Often taken for granted, communication occurs with every human interaction. We communicate in the grocery store, on the phone, in class, at work, or simply when sitting next to another person. In the clinical setting, communication can strengthen relationships with coworkers and patients. Although some people seem to be naturally strong communicators, communication is a skill that can be learned and improved.
Nurses spend a significant amount of time providing direct patient care, and communication is key to positive outcomes. However, a study conducted by Fite and colleagues showed that 33.9% of nurses lack therapeutic communication skills.1 To be prepared to effectively communicate in the clinical setting, nursing students can work toward becoming skilled communicators during nursing school. This article will help nursing students achieve this goal by discussing the basics of communication, including barriers to and facilitators of communicating effectively.
COMMUNICATION BASICS
The main elements of communication are the sender, receiver, and message.2,3 Additional elements are feedback, the channel, and interpersonal variables.3 The person who delivers the message is called the sender and the person the message is sent to is called the receiver. The message is the information being sent from the sender to the receiver. It's important to note that the sender and receiver will switch roles throughout the process. A good message is clear, organized, and understandable.3 Feedback is the reply or response to the message. The channel is the way that the message is sent and received, including visual, auditory, and tactile senses.3 Interpersonal variables include a variety of things, such as education level and socioeconomic status. These interpersonal variables should be considered by the sender before sending the message to enhance communication (see Consider this).
Communication in the clinical setting can't be discussed without covering the topic of therapeutic communication--the exchange of information between the nurse and patient. Therapeutic communication can be used to enhance a patient's physical, emotional, and mental well-being. The idea of therapeutic communication first emerged in the late 1700s to early 1800s (see Therapeutic communication techniques).4 In the late 1800s, Florence Nightingale spoke about the importance of communication between the nurse and patient.4
Communication can be either verbal or nonverbal. Verbal communication doesn't only include spoken word, but also written words. Making up approximately 70% of messages sent, nonverbal communication includes facial expressions, eye contact, gestures, and posture.2 This is important to understand because many people don't think about the fact that communication happens even when we aren't speaking. Facial expressions, gestures, and posture can convey a variety of different meanings.3 For example, standing with your arms crossed while communicating with a pediatric patient could make them worry that they're in trouble and you're upset with them.
COMMUNICATION IMPROVES OUTCOMES
Effective communication improves patient outcomes, whereas poor communication is associated with medical errors, decreased quality of patient care, mistrust between the patient and nurse, patient harm, and increased cost and liability. Communication failures have also been associated with preventable patient deaths in the acute care setting.5 Patients notice when communication is poor and will rate satisfaction scores higher when it's effective.1,4 Research has shown that effective communication can decrease hospital readmissions, whereas poor communication can increase them.5 It's also important to note that poor communication can lead to an unhealthy work or clinical environment.5
In some instances, patients may withhold pertinent information. The following may be associated with a failure to disclose:1
* feeling intimidated by the nurse
* not believing that the nurse will listen
* struggles with trauma
* mistrust of the medical field in general.
Be aware of factors that can affect communication, such as physical health, emotional status, pain, age, developmental level, unmet needs, perceptions, personality, self-concept, language barriers, and sensory impairments.1,3 Patients who are preoccupied with their condition or struggling emotionally may have difficulty communicating.1 Patients who are in pain may also struggle with communication.1 The patient's physical and emotional health, including pain, should be addressed before attempting to communicate pertinent information. For example, educating a patient being treated for myocardial infarction in the ED about lifestyle changes to improve health won't be effective, but educating the patient about this information after they're stabilized can be very effective.
A patient's age and developmental level will also affect communication. Keep in mind that age refers to chronologic age, whereas developmental age refers to the age of the patient emotionally, physically, cognitively, and socially. For example, a 50-year-old man with Down syndrome may be developmentally similar to a 10-year-old. You would communicate with this patient as if he were 10 years old and not 50 years old.
When communicating with patients, attempt to meet the patient's needs first. A patient who needs to use the bathroom won't be a good candidate for education. Assist the patient to the bathroom and meet their needs before communicating important information. Also consider the patient's personality, perceptions, and self-concept. Understanding that each patient is different will help you communicate more effectively.
Patients with language barriers or hearing impairments may face challenges with communication.2 Acknowledge that language barriers may exist and find ways to effectively communicate with patients who don't speak English as their first language.3 In these instances, you should request an interpreter, keeping in mind that family member interpreting is discouraged. Family members may try to shelter their loved ones and not share all the information being conveyed. Hearing impairments can make communication challenging, especially now that masks are worn in all clinical environments. When communicating with a patient who has a hearing impairment, speak clearly and face the patient. If the patient reads lips, you should consider wearing a mask with a clear front piece to allow for lip reading.
THERAPEUTIC COMMUNICATION TECHNIQUES
An important component of effective communication is active listening, which occurs when you truly listen to what another person is saying, without typing on a computer, writing on paper, or thinking about your response.6 This shows the patient that you're interested in what they have to say. If you need to type on the computer, explain to the patient that you'll be typing and may need to look away but you're listening and interested in what they're saying. Research has shown that communication is improved when both the nurse and patient are sitting.6 Active listening is a skill that can be practiced and enhanced while in the clinical environment.
When first meeting a patient, introduce yourself and let the patient know that you're a nursing student. You should also ask the patient what they would like to be called and avoid terms of endearment such as honey or sweetie. Ask the patient open-ended questions to allow them to answer more fully. When communicating with patients, avoid false reassurance, minimizing, the use of the word "why," close-ended questions, providing answers, changing the subject, and approving/disapproving.2 It's also important to avoid using medical jargon.6 When communicating with your professors or taking tests, you'll be expected to use medical terminology; but when talking with your patients, you need to use terminology that's easily understood. For example, patients may not understand what voiding means, but will typically understand the term urinating.
When communicating orally, understand that subcultural variations of words can affect communication.3 For example, the word "salty" can be used to describe a person with an attitude or a meal with too much salt. Be aware of the following:
* eye contact may be offensive to some
* hand gestures can mean different things to different people
* slang terms can be offensive to some or be difficult to understand
* gender references may be offensive.
Maintaining patients' confidentiality and privacy will improve communication. Know which information is necessary to share and what doesn't need to be shared. Also remember that it's always inappropriate to share information about patients via social media. Failure to maintain confidentiality will damage the nurse-patient relationship and could result in dismissal from the clinical agency or nursing program. When communicating with patients, ensure privacy by closing the door or curtain. It's appropriate to ask visitors to leave, especially if teaching or asking about sensitive topics. This can be challenging but will get easier with practice and time. If nursing units have specific visitor times due to COVID-19, it may be beneficial to plan around these visits.
One technique that can be used to enhance communication is the BATHE mnemonic: background, affect, trouble, handling, and empathy.6 This tool can help you develop a good rapport with patients (see The BATHE technique).5 To use this technique, ask the patient to describe what's happening.6 It's important to collect this background information to gain a better understanding of what's going on with the patient. Then ask the patient how their health is affecting their emotions.6 This will help you better understand the whole picture and how the illness is influencing the patient. Next, ask about any worries related to the patient's health condition, as well as how the patient feels they're handling the health issue.6 Lastly, show empathy by listening and reflecting back.6 For example, you could state, "That sounds frustrating. Could you tell me more about it?"
Another effective patient communication technique is teach-back. The teach-back technique involves educating the patient and then asking the patient to repeat back what was said in their own words. This can help ensure that the patient understands what has been said. In many cases, patients will verbalize that they understand when they don't have a full understanding. This technique helps address misconceptions and misunderstandings. Patients need to understand why a treatment or medication is necessary and they need to trust the person communicating the information to them. Teach-back will ensure that the patient understands the treatment plan and improve adherence, which is associated with good communication.4
In the clinical environment, nursing students need to be able to communicate with nurses, healthcare providers, and other staff within the facility. An important tool for nurse-to-nurse or nurse-to-provider communication is SBAR: situation, background, assessment, and recommendation (see The SBAR tool).5 When using this tool, describe the situation by identifying yourself, the patient, and the reason for the communication.5 The next step is to provide the patient's background information. For example, admission date, reason for admission, and so on. Then provide pertinent assessment information.5 When first learning the SBAR tool, it can be challenging to differentiate necessary from unnecessary information. This is where the clinical instructor or preceptor can help build skills. The last step is making a recommendation, in which you outline the actions you feel should be taken.5
ALWAYS IMPROVING
During nursing school and when working in the clinical setting, nursing students may find that education regarding therapeutic communication is lacking.1 In these instances, be proactive. Seek out information and always work to improve your communication. Safe and effective patient care depends on it.
Consider this
You're in the clinical setting caring for three patients for the first time. In your previous clinical experiences, you cared for two patients maximum and one on most occasions. You're feeling rushed and trying to get through your list of tasks. You don't take the time to stay in the rooms with your patients because you have so much to do. Midway through the day, your preceptor asks you why you didn't report that your patient was in 8/10 pain. You go to your patient's room to ask about their report of pain. They state, "You were so busy, I didn't want to bother you, so I didn't tell you I was in pain." What could you have done differently? How would you approach your patients in the future?
cheat sheet
Therapeutic communication techniques
* Provide privacy
* Maintain confidentiality
* Introduce yourself
* Ask the patient what they would like to be called
* Ask open-ended questions
* Listen actively
* Repeat back what the patient said
* Provide rationales for nursing care and treatments
* Avoid medical jargon
Memory jogger
The BATHE technique
Background: Ask about what's happening
Affect: Ask how the patient's health is affecting their emotions
Trouble: Ask about worries related to health
Handling: Ask the patient how they feel they're dealing with their health issue(s)
Empathy: Make an empathetic statement
Memory jogger
The SBAR tool
Situation: Person reaching out, patient, reason for communication
Background: Pertinent background information about the patient and situation
Assessment: Pertinent nursing assessment data
Recommendation: Actions to take
REFERENCES