3.2 Communication

The third IPEC competency focuses on interprofessional communication and states, “Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease.”^[1] See Figure 3.1^[2] for an image of interprofessional communication supporting a team approach. This competency also aligns with The Joint Commission’s National Patient Safety Goal for improving staff communication.^[3] See the following box for the components associated with the Interprofessional Communication competency.

Transmission of information among members of the health care team and facilities is ongoing and critical to quality care. However, information that is delayed, inefficient, or inadequate creates barriers for providing quality of care. Communication barriers continue to exist in health care environments due to interprofessional team members’ lack of experience when interacting with other disciplines. For instance, many novice nurses enter the workforce without experiencing communication with other members of the health care team (e.g., providers, pharmacists, respiratory therapists, social workers, surgical staff, dieticians, physical therapists, etc.). Additionally, health care professionals  tend to develop a professional identity based on their educational program with a distinction made between groups. This distinction can cause tension between professional groups due to diverse training and perspectives on providing quality patient care. In addition, a health care organization’s environment may not be conducive to effectively sharing information with multiple staff members across multiple units.

In addition to potential educational, psychological, and organizational barriers to sharing information, there can also be general barriers that impact interprofessional communication and collaboration. See the following box for a list of these general barriers.

There are several national initiatives that have been developed to overcome barriers to communication among interprofessional team members. These initiatives are summarized in Table 3.1.

Communication Strategies

Several communication strategies have been implemented nationally to ensure information is exchanged among health care team members in a structured, concise, and accurate manner to promote safe patient care. Examples of these initiatives are ISBARR, handoff reports, closed-loop communication, and I-PASS. Documentation that promotes sharing information interprofessionally to promote continuity of care is also essential. These strategies are discussed in the following subsections.

Closed-Loop Communication

The closed-loop communication strategy is used to ensure that information conveyed by the sender is heard by the receiver and completed. Closed-loop communication is especially important during emergency situations when verbal orders are being provided as treatments are immediately implemented. See Figure 3.2^[7] for an illustration of closed-loop communication.

1. The sender initiates the message.
2. The receiver accepts the message and repeats back the message to confirm it (i.e., “Cross-Check”).
3. The sender confirms the message.
4. The receiver notified the sender the task was completed (i.e., “Check-Back”).

See an example of closed-loop communication during an emergent situation in the following box.

Communication is a process by which information is exchanged between individuals through a common system of symbols, signs, or behavior.^[8] In the health care setting, good communication is the foundation to trusting relationships that improve client outcomes. It is the gateway to providing holistic care. Holistic care addresses a client’s physical, emotional, social, and spiritual needs.^[9] The communication process involves a sender, the message, and a receiver. See Figure 3.3^[10] for an illustration of the communication process.

Verbal Messages

There are many aspects of the communication process that can alter the delivery and interpretation of the message. These aspects relate to the language and experience of both the sender and receiver, referred to as semantics. People typically make reference to things they are familiar with, including landmarks, popular culture, and slang. Barriers can occur even when both parties in the conversation speak the same language. For example, if you asked a person who has never used the Internet to “Google it,” they would have no idea what that means.

Nonverbal Messages

Nonverbal messages, also referred to as body language, greatly impact the conversational process. Nonverbal communication includes body language and facial expressions, tone of voice, and pace of the conversation. See Figure 1.2^[11] for an illustration of body language communicating a message. Nonverbal communication can have a tremendous impact on the communication experience and may be much more powerful than the verbal message itself. You may have previously learned that 80% of communication is nonverbal communication. The importance of nonverbal communication during conversation has been broken down further, estimating that 55% of communication is body language, 38% is tone of voice, and 7% is the actual words spoken.^[12] If the sender or receiver appears disinterested or distracted, the message or interpretation may become distorted or missed.

Health care professionals assess receivers’ preferred methods of communication and individual characteristics that might influence communication and then adapt communication to meet the receivers’ needs. For example, nursing assistants adapt verbal instructions for adult patients with cognitive disabilities. Although the information provided might be similar to that provided to a patient without disabilities, the way the information is provided is adapted based on the patient’s developmental level. A nursing assistant may ask a cognitively intact person, “What do you want for lunch?” but adapt this information for someone with impaired cognitive function by offering a choice, such as “Do you want a sandwich or soup for lunch?” This adaptation allows the cognitively impaired patient to make a choice without being confused or overwhelmed by too many options.^[13] Read more about developmental levels in the “Human Needs and Developmental Stages” section of this chapter.

Communication Styles

In addition to using verbal and nonverbal communication, people communicate with others using one of three styles. A passive communicator puts the rights of others before their own. Passive communicators tend to be apologetic or sound tentative when they speak and often do not speak up if they feel as if they are being wronged. Aggressive communicators[ on the other hand, come across as advocating for their own rights despite possibly violating the rights of others when communicating. They tend to communicate in a way that tells others their feelings don’t matter. Assertive communicators respect the rights of others while also standing up for their own ideas and rights when communicating. An assertive person is direct, but not insulting or offensive.^[14]

Assertive communication refers to a way of conveying information that describes the facts and the sender’s feelings without disrespecting the receiver’s feelings. Assertive communication is different from aggressive communication because it uses “I” messages, such as “I feel…,” “I understand…,” or “Help me to understand…,” to address issues instead of using “you” messages that can cause the receiver to feel as though they are being verbally attacked. Using assertive communication is an effective way to solve problems with patients, coworkers, and health care team members. For example, instead of using aggressive communication to say to a coworker, “You always leave your patients’ rooms a mess! I dread following you on the next shift,” an assertive communicator would use “I” messages. The assertive communicator might say, “I feel frustrated spending the first part of my shift decluttering patients’ rooms. Help me understand the reasons why you don’t empty the wastebaskets and clean up the rooms by the end of your shift.”^[15]

Overcoming Communication Barriers

It is important to reflect on personal factors that influence your ability to communicate with others effectively. There are many factors that can distort the message you are trying to communicate, resulting in your message not being perceived by the receiver in the way you intended. When communicating, it is important to seek feedback that your message is clearly understood.^[16]

Communicating With the Client, Families, and Loved Ones

Therapeutic communication is a type of professional communication used with patients. It is defined as the purposeful, interpersonal, information-transmitting process through words and behaviors based on both parties’ knowledge, attitudes, and skills that leads to patient understanding and participation.^[18] Therapeutic communication techniques have been used by nurses since Florence Nightingale, who insisted on the importance of building trusting relationships with patients. She believed in the therapeutic healing that results from nurses’ presence with patients.^[19]

There are several components included in therapeutic communication. The health care professional uses active listening and attending behaviors to demonstrate they are interested in understanding what the patient is saying. Touch is used to professionally communicate caring, and specific therapeutic techniques are used to encourage the patient to share their thoughts, concerns, and feelings.

Active Listening and Attending Behaviors

Listening is obviously an important part of communication. A well-known phrase from a Greek philosopher named Epictetus is, “We have two ears and one mouth so we can listen twice as much as we speak.” It is important to actively listen to patients and not use competitive or passive listening. Competitive listening occurs when we are primarily focused on sharing our own point of view instead of listening to someone else. Passive listening occurs when we are not interested in listening to the other person or we assume we correctly understand what the person is communicating without verifying their message. During active listening, we communicate verbally and nonverbally that we are interested in what the other person is saying and also verify our understanding with the speaker. For example, an active listening technique is to restate what the person said and verify our understanding is correct, such as, “I hear you saying you are hesitant to go to physical therapy because you are afraid of falling. Is that correct?” This feedback process is the main difference between passive listening and active listening.^[20]

Touch

Touch is a powerful way to professionally communicate caring and compassion if done respectfully while being aware of the patient’s cultural beliefs. For example, simply holding a patient’s hand during a painful procedure can be very effective in providing comfort. See Figure 1.4^[21] for an image of a nurse using touch as a therapeutic technique when caring for a patient.

Therapeutic Communication Techniques

Therapeutic communication techniques are specific methods used to provide patients with support and information while focusing on their concerns. It is important to recognize the autonomy of the patient to make their own decisions, maintain a nonjudgmental attitude, and avoid interrupting. Depending on the developmental stage and educational needs of the patient, appropriate terminology should be used to promote patient understanding and rapport. When using therapeutic communication, health care professionals often ask open-ended questions, repeat information, or use silence to prompt patients to process their concerns. Table 1.3a describes a variety of therapeutic communication techniques.

In addition to the therapeutic techniques listed in Table 3.2, health care professionals should genuinely communicate with patients with empathy. Communicating honestly, genuinely, and authentically is powerful. It opens the door to establishing true connections with others.^[23] Communicating with empathy can be described as providing “unconditional positive regard.” Research has demonstrated that when health care professionals communicate with empathy, there is improved patient healing, reduced symptoms of depression, and decreased medical errors.^[24]

Nontherapeutic Responses

Health care professionals must be aware of potential barriers to communication. In addition to the common communication barriers discussed in the “Communication Styles” subsection of this chapter, there are several nontherapeutic responses to avoid. These nontherapeutic responses often block the patient’s communication of their feelings or ideas. See the table below for a description of nontherapeutic responses.^[25]

Strategies for Effective Communication

In addition to overcoming common communication barriers, using active listening and therapeutic communication techniques, and avoiding nontherapeutic responses, there are additional strategies for promoting effective communication when providing patient-centered care. Specific questions to ask patients are as follows^[27]:

• What concerns do you have about your plan of care?
• What questions do you have about your daily routine?
• Did I answer your question(s) clearly, or is there additional information you would like?

Listen closely for feedback from patients. Feedback provides an opportunity to improve patient understanding, improve the patient-care experience, and provide high-quality care. Other suggestions for effective communication with clients include the following:

• Read the care plan carefully and access any social history available. If family members or friends visit and it seems appropriate, talk with them about the client without intruding or taking up a lot of their time together. This information helps you build trust and care for the client based on their preferences and life history. For example, you might learn the resident lived on a farm most of their life and enjoyed taking care of their horses. Striking up conversations about horses is a way to build rapport with this client.
• Review any changes in routine or in the plan of care
• If there are questions you can’t answer, be sure to report to the nurse so someone can follow up with the client. Check back with the client to ensure they have had their questions answered.
• Observe nonverbal communication from clients. Do they seem to interact during care, or is it something that they are merely tolerating and just trying to get through each day? Find an approach so they are comfortable with receiving care.

Adapting Your Communication

When communicating with patients, their family members, and other caregivers, note your audience and adapt your message based on characteristics such as age, developmental level, cognitive abilities, and any communication disorders. For patients with language differences, it is vital to provide trained medical interpreters when important information is communicated.

Adapting communication according to an individual’s age and developmental level includes the following strategies^[28]:

• When communicating with children, speak calmly and gently. It is often helpful to demonstrate what will be done during a procedure on a doll or stuffed animal. To establish trust, try using play or drawing pictures.
• When communicating with adolescents, give freedom to make choices within established limits.
• When communicating with older adults, be aware of potential vision and hearing impairments that commonly occur and address these barriers accordingly. For example, if a patient has glasses and/or hearing aids, be sure these devices are in place before communicating.

Strategies for Communicating With Patients With Impaired Hearing, Vision, and Speech

In addition to adapting your communication to your audience, there are additional strategies to use with individuals who have impaired hearing, vision, or speech.

Impaired Hearing

• Gain the person’s attention before speaking (e.g., through touch)
• Minimize background noise
• Position yourself 2-3 feet away from the patient
• Facilitate lip-reading by facing the person directly in a well-lit environment
• Use gestures, when necessary
• Listen attentively, allowing the person adequate time to process communication and respond
• Refrain from shouting at the person
• Ask the person to suggest strategies for improved communication (e.g., speaking toward a better ear, moving to well-lit area, and speaking in a lower-pitched tone)
• Face the person directly, establish eye contact, and avoid turning away mid-sentence
• Simplify language (e.g., do not use slang but do use short, simple sentences), as appropriate
• Read the care plan for information on the preferred method of communicating (whiteboards, pictures, etc.)
• Assist the person using any devices such as hearing aids or voice amplifiers
• Report any changes to the nurse

Impaired Vision

• Identify yourself when entering the person’s space
• Ensure the patient’s eyeglasses are cleaned and stored properly when not in use, and assist the patient in wearing them during waking hours
• Provide adequate room lighting
• Minimize glare (e.g., offer sunglasses, draw window covering, position with face away from window)
• Provide educational materials in large print as available
• Read pertinent information to the patient
• Provide magnifying devices
• Report any changes to the nurse

Impaired Speech^[29]

Some patients may have problems processing what they are hearing or in responding to questions due to dementia, brain injuries, or prior strokes. This difficulty is referred to as aphasia. There are different types of aphasia. People with expressive aphasia understand speech and know what they want to say, but frequently speak in short phrases that are produced with great effort. For example, they may intend to say, “I would like to go to the bathroom,” but instead the words, “Bathroom, Go,” are expressed. People with receptive aphasia often speak in long sentences, but what they say may not make sense. They are unable to understand both verbal and written language. Aphasia often causes the person to become frustrated when they cannot communicate their needs. Review the following evidence-based strategies to enhance communication with a person with impaired speech^[30]:

• Modify the environment to minimize excess noise and decrease emotional distress
• Phrase questions so the patient can answer using a simple “Yes” or “No,” being aware that patients with expressive aphasia may provide automatic responses that are incorrect
• Monitor the patient for frustration, anger, depression, or other responses to impaired speech capabilities
• Provide alternative methods of speech communication (e.g., writing tablet, flash cards, eye blinking, communication board with pictures and letters, hand signals or gestures, or computer)
• Adjust your communication style to meet the needs of the patient (e.g., stand in front of the patient while speaking, listen attentively, present one idea or thought at a time, speak slowly but avoid shouting, use written communication, or solicit the family’s assistance in understanding the patient’s speech)
• Ensure the call light is within reach
• Repeat what the client said to ensure accuracy
• Instruct the client to speak slowly
• Read the care plan for instructions from the speech therapist
• Report any changes to the nurse

Responding to Challenging Situations

Being a care provider is a very rewarding career, but it also includes dealing with challenging situations. Using strong communication techniques can de-escalate situations and put patients, loved ones, and staff at ease. It is impossible to predict what behavior you may encounter as a health care worker, but having a solid basis of communication techniques can prepare you to better handle unique situations.

Memory Impairment and Behavioral Health Issues

Healthcare workers may encounter older adults with varying degrees of memory impairment. Older adults are defined as adults aged 65 years old or older.^[31] Residents with memory issues often become confused and can feel overwhelmed by everyday situations. For those with impaired cognitive functioning like dementia, it may not be possible to reorient them to the current time and place or to move them on from thoughts that are not based in the current situation. Aphasia and confusion can cause frustration that can result in agitation or aggression. Agitation refers to behaviors that fall along a continuum ranging from verbal threats and motor restlessness to harmful aggressive and destructive behaviors. Mild agitation includes symptoms such as irritability, oppositional behavior, inappropriate language, and pacing. Severely agitated patients are at immediate risk of harming themselves or others through assaultive or self-injurious behavior, and they are capable of causing property damage.^[32] Aggression is an act of attacking without provocation.^[33] See below for general guidelines to prevent aggression and agitation:

• Keep the environment calm and as quiet as possible.
• Build trusting relationships by learning resident preferences and routines.
• Gather information from family members and loved ones about the patient’s background and beliefs.
• Offer choices to allow the patient to communicate preferences, but do not cause them to be overwhelmed with too many decisions.
• Empathize with the resident and understand that challenging behavior is often communication of emotion due to cognitive impairment and not a choice.
• Practice validation therapy. Validation therapy is a method of therapeutic communication used to connect with someone who has moderate- to late-stage dementia and avoid agitation. It places more emphasis on the emotional aspect of a conversation and less on the factual content, thereby imparting respect to the person, their feelings, and their beliefs. Validation may require you to agree with a statement that has been made, even though the statement is neither true or real, because to the person with dementia, it feels both true and real.^[34] For example, if the resident with dementia believes they are waiting to catch the bus and is intent on doing so, sit with them by the window as if you are waiting for a bus and continue to have interaction with them until they are no longer concerned with the bus.
• Redirect behavior if appropriate. For example, suggest alternative activities such as walking around the facility, looking at photos, listening to music, or other activities the resident enjoys.
• Focus on safety for residents experiencing delusions or hallucinations. Delusions are unshakable beliefs in something that isn’t true or based on reality. For example, a resident may refuse to eat breakfast because they have a delusion that staff are trying to poison them. Hallucinations are sensing things such as visions, sounds, or smells that seem real but are not. For example, a resident may refuse to enter a room because they have hallucinations of big spiders crawling on the walls. If a patient is having delusions or hallucinations, never contradict them or tell them what they perceive isn’t real. Instead, empathize with them and do whatever is possible to help them feel safe. For example, offer to move to another area or investigate what the resident is concerned about.

Attribution

The content from this chapter was taken from:

Nursing Assistant by Chippewa Valley Technical College and is licensed under a Creative Commons Attribution 4.0 International License.

Nursing Management and Professional Concepts by Chippewa Valley Technical College and is licensed under a Creative Commons Attribution 4.0 International License.