A simple definition of communication is the passing on of information to someone (Websters English Dictionary 1994) Many have studied communication and have developed their own definitions. One such examples are Ruesch (cited by Cresia et al 1996) who stated that communication is all those processes by which people influence eachother and Watzlawick (cited by Creasia et al 1996) who suggested that “all communication is behaviour and behaviour is communication” Communication skills have become recognised as a vital part of nursing practice.
At the turn of the century, the word nurse was defined as “someone trained to care for the sick” (Blondis et al 1982). During the twentieth century, the emphasis in nursing has gradually shifted from not only being a caring role but to one of excellence in nursing skills, techniques and procedures. However, Blondis et al (1992) notes that nursing procedures must not take precedence over the patient as a person who must be approached humanistically.
The World Health Organisation states that “nursing is both an art and a science. It draws on knowledge and techniques derived from the humanities and the physical, social, medical and biological sciences” It is clear from this statement that nursing is a multifaceted profession requiring not only scientific skills but social skills too. To address a patient’s physical well being alone would not be addressing the patients whole wellbeing, the patient’s psychological needs and social needs also require attention.
Faulkner (1998) recognises that effective communication is at the heart of all patient care and Brilhart et al (1981) has discovered that a nurses need to use communication skills in their relationships with patients and their families are limitless. Faulker states that a nurse needs to understand the fundamental difference between what is social interaction and what is professional interaction. The literature studied on communication in nursing all identify the same fundamental skills required by the nurse to interact professionally and interactively with the patient.
According to Verhellen et al (1997), patients have two distinct goals. Firstly patients want information, clarification and care for health related problems. In addition, patients have emotional needs such as reassurance, concern and understanding. It is the job of the nurse to ensure that these needs are met. For the first goal of providing information, nurses need to scrutinise their use of words as medical jargon may confuse or alienate the patient. They must also speak clearly in a tone appropriate to the message that is being conveyed.
To meet the patient’s second need, the nurse can use listening skills, empathy and self-awareness. Webb (1994) describes aspects such as showing respect, trust and giving comfort as essential to establishing a good relationship with the patient. A therapeutic relationship is important so that patients can express their fears and doubts. Being able to talk to the nurse and discuss medical procedures helps dispel much of the patient’s frustration and also reassured them.
Relatives are a very important factor in the improvement of the patient, especially in the care of children. Nurses must also develop a therapeutic relationship with relatives as she may need to take on the role of health teacher to promote and maintain the health of the patient aswell as preventing ill health reoccurring. In the case of the terminally il patient Jenson (1995) reports that realtives need support and for a nurse to provide it, he/she needs communication skills to enable her to explore any issues, share information, answer questions and spend time listening.
A nurse may also be required to break bad news to relations and Buckman (1992) discusses the importance of good communication skills in approaching this very sensitive and difficult subject. (608) Providing Information In providing the patient with information and care regarding health problems, the nurse acts as a resource person, giving specific answers to questions, many of which are formulated with relation to a larger problem (Peplau 1988). Kreps and Kunimoto (1994) realises that patients may not be assertive enough to claim their right to information.
When confused, patients often feel embarrassed to ask the nurse to provide clarification. When asked if they understand explanations and instructions, they may say yes rather than admit their confusion. Kent et al (cited by Faulkner 1998) found that patients were often confused as a result of poor communication. Many patients concerns are linked to a lack of knowledge of their diagnosis, prognosis and future outlook (Faulkner 1998). Patients may also lack knowledge about the body and the steps they could make to improve their physical state, such knowledge may seem obvious to the nurse but unclear to the patient.
Kreps et al (1994) identifies that health care providers must be receptive and responsive to the information and communication needs of patients and invite them to participate in informed health care decision making. This puts a responsibility on the nurse to develop the skills required to give information so that needs are met (Faulkner 1998). Kreps et (1994) notes that nurses often underestimate the level of knowledge patients may already possess in some cases, assuming that they are unlikely to unlikely to comprehend health care issues and therefore do not include them in health care meetings.
Peplau (1988) suggests that teaching should always proceed from what the patient already knows and then develop around his interest to learn more and understand additional information. Faulkner (1998) is of the same opinion, recognising that there is little point in giving information on diagnosis, treatment or prognosis until it is established what the patient knows and believes about his illness. It is also necessary to access the patient’s ability to absorb information so that he or she is not bombarded with too much information at once.
Information should be given at a rate at which the patient can absorb it and in a language he understands. It is therefore inappropriate to use medical jargon that the patient is unfamiliar with, causing him to misunderstand information. Faulkner (1998) considers helping the patient to explore his feelings often gives the nurse a picture of how likely he is to accept new information which necessitates a change in lifestyle. Psychology studies have shown that most people can only take in an average of seven pieces of information at a time. Nonverbal Communication
Nonverbal communication cues are vital in interpersonal communication, evoking a much higher meaning than words. They serve to supplement verbal signals, substitute for them, express feelings and establish relationships (Brilhart et al). Draper et al (1998) suggests that nurses need to pay as much attention to the effect of nonverbal communication as they do to the impact of their words. Usually verbal and nonverbal communication reinforce or support eachother. Devito (2000) notes that all parts of a message system normally work together to communicate a particular meaning.
An example of this is a patient expressing fear; he does not say the words in a relaxed manner. Verbal and nonverbal communication work together to reinforce one-another (Draper et al 1998). Nonverbal communication enables a verbal message to be delivered more accurately and efficiently by strengthening the effect of the words. Nonverbal communication can also work to contradict verbal communication. Communication research has shown that when the two are inconsistent or contradictory, the nonverbal message will override the verbal message e. g. f the nurse asks a patient if he has a problem and the nonverbal cues and speaking quickly and looking agitated, the patient will make the correct assumption that time keeping is more important to the nurse than his problem. Draper et al (1998) concludes that if verbal and nonverbal signals are contradictory, at the very least the nurse runs the risk of the patient feeling confused. At worst, the nonverbal mess will win out. Without attention to nonverbal aswell as verbal communication and without making an effort to include the patient in his own care, many problems may arise.
Not only will the long-term relationship with the patient suffer but even in the short-term, patients will feel less understood and supported. Harrigan et al (cited by Draper et al 1998) demonstrated that health care professionals who face their patients directly have more eye contact and maintain open arm postures are regarded as more empathetic, interested and warm. According to Brilhart et al (1981), the variety of communicative nonverbal behaviours are endless. Some examples of these are rhythm and rate, pitch and patterns of pitch, actions and movements.
When we are unsure of what we want to say or feel we are being judged, we tend to speak at a much slower rate, stumble over words or make long pauses. The action of facing full front toward the patient generally is indicative of openness, liking and trust. Listening Nightingale (cited by Dwyer 1985 pp. 33) suggested that nurses should do less chattering and advising and much more listening. Burnard (1997) considers listening and attending to be by far the most important aspects of being a health care professional.
Unlike listening, hearing begins and ends with the first stage of receiving. Hearing is something that just happens when the ears are open. Listening begins with receiving messages the speaker sends, therefore receiving both verbal and nonverbal messages. The term active listening is sometimes used to imply that simply the passive act of sitting and hearing what the patient is saying is not enough. Creasia et al (1996) describes this as giving full attention to the client both verbally and nonverbally.
As the listener expects an active speaker, the patient has a right to expect an active listener. Active listening requires understanding, skill, patience and perseverance (Blondis et al 1982). Encouraging the patient to express himself will not be helpful if he senses the nurse is not listening. This refers to the attitude of the nurse, it means that she is ready to listen to what the patient wants to say and will endeavour to understand his situation without argument or interruption.
Webb (1995) considers giving the patient such individual attention and acknowledging his current situation to be a prerequisite to active listening and maintains that it is the first step in the process of successful communication. If the nurse gives the impression that she always has time to listen to the patient, then she is complying with the current holistic approach to nursing. Stein-Parbury (1993) considers listening to be the greatest sign of respect a nurse can show to a patient. Empathy
In order for nurses to be able to truly understand what hospitalisation means to patients, they must learn to empathise with others (Burnard 1990). The importance of empathy in nursing seems well accepted as a communication skill and widely supported in nursing literature (Baillie 1995, Gould 1990). Corbett (1993) describes empathy as trying to see the world from another person’s perspective while setting aside your own separateness. This gives the nurse a better understanding of the pain and distress a patient is experiencing.
Empathetic responses are not always practice if the nurse does not maintain a degree of separateness. Jones (cited by Watson 1980) gives the example of counselling a patient with a life threatening illness. Empathetic responses would not be appropriate if the nurse did not separate herself from the situation as too much anxiety would be aroused. While Corbett (1993) identifies empathy as the most important part of a helping relationship; Keighley (1998) regards self-awareness as the first step to deeper personal and interpersonal understanding.