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Course #453


This course expired Mar 31, 2018 and is no longer available for purchase.

Communication Strategies

Authors: Dr. Carolyn Mikanowicz, RN, Ph.D | Antoinette Gmeiner, RN, Ph.D

The goal of this course is to provide healthcare 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.

Course objectives include:

  • Define communication and list the basic types of human communication
  • List the various models of communication
  • Outline the role that gender plays in styles of communication

About the Authors

Dr. Carolyn Mikanowicz, RN, PhD is an Associate Professor in the Health Professions Department and Program Director for the Master in Health and Human Services at Youngstown State University. She is a registered nurse and family planning nurse practitioner registered in Pennsylvania.

Antoinette Gmeiner, R.N. Ph.D. completed her Ph.D. at the 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. Currently is senior lecturer at Rand Afrikaans University, Auckland Park, South Africa and responsible for the under-graduate programs 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.

Instructional Objectives

  1. Define communication and list the basic types of human communication.
  2. List the various models of communication.
  3. Enumerate the variables that influence communication.
  4. Name sources of conflict between healthcare professionals.
  5. List components and strategies involved in professional-professional relationships.
  6. Define personal power.
  7. Outline the role that gender plays in styles of communication.
  8. Compare and contrast different techniques of communication.
  9. Differentiate between verbal and non-verbal communication techniques.


As long as people have wondered about the world, they have been intrigued by the mysteries of human nature. The most commonplace activities of our lives – the things we take for granted – can become puzzling when we try to understand them systematically. Communication is an everyday activity that is intertwined with all of human life so completely that we sometimes overlook its pervasiveness, importance, and complexity. Every aspect of our daily lives is affected by our communication with others, as well as by messages from people we don''t even know – people near and far. This course is designed to help you better understand communication in all of its aspects – its complexities, its powers, its possibilities, and its limitations.

Theories of communication provide explanations that help us understand the phenomenon we call communication. By developing an understanding of a variety of communication theories, you can be more discriminating in your interpretation of communication and gain tools to improve your communication. Studying communication theory will help you to see things you never saw before, to see the unfamiliar in the everyday. This widening of perception, or unhitching of blinders, will enable you to go beyond habitual thinking and to become increasingly adaptable, flexible, and sophisticated in terms of your approach to communication. 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 special process seen as a dynamic social interaction involving exchange of ideas between two or more people. It is also to express feelings and probably the most significant of all human behaviors. It is said that all behavior is communication and all communication affects behavior.

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

Communication is the foundation of all interpersonal relationships and our daily lives are filled with one communication experience after another. The purpose is twofold: the giving and receiving of information; and the making of contact between people. If there is no communication there can be no relationship, therefore some will say that communication is not only a behavior, it is the relationship.

Therapeutic communication utilized in the healthcare professions is facilitative in nature, focusing on a specific goal. The message conveys a presenting problem, learning of more effective coping mechanisms and the development of ego-strengths. The core of this is meaningful reaction of the nurse.

Clients use communication to share their ideas and feelings, express thoughts and convey their life stories to co-construct new meanings. Through the contact between health professional and client, new meanings (stories) are co-constructed and clients learn more effective ways of communicating with others. 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.

Definition of Communication

Communication is a key tool that health care professionals must use to elicit cooperation among individuals in the delivery of health care services. It is an integral part of socialization and imperative in establishing relationships. In the medical community, it can be described as a process for sharing information through utilization of a set of common rules. These rules vary with circumstances: for instance, the transfer of information can be interrupted by situational pressure; differences between the professionals'' perspectives can interfere with shared meanings; and the rules of the process of communication can be changed with inappropriate responses.

Communication among health professionals can:

  1. increase awareness of a health issue, problem, or solution
  2. affect attitudes to create support for individual or collective action
  3. demonstrate or illustrate skills
  4. increase demand for health services
  5. inform or reinforce knowledge, attitudes, or behavior

With the disciplines of medicine and nursing working in close proximity, communication is not just practicing together, but individually interacting to achieve a common good: the health and well-being of patients.

Human communication is a subset of communication. It refers to the interaction between people through the use of symbolic language. For example, it can be an ongoing dialogue about a patient concern, behavior, attitude, or diagnosis. It reflects how medical professionals seek to maintain health and deal with health-related issues. These transactions that occur among health professionals can be verbal or nonverbal, oral or written, personal or impersonal, and issue oriented or relationship oriented.

Human Communication Types

Among the different kinds of human communication are:

  • intrapersonal communication
  • interpersonal communication
  • small group communication
  • organizational communication
  • public communication
  • mass communication

Intrapersonal communication refers to inner thoughts, beliefs, and feelings, and inner talk about health issues that influence the individual''s health-directed behaviors.

In the interpersonal context, communication includes those variables that directly affect professional ­ – professional and professional – client interaction.

Within the small group context, communication includes treatment planning meetings, staff reports, and health team interactions.

In organizational communication areas listed are hospital administration, staff relations, and organizational communication.

Public communication refers to presentations, speeches, and public addresses made by individuals on health-related topics.

Finally, mass communication points to areas such as national and world health programs, health promotion, and public health planning.

The Process of Human Communication

Communication is a cyclic, dynamic, ever-changing process where information is continuously transmitted to a receiver and where the reaction of the receiver changes the sender''s next message. This process is continuous, that''s why we can say it''s a cyclic process. It is important, though, to remember that the sender and receiver mentioned are people, whose intelligence, feelings, values, beliefs and cultural backgrounds will affect the way in which they communicate. These contextual factors include community, individual, family, and social influences, such as age, gender, educational background, specific aims, and attitudes.

The meaning of communication cannot be transferred; it must be mutually negotiated, because meaning can be influenced by many of the above-mentioned contextual factors.

For example, it insinuates that communication between person A and person B is a continuous interaction with an extremely large number of variables, all of which continually change during a communication event. Essentially during the communicative process the physical, emotional and social states of person A and person B may change, which could cause further changes in their interaction. The understanding that human communication is a process is important because it forces one to recognize the complexity of human communication and the many relationships that it involves.

In health care, the process directs one''s attention to professional – professional and professional – client communications as ongoing dynamic processes rather than one-way, fixed sequences of events. The process not only directs us to review the factors that affect the client, but also to analyze factors that affect the individuals involved in the case, i.e., nurse, physician, social worker, or physical therapist, and to examine how the ongoing interchange among all of these people will vary depending on the nature of the situation.

Influencing Variables


Perception is a process whereby each individual selects, organizes, and interprets images of the world around him. Each individual also has a different perception about things in the world and how they view the world related to needs, values, beliefs, and culture. This makes perception a highly personal and internal process. What individuals perceive depends on understanding past experiences. Past experiences have prepared us to see things, people, and events in a particular way. Individuals can look at the same object and see different things.

As people''s perceptions differ and meanings differ, it is of vital importance to take note of this, as it inevitably affects human communication. If a sender shares information with the receiver, the receiver must perceive what the sender intended. It is therefore important to ask for feedback, comparing perceptions, reaching a common denominator. It is then checked that the message sent (meaning/perception) is the message received (meaning/perception).

To be able to view others as they are, people should know themselves and know how the self affects the perceptions of others.


Individuals have their own set of values. People value what is of worth and importance to them. Values also influence the process of communication because people''s values differ. These values are based on moral or religious systems found in all cultures and societies. A person is not born with it, values are acquired through the process of socialization and interaction with others for instance parents, teachers, siblings, peer group, and media figures.

Values determine what we think is right or wrong, important or not, beautiful or ugly and so forth.

The daily roles we play as humans also influence our values. In any one day, a woman can be a student, a sister, a mother, nurse, citizen, consultant, artist, daughter, and teacher.

It is all of this above uniqueness that acts as a filter to communication and can lead to misunderstanding and misinterpretation.

It is important therefore, to be aware and sensitive to other value systems when communicating with them and never imposing your own value system on others.


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. The way you dress, the food you eat, your relationships with your parents and friends, your marriage, your job, 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 language, clothing, jewelry, hand gestures, facial expression, and even the way they utilize space.

It is important to view the way in which culture affects communication and to be aware of cultural influences when communicating with others, especially when communicating with people from different cultures. The complexities in communication between cultures are many, for instance, nonverbal communication, public bodily contact, eye contact, the use of silence in communication and emotional expression. Communicating with meaning requires that culture is of vital importance and must be taken into account. How people communicate with others who do not share similar cultures is of critical importance in comprehensive healthcare practice. Try to be sensitive toward these differences and implement some of the following principles in communicating transculturally:

  • Be sensitive toward other cultures and be curious, not an "expert." This will help you to learn from people.
  • Be honest and mindful and admit your shortcomings.
  • Be unconditionally accepting and do not try to change or control them.
  • Be peaceful, ethical, and engage in behavior that is morally right.
  • Strive for harmony and do not be secretive.
  • Be understanding and recognize how culture influences the way we think and behave. Search for commonalities.
  • Avoid using your own frame of reference when communicating with others, and work within their frame of reference. Always negotiate when working transculturally.

Gender Differences

Researchers have shown us that both conversational and professional interaction reflect gender as well as professional styles of communication.

Conversational Speech

In conversational speech, generalized differences exist between genders. It has been reported that in comparison to women, men produce more units of speech, speak faster, interrupt more (although women are more likely than men to interrupt by asking questions), break silences more often, make more speech errors, and fill pauses more (with "ah" or "uh"). Some people have interpreted these gender differences as reflecting a tendency by men to attempt to dominate conversations. Others have expressed that men are less skilled verbally, and that some of these observed behaviors are compensatory.

In healthcare settings, it is well documented that women usually verbally disclose more information about themselves than men do. Likewise, healthcare workers, particularly physicians, tend to verbally interact more with women than with men. Women often receive more time, more explanations, and less descriptive responses from physicians than do men. This may indicate that the greater information received by women from physicians could be the result of women''s requests for information, not the amount of information volunteered by physicians.

With regard to nonverbal communication, women are better than men at decoding (judging the accuracy of) nonverbal cues, recognizing faces and expressing emotions through nonverbal means. They smile and gaze more than men and may use smiling as a mechanism for coping with social tension.

Women in general are better suited than men are to elicit information-giving behaviors. Because of their superior skill at interpreting nonverbal cues, their greater facial expressiveness, and their speech patterns, which tend to enhance the speaker''s position, women may obtain more information from physicians both by interpreting physician''s nonverbal cues more accurately and by reinforcing physicians'' speech.

In reference to gender communication, differences exist between same-gender and opposite-gender conversations. In same-gender conversations, men and women display patterns of interrupting, whereas in opposite-gender conversations, men interrupt women more frequently than the reverse. Smiling is more likely in same-gender than opposite-gender interactions, but in opposite-gender adult pairs, women smile more than men do.

Finally, opposite-gender communications have been found to be louder and more unpleasant than same-gender communications. Female-female loudness, dominance, unpleasantness, business-like tone, and anxiety were lower than in male-male or opposite gender communications.

Nonverbal gender differences are most evident when one is within one''s gender. With the opposite gender, people control their behavior so it approaches the other gender''s norms. Thus, individuals from the same gender may be more likely to deviate from their norms when they are communicating with individuals from the opposite gender; individuals may behave more stereo typically when they are communicating with members of their own gender.


World-view is the way people view the world, man and God. This is revealed in people''s religion, art, language, values and health care practices.

Every health professional should know who she is, where she comes from and where she is going. If she has a definite world-view, she will be able to be sensitive to the world-view of her patients without judging them and being respectful of who they are and what they believe.

Functional Elements

The communication process is made up of certain functional elements.

The first is the sender (communicator) and involves the person sending the message and the body parts necessary for sending the message. For instance, shaking of the head, frowning, raising an eyebrow.

The second component is the message itself, what is said and its corresponding nonverbal communication. The actual word, nonverbal body language, tone of voice, pitch of voice, loudness are all part of the message sent. This is thus the transmitting of the symbols of communication.

The third component is the receiver and this is the person at whom the message is aimed plus all the anatomic structures necessary for receiving the message. These are all the senses that can be involved.

The fourth component is when the receiver returns a response to the sender and is called feedback. This is also a way of clarifying that the message sent is the one received.

The last component is context, the place where the communication takes place. Context is dynamic and never the same, that''s why communication can never be repeated, the context will never be the exact same again, for instance time.

Since communication is a process, sending and receiving messages often take place simultaneously. A person can be sending a message while paying close attention to the receiver''s nonverbal responses.

Some basic assumptions about human communication are that it is a transactional and multidimensional process.


An assumption about human communication is that it is transactional, which means that both individuals in an interaction are affected by and affect each other. For example, as person A constructs a message for person B, A is receiving cues from B that influence how A formulates the message.

A transaction forces one to view the simultaneous interplay between the sender and receiver of a message. It features the relationships between individuals that are developed and maintained through their mutual influence on one another.

For example, the interaction could be influenced by the desires of the health professional, by their perceptions of the other person''s desires, or by a combination of these factors working together simultaneously.


Another assumption is that human communication, which is multidimensional, occurs on two levels: content dimension and relationship dimension. The content dimension refers to language, words, and information in a message; the relationship dimension defines how participants in an interaction are connected to each other. For example, consider the following hypothetical statement made by a physician to a nurse: "Please take this specimen to the laboratory." The content dimension refers to taking the specimen to the laboratory. The relationship dimension of the message refers to how the physician and nurse are affiliated: to the physician''s authority in relationship to the nurse, the physician''s attitude toward the nurse, the nurse''s attitude toward the physician, and their feelings about one another. Both content and relationship dimensions influence the development of meaning in human interaction.

Selected Models

Researchers have developed many models to assist individuals in understanding the structure of the communication process. These models can help with the underlying structure of the communication process and can illustrate how these aspects are interconnected. Five models that illustrate the complexity of human communication will be discussed. The five are the:

  1. Shannon-Weaver model
  2. SMCR model
  3. Speech Communication model
  4. Leary model
  5. Symbolic Interactionist model

Shannon-Weaver Model

The Shannon-Weaver was one of the first models of communication. In this linear model, communication is represented as a system where a source selects information that is formulated into a message. This message is transmitted by a signal through a channel to a receiver. The receiver interprets the message and sends it to a destination. Noise indicates those factors that disturb or otherwise influence messages as they are being transmitted.

A strength of this model is the uniform manner in which it attempts to describe the pathway of a communication from source to destination. However, a limitation is that it does not demonstrate the transactional relationship between the source and the receiver. Because the model is linear, it implies that the communication is one way and lacks feedback that regulates and monitors the flow of information.

The use of this model in a healthcare setting would only demonstrate the communication pathway from a physician to a nurse, or from a nurse to a patient, and vice versa. In this model, the interaction component would be missing. (Figure 1)

Figure 1
Shannon–Weaver Communication Model (1949)
Figure 1

SMCR Model

Berlo''s SMCR (Source, Message, Channel, and Receiver) model represents a communication process that occurs as a source drafts messages based on one''s communication skills, attitudes, knowledge, and sociocultural system. These messages are transmitted along channels, which can include sight, hearing, touch, smell, and taste. A receiver interprets messages based on the individual''s communication skills, attitudes, knowledge, and sociocultural system.

The strength of this model lies with how it represents the complexity of communication and treats communication as a process. The limitations are its lack of feedback and not illustrating the process function.

If this model were used in a healthcare setting, it would assist individuals in recognizing the many factors that influence a person''s communication. However, the effect of feedback would not be demonstrated in this model. Similarly, this model assists in explaining how experience and education affect professional – professional communication (i.e., the communication between a physician and a graduate nurse) but it lacks expertise in explaining how feedback influences ongoing professional – professional dialogue.

Speech Communication Model

Miller''s model represents speech communication and includes the feedback feature not found in the previous model, SMCR. The speech communication model is representative of three factors: the speaker, the receiver, and feedback. The speaker interprets (encodes) the messages based on the individual''s attitudes; the messages are translated (decoded) by a receiver based on that person''s attitudes. Then, the receiver gives positive or negative feedback to the speaker who then is able to interpret and modify subsequent messages.

This model represents the typical sequence of events in speech communication. However, in its simplicity it fails to capture the complexity of the communication process. For example, in healthcare settings this model''s simplicity may deter our full understanding of the incident of communication on site. Especially, this incident can occur where such factors as the context or the setting may significantly influence the process of communication. In contrast, this model makes it easier for individuals to understand the important transactional and feedback components that exist in the communication process between professionals.

Leary Model

This model is different from the previous models. It is a transactional and multidimensional model, which stresses relationships and the interaction aspects of interpersonal communication. It emphasizes that communication between humans is a two-person process where both individuals influence and are influenced by each other. Behavior plays an important role in this model. People adapt roles based on how they want to be perceived by other individuals.

Figure 2
Leary's Reflective Model (1955)
Figure 2

For example, if I want to be submissive, I condition the other person to be dominant toward me; conversely, if I want to be dominant, I condition the individual to be submissive toward me.

From Leary''s model every communication can be recognized as occurring along two dimensions: dominance-submission and hate-love. Both of these dimensions are capable of occurring during an interaction. When individuals interact, each message has a dominant-submissive quality and a hate-love quality. Responses are made to messages based on the perceived message from the individual.

Leary states that in human communication two rules govern the function of these dimensions. (Figure 2)

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.

This model can be directly applied to communication in the healthcare setting. The strength in the Leary model is the transactional way in which power and affiliation issues are described in human interactions. If individuals are to truly understand communication with others, the qualities that both people bring to the interaction must be recognized. Two weaknesses of the model are that it does not portray the ongoing, fluid process of human communication; and it omits other important variables that arise from the environment.

Symbolic Interactionist Model

This model has a transactional perspective and views man as a whole person (body, mind and spirit) involved in the process of communication. When involved in communication any person has certain values, beliefs and cultural background. This will definitely influence your communication, as there is no such a thing as true "objectivity". One can try and "bracket" values and beliefs, but never be completely "empty". Communication and the outcome thereof, depends on interaction between people and what that interaction means to them. It depends on the reaction of the other in the communication process and has an interpersonal feedback loop.

The symbolic interactionist view of communication includes the following concepts:

  • Communication is a dynamic process that is unique, context bound, and exists in different realities.
  • Reality is determined by the people involved in the process at a certain point and time.
  • Therefore, communication is complex.
  • Meaning of messages is not transferred or universal, it is mutually negotiated in this context and reality.
  • Realities change from day to day and events moment to moment.
  • People involved in this process will transmit the message that will, in their view, have the highest probability of success.

Communication is, at the very least, a more complicated process than we have ever thought!

Communication Techniques

Communication as an interaction takes into account the process of mutual influence in communication. This process is cyclic, where information is transmitted to a receiver, but in which the reaction of the receiver continuously alters or changes the sender''s next signal.

Thus, when two people interact, they put themselves into each other''s shoes and try and perceive the world as the other. This then helps to predict how the other will respond. In this circular process the participants take turns at being the communicator and the receiver.

It is, however, important to remember that the communicator or the sender and the receiver are people, whose feelings, intelligence and cultural backgrounds will affect the way in which communication progresses.

In a sense each person is a communicator or a receiver simultaneously. Even while you are speaking, you are simultaneously observing the other person''s behavior and reacting to it. Two or more people involved in communication, create a relationship as part of their communicating. Participants become interdependent, and their communication can be analyzed only in terms of the unique context of the event.

Understanding the basic components of communication assists us in developing more effective communication skills. Seven key elements contribute to the success or failure of individual communication. These components are the medium, message, speaker, listener, feedback, interference, and context.

The medium is associated with the carrier of the message, which may be personal communication through face-to face interaction, telephone call, or a letter.

The message in personal communication is most critical because it is influenced by culture and directness. Communication to be successful usually must be direct.

The speaker must be clear, effective, and culturally sensitive to the individual''s needs. An adequate vocabulary and clear expression are priorities for success.

The listener must devote full attention to the speaker. It is imperative to provide the speaker with feedback; a reaction to the conversation as an indication of attentiveness includes clarification of misunderstood statements.

Interference occurs when a listener fails to hear the message because of external (noise) or internal (something else on mind) interference.

The context is related to the time, place, and situation in which the conversation occurs. The effectiveness of a communication may be related to the receptiveness of and lack of interference for the participant.

Some techniques one can use for communication include:

  • effective speaking
  • effective listening
  • feedback
  • alert to nonverbal signals
  • assertiveness, and
  • handling conflict

Effective Speaking

For effective speaking the person should have something to offer to the conversation. Individuals should have familiarity with a broad range of topics and possess sensitivity to the interests of the listener. If you are highly knowledgeable about your major field, but have little knowledge of other subjects, there will be relatively few people who will find you a stimulating conversationalist. If misunderstanding is occurring, improve the exactness of your communication through vocabulary building. In communication between health professionals, the use of precise terminology is most effective in promoting a collegial environment. To ensure communicative clarity, formulate your thoughts before speaking and be cognizant of the verbal and nonverbal feedback from your listeners.

"I" Statements

"I" statements indicate to others that you believe and trust your thoughts and feelings and that you are taking responsibility for what you''re saying. Try and avoid "you" messages as they can be confrontational and judgmental. The following is an example of how to use an "I" statement instead of a "you" statement. "I become very irritated when you slam the door so hard when I''m trying to study" instead of "You irritate me, please go away".

Giving and Getting Information

In conversation with another person you can give information about yourself by utilizing the skills of active listening and empathic responses. It is also important for the other person to be able to have a chance to share personal information. This is the foundation of mutual trust, mutual respect and the chance to get to know each other.

Constructive Criticism

It is important that an assertive person is able to give constructive feedback. Some of the guidelines in giving constructive criticism are: utilizing "I" messages instead of "You" messages; be direct; matter-of-fact firm voice; describe the behavior that you are critical about and not the person; try and view the situation from the receiver''s point of view.


It is positive and helps to be persistent when you want to be heard or you want change in another person''s behavior.

Precise Words

Use direct, concise words to communicate what you think so that the other person can understand what you say.

Effective Listening

Most probably, one of the most crucial aspects of successful communication is the ability to really listen. An effective listener is as actively involved in the conversation as the speaker is, but the role involves a greater effort and more concentration than that of speaking. Since the speaker''s nonverbal communication reveals more than the actual words, the listener must be alert to posture, gestures, facial expressions, eye movement, and the tone and inflection of the speaker''s voice. If listeners misinterpret what has been spoken, major misunderstandings can be avoided if clarification is sought immediately.

Listen carefully to the other person''s point of view – is it valid or true? Is it constructive? It is important to acknowledge what is being said, even if you don''t agree. Then you can take the opportunity to state your beliefs.


Feedback is another important aspect in communication that can reinforce some behavior and extinguish others. This can also describe the effect you have on other people and can point out the importance that communication problems are the result of mutual contribution. Thus, feedback can also be an important source of information about yourself.

Initially, a response to communication (feedback) is internal. The person''s emotions, knowledge, and past experiences initiate a particular response. Some common styles of response by listeners are withdrawing, judging, analyzing, questioning, reassuring, and paraphrasing.

Withdrawing can occur when the topic of discussion creates uncomfortable feelings. It usually is interpreted as lack of concern or callousness. Judging almost immediately extinguishes open communication. Judgmental responses can be damaging to relationships, especially when someone is judged negatively. The judged person has to defend her/his opinion, belief, or behavior, placing the person in a position of rejection of or resistance to the judge.

Analyzing is similar to judging. It explains to a person why they reacted as they did. This leads to the person becoming defensive and less willing to reveal their thoughts and feelings. Questioning can either enhance or inhibit communication. Helpful questions are neither judgmental nor threatening, but allow the individual to gain insights that they previously overlooked. These questions usually encourage people to communicate rather than become defensive.

Reassurance indicates acceptance to the person. When appropriate, it includes addressing positive ways of viewing the troubling situation, but also guarding against making a judging response. Paraphrasing is the listener reiterating the speaker''s message and providing the speaker with the opportunity to correct any misconceptions. It emphasizes the listener''s attentiveness to the speaker''s words.

Alert to Nonverbal Signals

Effective communication requires that one is alert to the many nonverbal cues expressed by listeners. These include posture, gestures, facial expression, tone and inflection of words, personal dress, and personal space. It reflects the individual''s personality and culture. For example, how close to you does a person stand as you talk? In general, moving close to you 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.

Watch the person''s hands as you interact. Even though the person appears calm, nervousness is often revealed through hand activity. The classic sign of folded arms over the chest may indicate that the individual may be feeling defensive, and it is necessary for you to regress in your approach; or it can indicate that the person is cold. This action demonstrates how easily body language can be misinterpreted. The most important signs to watch for are incongruent facial expressions. Genuine emotions usually cause a quick smile that encompasses the entire face. If someone is faking an emotion, they often hold the expression too long. During interactions, nonverbal and verbal messages often conflict. Usually, the nonverbal message is the more accurate. It is easy to control our words, but more difficult to control tone of voice, facial expression, posture, and other nonverbal signals. (Figure 3)

Figure 3
  Non-Assertive Agressive Assertive
General: Very Passive. Actions only, instead of words. Looking as though you don''t mean what you say. Sarcastic, harsh. Air of "I know all" and superiority. Congruent, firm messages.
Voice: Weak, stuttering, soft, more monotone. Loud, shrill, very cold, demanding. Firm, warm, confident.
Eyes: Teary, down-casted, pleading. Narrow, cold, staring expresionless. Warm, keep appropriate eye-contact.
Stance: Stooped, leaning for support. Hands on hips, feet apart, pointing fingers. Relaxed.
Hands: Clammy, sweaty, fidgety. Pointing fingers, making fists, clenched Natural gestures at appropriate times.

The following comparison is made between non-assertive, aggressive and assertive behavior in the nonverbal skills.


What do we mean by "channels" of communication. This is the sensory organs we utilize when communicating, and the most important is hearing, touch and sight. When you are empathic towards someone, you may put your hand on their shoulder.

In organizations, channels of communication include bulletin boards, newsletters, even E-mail are used as a channel of communication.


Do you often wonder what happened to the message you sent? Did the receiver, in fact, receive your message or was there some kind of interference. Interference can mean many things, but a broad definition will be anything that distorts the message in such a way that the message that was sent, wasn''t the same message that was received.

Interference can be from a person that mumbles to such an extent that he could not be clearly understood to a blaring radio which makes it difficult to hear the response of others.

Can you think of more interferences? Can you think of ways to minimize these interferences? Remember, that some interference will always be present in human communication and that it must be seen as an obstacle that can be minimized/overcome.

Emotional Effect

Emotions include feelings, physiological changes, and a pattern of overt expression. Even people who have difficulty verbally expressing their emotions can display them through their facial expressions and body language.

One of the more difficult forms of communication for some people is sharing emotions. Before individuals can express their emotions they have to understand their feelings. In sharing emotions, it is more effective to use "I" statements rather than "you" statements.

"I" statements are expressions of personal feelings. "You" statements judge another''s behavior and place the responsibility for emotions on the other person. "You" statements place blame and can force the listener into a defensive position, while "I" statements encourage discussion.


What effect does time have on communication, if any? Time has a great influence on communication because in every message sent, time has relapsed and meanings can change. As realities in time change, new meanings are created. In every context and time change, messages will have a new meaning and a new story will be told. That is why, in the postmodern therapies, we work in a reality that can have a different meaning every day in a different context. What a person communicates today, can have a different meaning tomorrow, because time has relapsed and the context will be different ("a new and different story and meaning").


Assertion or assertive behavior means to stand up for your own rights without violating the rights of others or having negative feelings in the process. 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. People who are assertive express their points while at the same time respecting the rights of others. Verbally, assertive communicators speak clearly, calmly, and directly to those whom they are addressing. Nonverbally, they maintain direct eye contact, and stand or sit with an erect posture that indicates control and confidence. When becoming more assertive, you will also become more sensitive toward others and situations. It also becomes easier to convey greater empathy and sensitivity, or to effect change in other''s behavior. What are the advantages of being assertive?

  • You are able to communicate your needs and feelings honestly and directly.
  • You are more relaxed.
  • You are more self-confident and self-assured.
  • You will try and compromise where you can – a "win-win" situation.
  • You will accept responsibility.
  • You will be able to promote your own self-worth and self-control.
  • It reduces negative emotions of anxiety, fear and stress.
  • You will be able to accept yourself better with regards to feelings, needs, wishes and values.
  • You will be seen by others as compromising and adult.
  • You will be able to maintain positive inter-personal relationships.
  • You will be able to manage conflict more effectively.

Handling Conflict

Conflict occurs in every relationship. It is generally any situation where the wants, intentions, and needs of one individual are incompatible with another person''s wants, intentions or needs. Usually, conflict is handled in one of five ways: reflecting differing degrees of aggressive, assertive, or passive, and cooperative or competitive behavior. Prolonged conflict can destroy relationships unless a type of conflict resolution is instituted. Conflict resolution is a concerted effort by all individuals to resolve in a constructive manner the points of contention.

Five steps that can be used to resolve conflict are:

  1. All parties should agree to work on the problem and clarify the necessity for participating in the process.
  2. Simultaneously, the problem should be identified by all.
  3. Each person should clearly describe and define his or her feelings about the issue.
  4. Solutions to the problem should be offered by all.
  5. From all suggestions, a tentative solution should be proposed, with a second meeting time scheduled to discuss the problem and evaluate progress toward the solution.

Personal Power

"There is absolute power in our words… They are so easy to utter, often tumbling out without much reason or forethought." James Dobson, PhD.

The Power of Words

Those who hurl criticism or hostility at others may not even mean or believe what they have said. Their comments may reflect momentary jealousy, resentment, depression, fatigue or revenge. Regardless of the intent, harsh words sting like killer bees. Almost all of us have lived through moments when a parent, teacher, friend, colleague, a husband or a wife said something that cut to the quick. That hurt is now sealed forever in the memory bank. That is an amazing property of the spoken word. We tend to forget the day-to-day experiences, but a particular painful comment may be remembered for decades. By contrast, the individual who did the damage may have no memory of the incident a few days later.

Accepting Criticism

We have three choices when dealing with criticism:

  1. say nothing
  2. attack the person verbally who is criticizing us
  3. express our feelings and opinions directly and honestly with respect to yourself and others. By saying things assertively we encourage others to be honest and open with us.

Types of Communication

Non-verbal Communication

Non-verbal communication entails all communication that is not using language and usually enhances the verbal/spoken language.

Non-verbal cues also help us judge the reliability of the verbal messages, especially when there is inconsistency between verbal and non-verbal components.

Non-verbal channels or means of communication are wide in variety and include the following: facial expressions; hand gestures; pitch, rate and volume of voice; use of personal and social space; touch; the use of cultural artifacts and eye contact.

Because two-thirds of any communication is considered to be non-verbal, it is critical that one understand, observe and respond to the non-verbal cues of your clients.

Body Movement

The study of body movement and positions as a means of communication is called kinesics. Facial expressions, gestures, and eye movements (eye contact) are some of the most important body movements.

Facial expressions generally communicate emotions and can enhance communication for instance if you greet someone and you smile warmly, the immediately feel more comfortable in your presence.

Body movements and gestures provide clues about people and how they feel toward others. Hand gestures, for instance, can indicate impatience, anxiety and indifference. Body position can give cues about how open someone is towards others, or how attracted or interested. When a person is talking to you and they fold their arms and turn their body away from you, they communicate that they are not open or maybe that they are quite defensive. (Defensive about sharing confidential information). This can give the nurse a cue that this specific therapeutic relationship, she must be aware of "too quick too deep".

Eye contact is very important in initiating, keep up, and terminating communication. Raised eyebrows may indicate interest, while frowning eyes indicate disagreement. Narrowed eyes convey suspicion and minimal eye contact may be evidence of shyness, low self-esteem or boredom. It is important, in a therapeutic relationship to be able to maintain adequate eye-contact in order to convey caring, attention and warmth. 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, not listening or not interested.


Paralanguage refers to something in addition to the verbal/spoken language. It can be the tone or pitch of the voice and noises accompanying spoken language, such as sobbing, grunting, laughing, sighing - noises without linguistic structure. This can also enhance what is actually been said in words or it can indicate incongruences. An example of this may be, "I feel fine today, I feel happy" in a shaky, soft tone of voice or bursting out in tears.


Space and boundaries are often culturally determined and can vary according to what is comfortable for each individual. It is important, however, to be sensitive toward the needs of your client in terms of personal space and not decrease distance when the client needs more space. For example: When the client moves his/her chair further away from you, he is indicating that he/she needs more space. It is wise then not to move closer but be sensitive toward this need. It is essential to respect clients'' boundaries by how closely you sit, how much space you give them when walking together, and getting permission when entering the room they are in.


A realization of the importance of touch and an understanding that touching is not necessarily a sexual behavior may make this channel of communication available to more people. It is extremely important to be sensitive toward the client in order to avoid misunderstandings. It may be a better idea to ask clients if you may touch their hands, than to make assumptions as to how comfortable they are with touch? Before touching, ask yourself what the purpose of the touch is, is it appropriate and what effect will it have on your client.

If you touch the client''s arm and they pull away, it can be on indication of being uncomfortable. It will be wiser to discontinue any form of touch.

Cultural Artifacts

Remember that people differ and come from different cultural backgrounds. For example, in some cultures, minimal eye contact does not indicate low self-esteem or shyness but respectfulness toward the other. Artifacts are items that may function as non-verbal stimuli: Jewelry, wigs, beards, hats, clothes, cosmetics and so forth. Think about what may be communicated by purple dyed hair and expensive jewelry and clothes or a military uniform?

Verbal Communication

Verbal communication occurs through the medium of words, spoken or written, and the way the helper reacts to what they hear; resulting in a meaningful reaction to what they observe and hear.

Verbal communication can convey factual information accurately, but is a less effective way of communication feelings or nuances of meaning, and it represents only a small segment of the total spectrum of human communication.

The following ingredients are crucial in the achievement of facilitative communication and has been discussed earlier, namely responding with empathy, respect, genuineness, immediacy and warmth.

A limitation of verbal communication is the fact that it has both denotative and connotative meanings. The denotative meaning of the word is the concrete representation of it. Connotative meaning, in contrast, is it''s implied or suggested meaning. Thus, the word "car''s" denotative meaning will be a metal structure with four wheels and an engine. The connotative meaning can then be in the person''s own frame of reference; i.e. a Rolls Royce, Mercedes, Land Rover or perhaps a fire-engine truck.

The nurse who wants to communicate effectively must be aware of the limitations and possible problems inherent with verbal language. The nurse should then strive to overcome these obstacles by checking interpretation and incorporating information from the non-verbal level as well.

It is important, however, to remember that the verbal and non-verbal elements of human communication are inextricably linked and interrelated. This can be demonstrated by the following examples:

  • A non-verbal cue may enhance what is said verbally for example the mother extends both hands to indicate the length and size of her "huge" newborn son.
  • Non-verbal behavior contradicts verbal expressions and this can be valuable to note this in a therapeutic relationship. Consider the client saying "I feel wonderful today", but the tone of her voice as well as her facial expression, indicates the opposite.

Sometimes non-verbal cues are used instead of words. When you see someone you know at a show, you will wave to say "hello" or just mouth the word "hello" and smile


Different types of attitudes will affect the interaction of communication and how well the information is transferred between the speaker and receiver.


Empathy is a crucial element in facilitative communication and it is an ability (which you can learn) to appreciate another person''s thoughts and feelings from his point of view but never losing your own identity!

It is the capacity to comprehend another''s experiences without actually having encountered the same/similar conditions within the context of your own life. It is the ability to feel "with" and "for" the patient. It is important, however, to note that empathy contains no elements of condolence, agreement or pity.

Primary empathy is concerned with responding to the patient in a way that shows him that the professional has listened and understood his point of view. The verbal response should only communicate the understanding and should not add information or involve personal details arising from the professional.

Advanced empathy is the communication and understanding of the client by the professional that goes beyond the words used to the implications or latent meaning of what has been said. It tries to precipitate implied feelings or thoughts.

In a helping relationship, empathy adds a dimension of real understanding between the participants. The central focus is "with" and "in" the client''s world. It involves accurate perception of the client''s world, communication of your understanding to the client, and then reacting in a helpful way… it is probably one of the most important aspects of the helping relationship. Through the use of empathy, clients can experience and understand themselves more fully and explore their problems and work through them in their continuous quest for health (body, mind and spirit). The basic formula for primary level empathy is:

"You feel…" indicate the feeling (one of the *four primary emotions) and the intensity of emotion/feelings *anger, fear, happiness, sadness.

"…because..." here indicate the experience and/or behavior that led to this feeling.

Example: "You feel angry and let down because she never came to your dinner party after she actually accepted the invitation".


If the healthcare professional can convey respect in relationships with clients it contributes to mutual respect and trust. Convey respect by the following:

  • Take time and energy to really listen.
  • Take care not to invalidate client''s experience of their world by moralizing, i.e. "don''t worry, time heals all wounds, so don''t worry".
  • Giving clients as much privacy as possible during any form of treatment.
  • Minimizing experiences that humiliate patients and strip them of own sense of identity – always help them to stay in control of their own lives as long as possible.
  • Being honest with clients about treatments, privileges, length of stay and so forth.
  • Being on time for appointments.
  • Treating your client''s room and belongings as his private property.

Respect is a point of view that states: "You are an important and unique human being. You have worth. You matter, you have dignity ... and I will treat you in a respectful, polite manner."


Warmth is closely linked with empathy and respect and is seldom communicated as an independent dimension. The professional should be aware of and accept the clients'' right to maintain distance. Initially high levels of warmth can be counter productive for clients who have received little warmth from others in their lives and have been taken advantage of by others.

Warmth is the ability to help the client feel cared for and comfortable. It shows acceptance of a client as a unique, whole individual (body, mind and spirit).

Warmth can be conveyed by eye contact, an interested, caring tone of voice, a touch on the arm, or a smile, or simply leaning forward and establishing eye contact.


Professionals are genuine when their verbal and nonverbal behavior shows congruency. Congruency is a necessary ingredient to building trust. Congruency is consistency of expression as related to thoughts, feelings, and actions. Congruency is consistency "sameness" between words and actions. It is consistency in what you believe, what you say, and what you live.

Unconditional Acceptance

Unconditional acceptance involves the ability to accept another person as a whole (body, mind and spirit), unique, God created human being, but not necessarily accept their behavior.

Acceptance is receptivity without judgment. It includes positive recognition and respect for a person. Acceptance should be an unconditional state of neutrality that acknowledges a person''s right to uniqueness and to be different but it does not imply agreement, approval, or tolerance for behaviors that are unacceptable.


Immediacy refers to the focusing of the interaction on the present situation in the relationship. Successful use of immediacy is closely related to the level of empathy that has been achieved.

Immediacy means responding to what is happening in the "here-and-now". Because this dimension may involve the feelings of the client toward the professional, it can be one of the most difficult to achieve.


Genuineness refers to the ability to be able to be real and honest with yourself and others. To be effective, genuineness must be timed properly and based on a solid, trusting relationship. The professional who is genuine, is more likely to deal with and eventually help the client resolve real problems, rather than just those that are safe or socially acceptable. Genuine people are at home with themselves and therefore can comfortably be themselves in all their interaction.

There are different techniques that contribute to facilitate effective communication. These will now be discussed.

Therapeutic Techniques

In therapeutic communication questions are asked in such a way as to create an atmosphere conducive to dialogue, openness, sharing and curiosity. Through this type of questioning, clients are actively drawn into dialogue and together they can co-construct new meanings (stories).


This is a way of gathering data and obtaining information on a particular subject or feelings, for example:

Patient: "I feel terrible today ..."

Professional: "Tell me what happened that you feel so sad..."

Professional: "Tell me more..."

Reflection (Content and Feelings)

Reflection is repeating the clients'' verbal or non-verbal message for the client''s own benefit. It conveys to the sender his expressed thoughts and related feelings.

Content is also known as validation. By this the professional conveys that she has heard what was said and understands the content. This has a more cognitive focus and is "safer" for the patient. It is quite useful in the beginning of a relationship when you are getting to know one another.

Feelings consists of responses to the client and let''s them know that the professional is aware of what he/she is feeling. Reflection of feelings signifies understanding, empathy, interest and respect for the patient. It is one of the most useful techniques in therapeutic communication and increases the level of trust and involvement. Just beware of becoming stereotyped, beginning every reflection in the same monotonous way, such as "You feel…"

Imparting Information

This technique is helpful in supplying additional factual information. Therefore further clarification is encouraged based on new or additional input. To impart information is also responding to direct questions with relevant and needed facts.

Client: "What time is my appointment with the doctor?"

Professional: "Let me check in the book. Your appointment is at three o''clock".

Client: "Where could I possibly go for support?"

Professional: "See me after the session and I will give you phone numbers of various support organizations".


Clarifying is an attempt to understand the basic nature of a clients'' statement. Asking them to give an example to clarify what they mean will help you better understand the intended message.

Client: "Sometimes I wonder if I really know what is going on. I feel anxious… and sometimes not".

Professional: "I''m quite confused about this whole issue… let''s go over that again…"

Client: "Are they really telling me everything?… I really don''t know!"

Professional: "I hear something I do not quite understand… what do you mean…?"

Clarifying what is really been said is an attempt to find the meaning of the communicated message to establish a mutual understanding.


The professional assimilates and restates in similar words what the client has said. It gives the opportunity to test understanding of what a client is attempting to communicate. It also indicates that the professional is interested and listening.

Client: "My mother keeps on yelling at me as if I''m a child!"

Professional: "In other words, you''re tired of being treated like a child".

Checking Perceptions Validating

This technique gives clients an opportunity to validate or correct your understanding of what is being communicated. Professionals also use perception checks to make sure they really know what their clients are communicating… this conveys a message of "I really care… I really want to understand". Therefore, this technique will decrease confusion. It is also a way to explore incongruent communication.

Professional: "You''re smiling, but I see that you are clenching your fists…"

Professional: "You say you really care about her, but every time you talk about her, you clench your fists. I wonder how you really feel?"

Professional: "It sounds as though you are talking about sad feelings…"

Giving Feedback

It is important for clients to know/become aware of how their behavior affects others and how others perceive their actions. Responding with feedback can be therapeutic self-disclosure. It allows the nurse to offer clients constructive information to make them aware of their effect on others for instance, "Sometimes when you turn your head away from me, I think you''re angry."


Constructive confrontation can lead to productive change. Confronting is a deliberate invitation to examine some aspect of personal behavior that indicates a discrepancy between what the person says and what the person does. Confrontation is a crucial technique in facilitation, but should be used with care, as not to be harmful to your client. The following skills should be remembered when using confrontation.

  • Use personal statements "I", "me".
  • Use relationship statements expressing what the professional feels in the here-and-now.
  • Confrontation must always be constructive.
  • Describe the behavior, do not get personal.
  • Use responses aimed at understanding, such as paraphrasing and perception checking.


This technique allows clients to stay with specifics and analyze problems without jumping from topic to topic. By focusing on feelings, thoughts and behaviors, you pave the way for increased understanding, and most important of all, responsibility


Summarizing is highlighting the main ideas expressed by the client. Summarizing is useful in focusing the clients'' thinking. The goal is to help clients explore significant content and emotional themes. It can be used to conclude the specific interaction, or to begin a next interaction by reviewing a previous one. This brings the discussion of a particular subject to a conclusion.

Silence/Minimal Verbal Response

Silence can be of great value, but some professionals feel uncomfortable utilizing this technique at first. It can be an effective facilitative technique when it encourages the client to communicate freely; when it gives time to collect his/her thoughts; or when it allows the client time to consider alternatives. The professional that is also uncomfortable with silence or uses silence because of a lack of knowledge and skills to communicate effectively, must work through this before actively getting involved with clients. Minimal responses are verbal and nonverbal reinforcers that include active listening and interest in what clients are saying.

Now let''s investigate some of the most often used sets of questions.

Open-Ended Questions

Open-ended questions are a direct form of communicating with clients. These questions are especially useful when you are seeking specific information, i.e. when you are assessing the client. When questioning, it is more effective to use open-ended questions than close-ended questions. An open-ended question focuses the topic, but allows freedom of response.

Professional: "How did you feel when your mother said that to you?"

Professional: "What do you do when… happens?"

Closed-Ended Questions

Closed-ended questions limits the clients'' choice of responses to "yes" or "no" and can also be seen as an obstacle in facilitative communication.

Professional: "Were you angry when your mother said that?"

Professional: "Did you come here because you were forced to?"

Closed-ended questions, however, can be utilized successfully when communicating with clients who are experiencing a high level of anxiety or disorganized thinking, for example "are you still hearing voices?"

Just remember not to use too many closed-ended questions in succession. If several are asked, the interaction takes place in an atmosphere of cross examination, and the client may become reluctant to continue.

Linear Questions

The professional can utilize these types of questions to orientate herself to the client''s "world" based on linear assumptions about what the clients'' "story" is. The professional conveys interest and curiosity by asking "Who", "Where", "When" and "Why" questions. These questions stimulate answers and more questions arise.

Circular Questions

Circular questions are more exploratory type questions and the professional is making a new discovery of the client''s world. Remember that in this philosophy, things are "connected". Whatever your clients tell you, is connected to many other things. These questions bring forth a "pattern that connects".

Strategic Questions

These questions are used with a specific goal in mind. The main goal is to "correct" behavior that may be "unhealthy." These questions can be useful in challenging problematic thinking patterns and behavior, without being too directive or dictating. This can make the client look at their world in a different way. Just beware, too much directness in this mode of inquiry may risk a disruption on the therapeutic alliance.

Reflective Questions

These types of questions are used to influence the client in a more indirect way, and are based on more circular assumptions to motivate the client in using their own problem solving resources. These questions also tend to open space for clients to gain new options and perspectives. These questions are reflective because they are utilized to help them reflect on the implications of their current perceptions and actions and to consider new options.

Obstacles in Communication

Health professionals who do not listen to what their clients are saying: avoid underlying feelings; remain on a more cognitive than affective level; who tell their clients what to do, or tend to moralize and be judgmental, are communicating on a ineffective level. Let''s look at the following ineffective communication techniques or obstacles.

Stereotypical Comments

These comments are non-therapeutic and include cliches'' and other trite expressions that are virtually meaningless. Problems can also occur when clients have concrete thinking, because many stereotypical comments rely on abstract understanding. These comments are often culture-specific and therefore will make no sense to people with different cultural backgrounds. Example: Professional: "How are you today?" Client: "Bad today… I wish I were dead…" Professional: "Every dark cloud has a silver lining." "Everybody has had bad days."

Changing the Topic

Sometimes the professional feels uncomfortable with a topic and doesn''t really know how to handle it, she then changes the topic to one that is not relevant to the client at that particular time. Clients may feel that what they are saying is not important. This puts the professional in charge of what is being discussed and the client will feel "I''m not being listened to."

Belittling Expressed Feelings

When the professional minimizes the feelings that the client expresses, it gives the message that they are being ignored and that their problems are of little/no significance.

Failure to Listen

Failure to really listen what the client is saying, can be most devastating to the development of trust in the therapeutic relationship. Failure to listen gives the client a message of "I''m bored", "You''re not of value", and so forth. The professional must be constantly aware of placing the needs of the client above their own.


This occurs when the professional fails to respect the client''s decision to be private (at that point and time) about feelings and thoughts. Prying is another manifestation of this and can occur when the professional attempts to uncover material irrelevant to the client''s main and important message, which he is not ready to reveal. Prying can be destructive to the therapeutic relationship as the client feels he cannot trust the nurse. The only real purpose prying has is to satisfy the need for control and power and most probably, gratification of their own needs.


Parroting differs from paraphrasing where you use similar words to give back to the client. Parroting is the repetition of the client'' words and phrases in an attempt to reflect or paraphrase – parroting is the extreme of these techniques, and non-therapeutic. Clients also do not progress in understanding and communication will come to an end. Parroting is then in actual fact telling the client: "I''m not listening to you ..."

False Reassurance

These statements often reassure the professional more than the client, especially if the professional is uncertain of how to manage the situation. Reassurance negates fears and feelings of clients and acts as if you know better than they do.

Advice Giving

This is not giving factual information where the client can use it and make a decision.

Advice giving takes away the client''s power to make decisions and gives them an inferior status. Telling the client what to do, results in the client feeling alone and powerless.

Being Judgmental/Moralizing

These statements actually tell the client that they should do as you do, or think. The statements are directive and the professional is using approving or disapproving statements to promote more dependency than independency in the relationship. These type of statements negate the self-worth of the client. The message given is that of "You need me, without me you cannot help yourself."

Imposing Values

This technique demands that clients'' share your values and prejudices. This is moralizing and the professional often doesn''t try and understand the values of the client.

Making Assumptions

Another obstacle is the making of assumptions based on own frame of reference. To avoid making assumptions about what is said, the professional must seek clarification on the communicated message. Everything that is communicated has a particular significance for each individual in a particular setting at a certain point in time.

Double/Multiple Questions

These are definite obstacles in communication, as they tend to confuse clients. They don''t know which question to answer first and really feel as though they are being cross-examined.


Disagreeing at any point in time denies your client the right to think and feel as they do and to express it. They feel as though they are only allowed to verbalize what will be acceptable to the professional and this will provide no opportunity for client self-growth.


By defending, the client is prevented to express opinions and feelings. Often the professional can feel threatened by the client''s comments. Defending statements deliver the message "you do not have the right to complain or express an opinion."

Absence of Channels

Sometimes professional-client interactions demand special skills on the part of the professional. There may be a lack of common language, the patient may be apathetic, sensory impaired or non-communicative. Although interpreters can be utilized to overcome this barrier, the importance of non-verbal communication is highlighted by this barrier. Data-collection is still severely limited by the lack of a common language.

Professional-Professional Relationships

The spirit of collegiality among health care professionals is necessary for the delivery of quality healthcare. Improvements have been occurring, but areas of contention and misunderstanding still exist. Three problem areas that have an impact on professional-professional relationships are:

  1. role stress
  2. a lack of inter-professional understanding.
  3. autonomy struggles.

It is important to address these conflicts as they affect the quality of patient care.

Role Stress

The daily task of facing ill, suffering people is not easy. As part of this role, professionals are often faced with explaining life-threatening diagnoses to patients, and must assist patients in maintaining their courage to live through another day. The very nature of healthcare contributes to the job stress experienced by individuals in the healthcare field.

Role stress is due only in part to the nature of the work. Another major source of work stress and strain is related to problems in carrying out professional roles. Role conflict and role overload are two types of role stress that can lead to problems in professional-professional relationships.

The person experiencing role conflict is socialized to fit one role, and yet is expected to fulfill a different role in the work setting. "Reality shock" describes the stress of new graduates upon discovering the gap between their education and their job. Graduates are not prepared in school with the skills and abilities to face the many stresses related to hospital employment. They learn that their ideals and aspirations are seldom the same as the values that receive praise on the job. Role conflict occurs as they experience the discrepancy between these two different value systems.

Role overload is a second factor that affects the stress of professionals. A recent study which examined work stress and job morale found that workload and scheduling stressors had a strong negative effect on staff morale and the ability to carry out their jobs. Emergencies frequently occur and we are required to accept more responsibility than can reasonably be manage within a given period of time. In addition, professionals are often expected to wear many hats and to negotiate with numerous departments. Interpersonal conflicts emerge between professionals as they struggle to cope with role overload.

Lack of Inter-Professional Understanding

Another factor that influences professional-professional relationships is a lack of inter-professional understanding. 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.

A study was conducted investigating the perceptions of nursing and medical students in regard to each other''s roles. The two groups differed significantly in their understanding of one another''s roles. In general, nursing students were clearer about the roles of medical students. The researchers found that the greater the gap in the students'' understanding of one another''s roles, the more negative they were toward collaborative decision-making.

Another factor that contributes to a lack of understanding is the lack of communication on a regular basis. One observer noted over a three-month period that physicians came to the unit and left without ever interacting with the nursing staff. If professionals don''t communicate, how can patients receive quality care and services?

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 shared with nurses. This shift in roles can cause concern in the professions in determining who has the expertise to accomplish these tasks. When roles overlap, one professional might perceive that the other person is trying to take over his or her power and responsibilities. This action can result in unproductive competition.

Role of Collaboration

Collaboration is the most preferred of the conflict resolution styles. It requires both cooperation and assertiveness, and involves fully recognizing others'' concerns while not sacrificing or suppressing one''s own. Collaboration requires energy and hard work. To resolve incompatible differences through collaboration, individuals need to take enough time to explore their differences, to identify areas of agreement, and to select solutions that are mutually satisfying. Collaboration may be difficult for professionals until they spend more time together in face-to-face interaction; and until they acquire a better understanding of the kinds of problems the other group faces.

Collaboration consists of sharing in planning, making decisions, solving problems, setting goals, assuming responsibilities, working together cooperatively, and communicating openly. Collaboration requires sharing control in an effort to obtain innovative solutions that are mutually acceptable. Usually with collaboration, the results are positive because both sides win: communication is satisfying, relationships are strengthened, and negotiated solutions are frequently more cost effective.

Collaborative Strategies

Strategies to promote collaboration include:

  • utilization of basic communication techniques.
  • recognition of professional-professional components.
  • changes of perspectives.
  • team development.

Utilization of Basic Communication Techniques

Both parties should recognize the importance of the basic communication techniques in conversations. Being an attentive listener and paraphrasing the speaker''s comments are among the techniques discussed earlier that the listener can use to promote communication.

Recognition of Professional Professional-Components

Professional communication can exhibit conflicts related to personal or patient interaction. The balance of power can interfere with the solution as a result of knowledge and autonomy. Both can perceive the expanded role as beneficial to their professions.

Changes of Perspectives

Generally in a professional environment, there are reduced communication skills in reference to patient care. The individuals should make an effort to understand the other discipline''s point of view.

Team Development

A multidisciplinary team approach is an option for improved communication and quality of care for patients. Physicians, nurses, social workers, respiratory therapists and other team members work together in the interest of the patient. The advantages of the multi-professional team are better service, easier workload management, and collegial support.

There are indications that the old hierarchical ways of communicating are changing. Physicians are increasingly depending on nurses'' expertise and skill in critical care settings and emergency departments, as well as in community settings, residential care settings, and home care services. In this time of service restrictions, it is most important for healthcare professionals to provide patients with the best possible care. The quality of care can only be enhanced through communication and good decision-making.


Communication is not an "optional extra", but a crucial element in healthcare as good/effective communication is central to professional care. Many will say that "nothing is new, we all know how to communicate", which is actually not true. Therapeutic communication is a "plan" to influence the client in a certain way. It is goal-directed and a deliberate action that is directed by scientific knowledge where the client is the central focus to the interaction. In research done recently, it was found that on a post-basic level verbalized that they did not need "yet another" interpersonal skills course, as they all "know how to communicate effectively." When actually tested, they responded to their clients in an nontherapeutic manner by moralizing, dictating, being judgmental, giving advice, using own frame of reference and giving false reassurance!

This actually highlights the importance of knowledge and skills in becoming a facilitative communicator in the professional-client relationship. If the professional does not acquire the necessary knowledge or skills to overcome all the above-mentioned obstacles in facilitative communication, they cannot be an effective communicator. t

Suggested Reading

Boykins AD. Core communication competencies in patient- centered care. ABNF J, Spring 2014, 25(2) p40-5

Clayton MF, Reblin M, Carlisle M, et al. Communication behaviors and patient

and caregiver emotional concerns: a description of home hospice communication. Oncol Nurs Forum, May 2014, 41(3) p311-21

Diedrick LA, Schaffer MA, Sandau KE, A practical communication strategy to improve implementation of evidence-based practice. J Nurs Adm, Nov 2011, 41(11) p459-65

Eberhardt S. Improve handoff communication with SBAR. Nursing, Nov 2014, 44(11) p17-20

Gregory S, Tan D, Tilrico M, et al. Bedside shift reports: what does the evidence say? J Nurs Adm, Oct 2014, 44(10) p541-5

Haynes J, Strickler J. Team STEPPS makes strides for better communication.Nursing, Jan 2014, 44(1) p62-3

Hodges AL, McGuinness T. Improving communication in distance-accessible advanced practice nursing courses via instructor presence. J Nurs Educ, Aug 2014, 53(8) p479-82

Laskowski-Jones L. Communication: the good, the bad, and the ugly. Nursing, Jun 2014, 44(6) p6

Puppe J, Neal AR. Enhancing communication in clinical nursing education.Nursing, Oct 2014, 44(10) p1-5

Webster D. Promoting therapeutic communication and patient-centered care using standardized patients. J Nurs Educ, Nov 2013, 52(11) p645-8

Additional Readings Available upon Request

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