1. Miller, Lisa A. CNM, JD

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The single biggest problem in communication is the illusion that it has taken place. - George Bernard Shaw


The three hardest tasks in the world are neither physical feats nor intellectual achievements, but moral acts: to return love for hate, to include the excluded, and to say, "I was wrong. - Sydney J. Harris


As an educator, I am obsessed with communication. If I am unable to successfully communicate concepts and principles, I will not be an effective teacher, regardless of my knowledge base. Invariably, clinicians who attend my classes ask for advice on communication, especially in clinical situations in which viewpoints between clinicians conflict regarding fetal monitor tracings, oxytocin management, or issues related to labor support or labor management. I must admit that I am frequently at a loss to provide helpful answers or suggestions, not because I am uneducated in the science of communication (yes, it is a science, as in social science) but because there are so many variables that need to be considered before I can even begin to formulate an answer that the participant may find useful. Nursing experience, hospital culture, variations in practice, geographical differences, gender issues, and many other factors may all play a role in communication. But I believe that there are some universal principles that each of us can adopt, and given that this issue is devoted to collaboration and innovation, this column will provide 3 principles for every clinician to consider on the subject of inter- and intradisciplinary communication. Readers may bristle at some of my ideas, but that is why this is an editorial column, essentially an opinion piece. Most of my suggestions are really quite simple and easily accomplished once the initial shock wears off. And at the end of the column, I'll provide a list of some suggested reading for those of you who are inclined to follow-up.


Communication Principle #1: It's not you against them, it's you against you. In other words, outside of dealing with someone who has an actual personality disorder or mental illness, most of your problems with communication are actually just that-your problems. The most common question I get is "How can I get the ----- (fill in the blank here-nurse, midwife, doctor, resident, patient) to ------ (understand, do something, stop doing something) that I ------ (don't like, think is wrong, am afraid will cause a problem)." This question is often followed by complaints about the failure of the other person to listen, the ignorance of the other person, the lack of respect the other person has for the one asking the question, or some variation on that theme. This tells me not only that the person seeking my advice is frustrated but also that the person seeking my advice may not be taking a great deal of responsibility for learning how to communicate or perhaps has not done much study or reading on the subject of communication. So here are my suggestions for less frustration and improved communication-instead of placing blame on the other party, accept responsibility for the communication process by looking at your own behavior and communication techniques when you find it difficult to reach someone or when you get push-back on an issue, read a book or attend a webinar on communication, become aware of the inherent differences in communication styles and perspectives of healthcare clinicians by reviewing the literature (see the reading list at the end of the column), and, finally, accept the fact that no matter how great your skills as a communicator, you cannot always get the other person to see your point.


Communication Principle #2: Don't take it personally. This perhaps seems contrary to the gist of principle number 1, in which I just asked you to take personal responsibility. However, it is actually complementary as taking personal responsibility is very different than taking it personally. You will be so much happier if you can relieve yourself of the burden of taking every disagreement, conflict, and difference of opinion as a personal attack on you as an individual. Unless the persons you are communicating with actually say something to make it clear that they are attacking you, don't assume that the fact that they have a different viewpoint or don't agree with you is meant as a personal affront. I work with a nationally renowned perinatologist, and we do not always agree on every issue, but when we disagree, it never affects our personal relationship or our respect for each other. Learning to respectfully disagree with your colleagues and to engage in dialogue that is rational and courteous is one of the most important things you can do to foster a saner, happier you!


Communication Principle #3: Know what you are talking about before you start talking. You have got to be very familiar with a subject in order to have a good discussion when questions or conflicts arise. Nothing can escalate a situation into an argument faster than the terse response "Sorry, the rules (or protocols) don't allow it" with no further explanation or clarification. Even worse is the overused opener "I'm uncomfortable with -----." Unless you can articulate not only what you are uncomfortable with but also why it makes you uncomfortable, and what you suggest as an alternative, you are not likely to find a sympathetic ear. So, if you want to discuss fetal heart rate monitoring, you've got to know not only the NICHD definitions but also the physiology and some type of approach to interpretation and management. Talking about uterine activity? Then know the differences between normal uterine activity in first versus second stage, the dosage regimens of oxytocin, and be able to engage in a discussion of evaluation of uterine activity that goes beyond the summary term "tachysystole." Yes, I know that many of you have to participate in discussions with clinicians who may not be well versed in current terminology or physiological approaches and that it is frustrating but all the more reason you need to be able to cite evidence and support your viewpoint. A lawyer would not enter a courtroom unprepared; you shouldn't enter the hospital unprepared. And while I fully support the call for hospitals to provide and pay for continuing education as part of professional staff development, the fact that a hospital can't or won't assist you in ongoing professional education is no excuse; there are plenty of inexpensive or even free resources available (try Google, search PubMed, or join the Perinatal ListServ).


That's it, just 3 core principles that you can adopt to improve your chances of success with communication. Of course, the details and nuances of communication are much more complex that can be addressed in an editorial, but I think you will find that embracing the concepts I have outlined here will not only improve your communications with colleagues but also reduce your frustration related to communication. I encourage you to take advantage of the resources listed below and to share any personal communication successes (or challenges) with me via e-mail, at


-Lisa A. Miller, CNM, JD




Perinatal Risk Management and Education Services


Portland, Oregon


Suggested Readings


1. Edmonds JK, Jones EJ. Intrapartum nurses' perceived influence on delivery mode decisions and outcomes. J Obstet Gynecol Neonatal Nurs. 2013;42(1):3-11.


2. Lyndon A, Zlatnik MG, Wachter RM. Effective physician-nurse communication: a patient safety essential for labor and delivery. Am J Obstet Gynecol. 2011;205(2):91-96.


3. Patterson K, Grenny J, Ron McMillan R, Al Switzler A. Crucial Conversations Tools for Talking When Stakes Are High. 2nd ed. New York, NY: McGraw-Hill; 2012.


4. Rosenthal L. Enhancing communication between night shift RNs and hospitalists: an opportunity for performance improvement. J Nurs Adm. 2013;43(2):59-61.


5. Seago JA. Professional communication. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality (US); 2008. Accessed February 21, 2013.