the person's hands as you interact. For example, even though the person's voice seems calm, you might detect discomfort through nervous hand activity.
  • Facial expressions. Does the person's facial expression match their voice and message? Sometimes you can see clues through facial expressions that someone does not actually feel what they are saying—for example, their eyes do not convey the same emotion that their face and words expressing. If someone is faking an emotion, they might also hold the expression too long.
  • Eye movement. If the persons eyes are shifting a lot or they have difficulty making eye contact with you, they might be thinking a lot or feeling uncomfortable about what they are saying.
  • Personal space. Space and boundaries are often culturally determined and can vary according to the individual. In general, if a person moves closer to you, it indicates an interest in you or the discussion. Keeping a distance may indicate uncertainty about you, or a dislike of or disinterest in your topic. It is important to be sensitive toward the needs of your patient in terms of personal space and not decrease distance when the patient needs more space. You can respect patients' boundaries by how closely you sit, how much space you give them when you are walking together, and getting permission before entering the room.

You can send signals through your own body language to show you are listening. While another person is speaking, you can face them, lean forward, make eye contact, nod, and when appropriate use touch to let them know you are interested and listening.

Effective Listening: A Case Study

"I was at work one Saturday making rounds to my patients, when I went to visit Grace, I asked how she was doing like normal.

The normally cordial, chipper Grace emphatically replied, "I'm fine, I'm fine, I'm fine!"

"You don't seem fine," I replied, reaching out and grasping her hand.

Grace's eyes looked glazed over and she repeated, "I'm fine," four times.

I realized I needed to check her cognition. I retrieved a yellow balloon and asked, "Grace, what color is this balloon?"

"I'm yellow, I'm yellow, I'm yellow," she replied, with her dazed expression.

At this point, I knew I needed to notify someone that could help. I went to locate the head nurse and explained Grace's change in state. However, I didn't feel any sense of urgency from her, and soon found that this nurse was an agency nurse--one only working a few Saturdays per month. When I realized this, I had to change my approach and explained to the nurse that I was deeply concerned.

After this, the nurse seemed to take more interest.

"Her ammonia levels were high in her blood-work this week, but I called the doctor and he hasn't gotten back to me . . . I will call again until I get someone who can help." We were able to get Grace to the hospital where they tested her ammonia levels to be in the 300s. She has since woken up from a coma that she was in for six days. I'm glad I asked follow-up questions and paid attention to body language!"

Maddie S, Caregiver and Physical Therapy Assistant, Utah

Asking Questions

Major misunderstandings can be avoided if clarification is sought immediately, so don't hesitate to ask questions! Good questions can help you show interest, better understand what the other person is trying to say and understand where they are coming from.

Here are some examples of questions you can ask to improve communication:

  • Clarification questions
    • "Could you repeat that?"
    • "Could you explain that a different way?"
  • Comprehension questions
    • "Are you saying that you feel ____________?"
    • "Are you saying that you think _______________?"
    • "Do you feel like I answered your question?"
  • Exploratory questions
    • "Can you tell me more?"
    • "Why do you feel that way?"

Some questions can be more harmful than beneficial. Here's some types of questions that you should avoid:

  • Questions that contain more than one idea. These questions can confuse the other person and prevent you from getting the information you wanted.
    • "How do you feel your husband is doing and has anyone talked to you about hospice care?"
  • Questions that the other person won't know the answer to.
    • "What do you think this medication will do for you?"
  • Prying questions, especially about non-essential information.
    • "What do you think of Dr. Smith?"
    • "Why do you wear that scarf?"
  • Too many close-ended ("yes" or "no") questions. Sometimes you need to ask close-ended questions ("Did you take your medication?"), but these questions don't provide as much information as exploratory questions. Also, too many of these questions can make the other person feel interrogated.
    • "Do you feel well?" (close-ended) versus "How do you feel?" (open-ended)
    • "Do you understand?" (close-ended) versus "Can you tell me what you understood?" (open-ended)

Effective Writing and Documentation

As a nurse, you might need to rely heavily on written communication to do your job. In fact, a 2015 study stated that writing was the principle method of communication between specialty and primary care. You could be asked to read and write emails, memos, doctor's notes, bedside shift reports, and updated protocols. Written communication can differ from verbal communication in many ways.

Legibility

Regardless of how well you craft your message, your efforts won't do much good if the message can't be read. Legibility applies not only to your handwriting—as your second-grade teacher might have reminded you—but also to digital lettering.

  • In your handwriting, try to make your print large and make each character distinguishable from the others (for instance, make sure your r's don't look like n's).
  • When communicating digitally, use standard, professional fonts (such as Times New Roman, Calibri, Arial, etc.) and dark, neutral colors such as black or blue as these are easier to read.
  • Make sure that the background color the page doesn't make your font hard to read (for example, don't use a blue font on a grey background).
  • Go easy on bolding, italicizing, and using all caps or colors to draw attention to certain words. Emphasis works better when used sparingly.

Visuals

One great way to improve understanding and to draw people's attention to your message is to use visuals. Use diagrams to explain difficult concepts, or photos/illustrations to add color or emotional interest.

However, make sure that your visuals don't detract from your message by choosing visuals that are relevant and professional and that don't obscure the text.

Make information easy to find

Most healthcare professionals are extremely busy and want to spend the least amount of time possible sorting through the mountain of messages they receive each day. You can make the burden lighter (and get your message across more effectively) by making the important information in your message easy to extract. Try using:

  • Concise language. Leave out unnecessary information and avoid redundancy. For example, "*Several nurses on our floor collaborate together and the reason why is because it really improves patient care for cancer victims in this department"* can be shortened to "*Several nurses on our floor collaborate to improve cancer patient care."* If you can delete words and still communicate your message clearly, delete the words!

  • Lots of white space. Long, dense chunks of text are intimidating. If you've written a long paragraph with no breaks, there's a chance that a busy professional won't read it at all—it's too much work to find the message hidden in a haystack of words. Even if someone does read it, they might miss important parts of your message. Cluster sentences of related information into short paragraphs and leave an entire line of space between each one.

  • Headings. If you label sections, your reader can approach a section already knowing what type of information to look for, which can save time and energy. It also lets them know ahead of time if a section doesn't apply to them so they can skip it. If you are writing a long piece, use a hierarchy of headings, meaning bigger headings for more general topics and smaller sub-headings for the topics within the general topics.

  • Bulleted and numbered lists. It's very easy to miss items in a list if they are written out in sentence form. By writing out list items as bulleted or numbered points, you can draw attention to each one individually and you make it very obvious which items are part of the list. Broken-up lists also give your reader a break from reading paragraphs.

  • "Old to new" sentence structure. "Old to new" refers to putting information that your reader is already familiar with (from what you've written earlier) at the beginning of a sentence, then putting new information you want them to learn at the end. This allows your reader to have time to anticipate new information and know how it fits in with the rest of the information they've already learned. It also helps one sentence flow into the next in a logical way. For example, if you want your reader to focus on washing their wrists when they sanitize, you might write: Good handwashing technique is an important part of disease prevention. One example of good handwashing technique [old info] is washing your hands up to an inch above your wrists [new info].

Handling Conflict

Conflict occurs in every relationship. In any situation where the wants, intentions, and needs of one individual conflict with those of someone else, there will probably be conflict.

Conflict is not necessarily a bad thing. In fact, conflict is often a starting point for finding deeper understanding and better solutions. Healthy conflict can even enhance relationships. However, prolonged, unresolved conflict can destroy relationships, so let's learn how to resolve conflict effectively.

Crucial Conversations

As a good communicator, you can kickstart conflict resolution by starting conversations. The authors of a popular book on effective communication called Crucial Conversations explain that often, if you feel stuck in a situation, the thing standing between you and the outcome you want is a crucial conversation. Crucial conversations are conversations in which people have conflicting opinions, stakes are high, and emotions run strong.

Here are some steps to have a one-on-one crucial conversation with someone you find yourself in conflict with. After asking them to speak in a private setting, you can use the acronym S-T-A-T-E to resolve conflicts:

  1. State the facts. In this first step, share only the objective facts, not your conclusions based on the facts. "Objective" means that any on-looker on the situation would agree that the events happened the way you are describing them. For example, "_______ (the problem) has occurred three times in the last week," or "I have had multiple employees comment on __________ in your behavior."
  2. Tell your story. Your "story" is your assumptions based on the facts you shared. Make it clear that your story is simply your tentative conjecture, not what you are sure is fact. You could use language such as "Based on these facts, I can't help but wonder if …"
  3. Ask for the other person's story. Once you've shared your interpretation of the facts, ask for the other person's explanation. Be prepared to genuinely listen! After hearing their side and possibly after more investigation, you might realize your interpretation was flawed.
  4. Talk tentatively. Make sure to talk about any assumptions about a person's motives, character, or abilities as just that—assumptions. This will create a nonjudgmental environment where people feel safe to express their feelings.
  5. Encourage testing. Once both sides feel that their stories have been heard, it's time to start brainstorming solutions. You don't have to find the perfect solution in one sitting. Instead, you can find a course of action, make an agreement to try it out, and then keep the dialogue open. You can always re-evaluate and make a new plan later.

Here's an example of each of the five steps in an imaginary scenario.

Mel, the lead nurse, needs to speak with Pat, a recently hired nurse. Mel is frustrated because Pat hasn't been collecting vitals properly and so the doctor doesn't have the necessary information when the patient comes in to see her.

After the same issue has happened multiple times, Mel pulls Pat aside to a private area of their floor, so they have a safe environment to talk in.

First, Mel states the facts: "Pat, there's been something that's been kind of concerning to me. Three times this week, Dr. Smith has had patients come into his office that didn't have their vitals checked properly after you were assigned to work with them. It really slows down our ability to help patients when vitals aren't checked and documented in a systematic way."

Then, Mel tells a story: "I'm beginning to wonder if you weren't paying attention during your training week when Sue taught you how to take vitals."

But then, Mel asks for Pat's story: "But I would love to hear your side of things. Can you give me some more insight as to why that happens?"

This allows Pat to explain: "I'm sorry, Mel. At the last hospital where I worked, we had a different protocol that was actually more efficient. It's been really hard for me to break old habits, especially when I liked the other system better.

Now Mel and Pat can talk tentatively and encourage testing . Mel says: "Thanks for telling me that, Pat, that makes sense. Next time, maybe you can let me know right away when you are having a problem with a protocol so I can help."

Pat agrees to do that in the future. Then Mel says: "I'm interested in knowing more about the protocol that you used at the other hospital. Could you tell me more about it?" …

In this scenario, both parties got to express their feelings and feel understood, and they were able to find a solution that met both of their needs.

Responding to Criticism

Hearing negative feedback about yourself and responding appropriately is an important part of good listening. Occasionally a person will criticize you with the intent to hurt you, but most of the time criticism is intended to be helpful and can be a great tool for you to improve.

When you are given negative feedback, try to respond according to the following guidelines:

  • Take criticism in the spirit it was intended. The person criticizing you might not be good at giving feedback in a kind and gentle way, but it's your job to see through the tone of their words and realize their intent is for your well-being or the well-being of the establishment.
  • Try to understand their point. Sometimes we can be blind to our own faults and it takes another person making a comment for us to realize them. Whether the other person's criticism is right or not, you can almost always hear something in the message that you could improve. If nothing else, you can learn to be more sensitive to potential ways you might offend someone in the future.
  • Remove any emotional overtone in your response. A defensive or angry response will only escalate the situation—not to mention it's unlikely to convince the other person of anything. Try to control your emotions and respond in a calm, pleasant manner.

Dealing with Conflict in Emergencies

Critical and time-sensitive problems aren't unusual in a hospital setting. Occasionally, conflict arises during emergencies, and unfortunately, there's no time for lengthy negotiating.

Sometimes people become unreasonable in emergency situations due to stress or fear. In these situations, sometimes it's best to not engage with these people during the crisis, then approach the other person afterwards, when things have cooled off.

In other situations, you will need to do your best to seek compromise as quickly as possible.

Dealing with Conflict in Emergencies: A Case Study

"I had only been on evening call for a few hours in the VA emergency care unit when a man was brought in by ambulance who was having a heart attack. I ordered a series of stabilizing medications including aspirin, nitroglycerin and a beta-blocker to be urgently administered.

To my surprise, especially since what I ordered was standard of care, the nurse on duty refused to administer the beta-blocker. She had had a bad experience with this drug a few days earlier with a patient in a similar situation. In some instances, beta-blockers can cause acute respiratory problems and the nurse witnessed a serious respiratory complication. I had worked with this nurse many times in the past and we had a very good working relationship. I tried to discuss with the nurse why the medication was indicated in this situation, but she was adamant.

A multitude of thoughts crossed my mind including the possibility of calling a hospital administrator in the middle of the night to intervene and compel the nurse to administer the drug. I considered giving it myself, but I did not have proper authorization to access to the medications dispensing machine.

Ultimately, since the patient was currently stable and was immediately ready to be transferred to the ICU, I decided to simply call my colleagues in the ICU and ask them to administer the drug as soon as they reached the unit. They agreed. This course of action avoided an unnecessary, and likely a contentious, confrontation with the nurse. This also preserved the ability for us to work together in the future.

The next morning, as the hospital staff arrived for the day shift, I discussed the events of the evening before and asked the incoming attending physician to address proper acute heart attack treatment algorithms with the nursing staff and discuss proper ways of managing disputes with physician orders."

Bill L, MD, PhD, New Jersey

Lack of Inter-Professional Understanding

A healthy spirit of collegiality among healthcare professionals is important in delivering quality healthcare. Unfortunately, contention and misunderstanding still exist due to improper communication.

A great breakdown in cooperativity and communication occurs when professionals do not understand the roles of other professionals. For example, the distinctly separate educational experiences of physicians and nurses often lead to a lack of insight into one another's roles and responsibilities.

An increase in territorial disputes is a second problem created by a lack of interdisciplinary understanding. Nursing roles have expanded immensely in recent years, leading to confusion as to which professional has expertise in a particular area. For example, monitoring cardiac arrhythmias and drawing blood gases were regarded as primarily the tasks of physicians, but now are tasks shared with nurses. When roles overlap, one professional might perceive that the other person is trying to take over their responsibilities, or the task might not be accomplished efficiently because one professional assumes that the task is someone else's responsibility.

A 2014 study found that the best-performing health care teams had systems to clarify roles for doctors, nurses, and nurse practitioners. They communicated these expectations at both the individual and organizational level.

Keeping Up-to-Date

The medical field is ever-changing. Researchers are constantly releasing new medical treatments and improved procedures, but it's up to the hospitals to access the research, evaluate it, and implement it.

As a healthcare provider, it is your responsibility to stay up-to-date on new treatment information and adopt new protocols as directed by the administrators of your hospital. And if you are aware of an improved care practice, you should let your supervisors know.

Keeping Up-to-Date: A Case Study

"I was consulting with other specialty care providers about a patient one day in a nearby hospital. The treatment recommendations I was providing were published, evidence-based practice. However, although it wasn't new knowledge to me, the providers I was sharing it with weren't aware of the techniques I was sharing. Why did they not know about this advancement in medicine? And more importantly, how then could they be using it to care for their patients if they didn't? The truth is, medicine is advancing all the time. And to stay current you may have to seek out that information yourself. You can also learn from your peers who are specialists in the area. The information can be life-changing."

Lori K, RN, MSN, CPNP, Texas

Summary

Communication is not an "optional extra", but a crucial element in healthcare. The quality of care can be enhanced through communication and good decision-making.

References

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Christensen, A. (2019, August 12). Delivering bad news? Don't beat around the bush. Retrieved December 28, 2019, from https://news.byu.edu/news/delivering-bad-news-dont-beat-around-bush.

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Llopis-Lorente, A., Díez, P., Sánchez, A. et al. Interactive models of communication at the nanoscale using nanoparticles that talk to one another. Nat Commun 8, 15511 (2017) doi:10.1038/ncomms15511

Ospina, N. S., Phillips, K. A., Rodriguez-Gutierrez, R., Castaneda-Guarderas, A., Gionfriddo, M. R., Branda, M. E., & Montori, V. M. (2018, July 2). Eliciting the Patients Agenda- Secondary Analysis of Recorded Clinical Encounters. https://link.springer.com/article/10.1007/s11606-018-4540-5 Last accessed January 13, 2020

Patterson, K., Grenny, J., McMillan, R., & Switzler, A. (2012). Crucial Conversations: Tools For Talking When Stakes Are high. New York: McGraw-Hill.

Respect: Definition of Respect by Lexico. https://www.lexico.com/en/definition/respect Last accessed January 10, 2020

Vermeir, P., Vandijck, D., Degroote, S., Peleman, R., Verhaeghe, R., Mortier, E., … Vogelaers, D. (2015). Communication in healthcare: a narrative review of the literature and practical recommendations. International Journal of Clinical Practice<, 69(11), 1257–1267. doi: 10.1111/ijcp.12686




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