Communication involves the exchange of messages and is a process which all individuals participate in. Whether it is through spoken word, written word, non-verbal means or even silence, messages are constantly being exchanged between individuals or groups of people (Bach & Grant 2009). All behaviour has a message and communication is a process which individuals cannot avoid being involved with (Ellis et al 1995).
In nursing practice, communication is essential, and good communication skills are paramount in the development of a therapeutic nurse/patient relationship. This aim of this essay is to discuss the importance of communication in nursing, demonstrating how effective communication facilitates a therapeutic nurse/patient relationship. This will be achieved by providing a definition of communication, making reference to models of communication and explaining how different types of communication skills can be used in practise.
In order to engage in meaningful communication and develop effective communication skills, nurses must engage in the process of reflecting on how communication skills are utilised in practise. Reflection allows the nurse opportunity to gain a deeper insight into personal strengths and weaknesses and to address any areas of concern in order to improve future practise (Taylor 2001). A further aim will be to reflect on how communication skills have been utilised within nursing practise. Various models of reflection will be examined, and a reflective account of a personal experience which occurred during placement will be provided using a model. This reflective account will involve a description the incident, an analysis of thoughts and feelings and an evaluation of what has occurred. Finally, the reflective account will include an action plan for a similar situation, which may arise, in the future.
Communication involves information being sent, received and decoded between two or more people (Balzer-Riley 2008) and involves the use of a number of communication skills; which in a nursing context generally focuses on listening and giving information to patients (Weller 2002). This process of sending and receiving messages has been described as both simple and complex (Rosengren 2000 in McCabe 2006, p.4). It is a process which is continually utilised by nurses to convey and receive information from the patient, co-workers, others they come into contact with and the patient’s family.
Models of Communication.
The Linear Model is the simplest form of communication and involves messages being sent and received by two or more people (McCabe 2006). Whilst this model demonstrates how communication occurs in its simplest form, it fails to consider other factors impacting on the process. Communication in nursing practice can be complicated, involving the conveyance of large amounts of information, for example, when providing patients with information relating to their care and treatment or when offering health promotion advice.
In contrast, the Circular Transactional Model is a two way approach, acknowledging other factors, which influence communication such as feedback and validation (McCabe 2006). Elements of this model are also contained in Hargie and Dickinson’s (2004) ‘A Skill Model of Interpersonal Communication’ which suggests that successful communication is focused, purposeful and identifies the following skills; person centred context, goal, mediating process, response, feedback and perception. It also considers other aspects of the individual and the influence these may have on their approach to the process of communication (McCabe 2006).
For communication to be effective it is important for the nurse to recognise key components, and intrinsic and extrinsic factors, which may affect the process (McCabe 2006). They must consider factors such as past personal experiences, personal perceptions, timing and the setting in which communication occurs. Physical, physiological, psychological and semantic noise may also influence the message, resulting in misinterpreted by the receiver (McCabe 2006).
Communication consists of verbal and non-verbal. Verbal communication relates to the spoken word and can be conducted face-to-face or over the telephone (Docherty &McCallum 2009). Nurses continually communicate with patients; verbal communication allows the nurse opportunity to give information to the patient about their care or treatment, to reassure the patient and to listen and respond to any concerns the patient may have (NMC 2008). Effective communication is beneficial to the patient in terms of their satisfaction and understanding, of care and treatment they have been given (Arnold & Boggs 2007), while at the same time optimising the outcomes or care and/or treatment for the patient (Kennedy- Sheldon 2009).
Questioning allows the nurse to gather further information and open or closed questions can be used. Closed questions usually require a yes or no response and are used to gather the necessary information, whereas open questions allow the patient, opportunity to play an active role and to discuss and agree options relating to their care as set out in the Healthcare Standards for Wales document (2005). Probing questions can be used to explore the patient’s problems further thus allowing the nurse to treat the patient as an individual and develop a care plan specific to their individual needs (NMC 2008).
It is vital that the nurse communicates effectively, sharing information with the patient about their health in an understandable way to ensure the patient is fully informed about their care and treatment and that consent is gained prior to this occurring (NMC 2008). The nurse should also listen to the patient and respond to their concerns and preferences about their care and well-being (NMC 2008). In nursing, listening is an essential skill and incorporates attending and listening (Burnard & Gill 2007). Attending; fully focusing on the other person and being aware of what they are trying to communicate and listening; the process of hearing what is being said by another person are the most important aspects of being a nurse (Burnard 1997).
Non-verbal communication is a major factor in communication, involving exchange of messages without words. It relates to emotional states and attitudes and the conveyance of messages through body language; body language has seven elements; gesture, facial expressions, gaze, posture, body space and proximity, touch and dress (Ellis et al 1995). Each of these elements can reinforce the spoken word and add meaning to the message; it isn’t about what you say or how you say it but it also relates to what your body is doing while you are speaking (Oberg 2003). Patients often read cues from the nurse’s non-verbal behaviour, which can indicate interest or disinterest. Attentiveness and attention to the patient can be achieved through SOLER: S – sit squarely, O – Open posture, L – learn towards the patient, E – eye contact, R – relax (Egan 2002).
There must be congruency between verbal and non verbal messages for effective communication to be achieved. Non-verbal communication can contradict the spoken word and the ability to recognise these non-verbal cues is vitally important in nursing practice (McCabe 2006), for example, a patient may verbally communicate that they are not in pain, but their non-verbal communication such as facial expression may indicate otherwise. It is also important for the nurse to be aware of the congruency of their verbal and non-verbal communication. Any discrepancies between the two will have a direct influence on the message they are giving to patients, and may jeopardise the nurse/patient relationship.
Other factors may affect communication in a negative way, endangering the process, and nurses must be aware of internal and external barriers (Schubert 2003). Lack of interest, poor listening skills, culture and the personal attitude are internal factors, which may affect the process. External barriers such as the physical environment, temperature, the use of jargon and/or technical words can also negatively influence the process (Schubert 2003).
To fully assess the development of communication skills the nurse can make use of reflection to gain a better insight and understanding of their skills (Siviter 2008). Reflection can also be used to apply theoretical knowledge to practice, thus bridging the gap between theory and practice (Burns & Bulman 2000) and allows us opportunity, to develop a better insight and awareness of our actions both conscious and unconscious in the situation. Reflecting on events that take place in practice, allows opportunity not only to think about what we do, but also to consider why we do things. This helps us to learn from the experience and improve our future nursing practice (Siviter 2008). Reflection can be described as either reflection in action; occurring during the event, or reflection on action; which happens after the event has occurred (Taylor 2001) and is guided by a model, which serves as a framework within, which the nurse is able to work. It is usually a written process, and the use of a reflective model uses questions to provide a structure and guide for the process (Siviter 2008).
There are numerous reflective models that may be utilised by the nursing professional, for example, Gibb’s Reflective Cycle (1988), Johns Model of Structured Reflection (1994) and Driscoll’s Model of Reflection (2002). Gibb’s model (Appendix I) has a cyclical approach, consisting of six stages per cycle that guide the user through a series of questions, providing a structure for reflection on an experience. The first stage of the process is a descriptive account of the situation; what happened? Followed by an analysis of thoughts and feelings in the second stage; what were your thoughts and feelings? The third and fourth stages involve an evaluation of the situation, what was good and/or bad about the experience and an analysis allowing us to make sense of the situation. The last two stages are the conclusion of the situation, what else could have been done and finally an action plan to prepare for similar situations, which may arise in the future (Gibbs 1988).
Similarly to Gibb’s Reflective Cycle, John’s Model of Structured Reflection (Appendix II) and Driscoll’s (Appendix III) model of reflection promote learning through reflection. They have similar structures, which guide the user through the reflective process. Johns Model incorporates four stages; description, reflection, alternative actions and learning (Johns 1994) and Discoll’s model has three stages: a return to the situation, understanding the context and modifying future outcome (Discoll 2002). The three models described all have similarities in that the user is guided through the reflective process by describing the event, analysing their thoughts, feelings and actions and making plans for future practice. Considering the models of reflection described, the next component of this essay will make use of the Gibbs Reflective Cycle (1998) to provide a reflective account of a situation which I experienced during clinical placement in a community setting.
As part of this placement, I assisted my mentor, a health visitor, in the provision of a baby club for parents with babies and pre-school children, which takes place on a weekly basis and involves routine checks, such as baby-weighing, in addition to opportunity, for parents to socialise and opportunity for health visitors to provide information relating to the care and health of babies and children.
During the second week of this placement, I was asked to assist in the delivery of a forthcoming health promotion session relating to dental health. I have chosen this event as a basis for my reflective account as I feel that health promotion is an important area to consider. It enables individuals to play a pivotal role in their own health (Webster and Finch 2002 in Scriven 2005) and is a means by which positive health can be promoted and enhanced alongside the prevention of illness (Downie et al 2000). It gives clients the knowledge to make informed decisions about their health and prevention of illness and is an area in which the nurse or healthcare professional plays a key role (WHO 1989).
Description of the event.
The event occurred during a weekly session at baby club that takes place in a community centre. My mentor (Health Visitor) and I were present along with a group of ten mothers and their babies. As this event took place during a group session, I will maintain confidentiality (NMC 2008) by not referring to any one individual. Consent was gained from all clients prior to the session commencing, in line with the NMC Code of Conduct (2008) and the environment was checked to ensure it was appropriate and safe for the session to take place.
The aim of the session was to promote good dental health and oral hygiene amongst children and babies. Standard 1 of the Standards of Care for Health Visitors (RCN 1989) is to promote health, and the session aimed to provide clients with relevant, up-to-date information, thus allowing them to make informed choices about the future care of their children’s teeth. Chairs were set out in a semi-circle with a number of play mats and various baby toys placed in the centre. This allowed parents opportunity to interact in the session, to listen to the information and ask questions while at the same time being in close enough proximity to their children to respond to their needs. The Health Visitor and I sat at the front of the semi circle facing the group. I reintroduced myself to the group and gave a brief explanation of my role and the part I would play in the session. This was important; some of the clients were meeting me for the first time, and it is during this initial contact that judgements are made about future interactions, and the service being provided. Positive initial interaction can provide a good foundation for a future beneficial relationship (Scriven 2005). The session was broken down into two parts: information giving, focusing on the promotion of dental health and prevention of illness in the form of tooth decay (Robotham and Frost 2005). Secondly, information relating to tooth brushing was given along with a demonstration undertaken by myself that showed the clients good oral hygiene could be achieved through effective tooth brushing. A question and answer session followed which allowed us to clarify any issues raised.
Feelings and thoughts.
In the week, preceding the session it was important for me to consider a systematic approach to the planning of the session. The first stage was to gather relevant, up-to-date information relating to the subject and plan how it could be incorporated in the session. The NMC Standards of Proficiency (2004a) states that nurses must engage in a continual process of learning and that evidence-based practice should be used (Bach and Grant 2009). The plan was discussed with my mentor and advice was sought about any adjustments which may be necessary.
Prior to the session, I was apprehensive about delivering a health promotion session to clients (patients). I as I felt out of my depth as a first year student and my anxiety was exacerbated further as this was my first placement. However, support and encouragement from my mentor and other health visitors in the team helped me to relax. I was given the opportunity to discuss the topic with my mentor and was relieved when I was able to respond to any questions asked in an appropriate manner and that my knowledge had been increased through the research I had undertaken, thus boosting my confidence.
Despite my initial reservation about my knowledge of the subject and apprehension at delivering a health promotion session, I feel that my mentor’s decision to include me in the delivery of the session benefitted me greatly in the development of my knowledge and self confidence. During the session, I feel that I communicated well verbally with clients and that my non-verbal communication was appropriate and corresponded to what I was saying. The clients were focused on the session and seemed genuinely interested, nodding when they understood and showed attentiveness by making regular eye contact. Feedback from clients after the session also allowed me to reflect on my communication; one of the clients stated afterwards that she had gained a lot from the session particularly the demonstration relating to tooth brushing and was now more aware of the importance of early oral hygiene to prevent problems later in the child’s life.
Dental Health is a key Health Promotion target in Wales and is the most prevalent form of disease amongst children in Wales. Many of the participants were unaware of when and how children’s teeth should be cared for and the importance of ensuring good oral hygiene from an early age. The aim of the session was to provide information to parents as a means of promoting good oral hygiene and prevention of tooth decay in babies and young children. In order for the aim to be achieved, communication was a key element. Effective communication in a group can only be achieved if there is trust, participation, co-operation and collaboration among its members and the belief that they as a group are able to perform effectively as a group (Balzer-Riley 2008). The information was provided in a way that was easily understandable, a demonstration of how teeth should be brushed was given, and time was allowed for the client’s time to ask questions. Communication and listening skills allowed us to discover what knowledge the clients already had, and enabled us to adjust the information to meet the needs of the clients. Throughout the session, I was aware of my non-verbal communication and attempted to show attentiveness to individuals in the group, using the principles of SOLER I made the necessary adjustments. At times, this proved difficult as trying to lean towards the clients and maintain eye contact with each individual was not possible in a group situation.
My anxiety about delivering the session was also an area which I had some concerns with. Nervousness can have an influence on how a message is delivered, and I was constantly aware of my verbal communication, particularly my paralanguage. I have a tendency to speak at an accelerated rate when I am nervous, and was aware that this may influence the way in which the message was being received. It is important to be aware of paralanguage in which the meaning of a word or phrase can change depending on tone, pitch or the rate at which the word(s) is spoken. Paralanguage may also include vocal sounds which may accompany speech and which can add meaning to the words being spoken (Hartley 1999).
Throughout the session, I was aware of my verbal and non-verbal communication, and I tried to ensure that it corresponded to the information being given; I was also aware of non-verbal communication of the participants and made appropriate adjustments to my delivery when needed
After the session had finished, I was given an opportunity to discuss it with my mentor. I was able to articulate what I felt had gone well, what hadn’t gone quite as well and what could be improved. I noted that I was very nervous about delivering the session despite having the knowledge and understanding of the subject and felt that this may have been noticed by the participants. However, feedback from my mentor allowed me to realise that my nervousness was not apparent in my delivery. By undertaking this reflection, I have been able to question the experience and analyse my actions and behaviour, as a means of developing my knowledge for future practice
This session has helped with my learning and personal development and I now feel more confident in my ability to deliver health promotion activities in a group setting. I am, however, aware that speaking in a group setting is not an area I am very comfortable with but further practice will help alleviate this. I am confident that I will be able to use the knowledge gained on the subject of dental health in my future placements. In the future, I will repeat the process of thorough research, as it is best practice to keep knowledge up-to-date in order to provide care based on evidence (NMC 2008).
In summary, communication is a complex process and an essential skill which the nurse must be aware of in every aspect, of care and treatment they give to patients. A full awareness of not only the spoken word, but also the influence non-verbal communication has on the messages being communicated, is essential in the development of a therapeutic relationship between nurse and patient. The process of reflecting upon practice is also an essential element of knowledge development. After consideration of a number of reflective frameworks, the use of Gibb’s Reflective Cycle as a structure for creating a reflective account has proven to be beneficial in the exploration of personal thoughts and feelings in relation to a specified event and I recognise the importance of reflection as a learning tool that can enhance knowledge and practice.