Chapter 2. Communication
Introduction
The basis of effective caring involves relationship building between the individuals concerned. In order for this relationship to be established appropriate and effective communication must take place. How the woman perceives her carers can make a significant contribution to her evaluation of the birth experience. Women value being cared for by staff who can communicate effectively with them and appreciate the opportunity to get to know their carers (Mackinnon et al 2005). In a study by Kintz (1987) in which women were asked to identify the helpfulness of procedures during labour, it was concluded that, ‘interpersonal skills are at least as important as technical skills, if not more so’ (p. 30). Also, how professionals communicate with each other has ramifications for how women perceive their care. Such interactions impact on the level of commitment perceived by the woman (Peltier et al 2000).The purpose of this chapter therefore is to highlight the principles of good communication to enable appropriate relationships to be established between the midwife and the families in her care and the multi-professional team.
Consider the following scenario in relation to effective communication.
Janine is meeting the midwife Claire for the first time in the antenatal booking clinic. Janine sits with her chin down and stares at the floor. Claire sits at the desk with her side to Janine writing in the notes. ‘Everything going ok, Janine?’ she asks. ‘OK,’ Janine mumbles in reply. ‘Great,’ says Claire. ‘Is this your first pregnancy?’
Questions raised by the trigger might include:
■ In meeting a person for the first time are there particular ways a midwife should communicate?
■ Does the environment make a difference?
■ What methods of communication are being used here?
■ Is the way the midwife asks questions important?
■ What does Janine’s response indicate?
■ How could Claire have responded differently? 
Background
A definition of communication is:
a process that involves a meaningful exchange between at least two people to convey facts, needs, opinions, thoughts, feelings or other information through both verbal and non-verbal means, including face to face exchanges and the written word.
This definition indicates that communication takes place within the context of relationships. It aims to be a ‘meaningful exchange’ which suggests that it is responsive in some way; its success is dependent on the content of the message, the skills and emotions of the messenger and the context of the recipient’s life. There are many aspects of communication and these are now described.
Verbal communication
Verbal communication takes place in a number of different situations. It can be during a face-to-face conversation or by telephone. It may take place on a one-to-one basis, or in a group or lecture setting. It involves the use of words or sounds and language. Verbal communication usually involves two aspects: one person speaking and another listening.
Listening
Listening is a key part of a verbal exchange. Concentrating whilst someone is speaking demonstrates respect for the other person. Not listening carefully can lead to misunderstanding or to the speaker giving up trying to get their message across.
Active listening involves taking time and concentrating on what the other person is trying to convey. It is suggested that three techniques that demonstrate that a person is being listened to include:
■ Paraphrasing the speaker’s thoughts and feelings
■ Expressing understanding of the speaker’s feelings
■ Asking questions (DeVito 2001).
This process entails ‘reflecting back’ to the other what has been said to ensure there has been understanding. The application of these skills is also relevant for telephone conversations. The need to speak clearly and listen carefully to what is being said is essential, especially as the cues of body language are not available to assist in interpretation of meaning.
Questioning techniques are relevant to midwifery practice as midwives often need to take a detailed personal history or assess why a woman has presented to the maternity services for care. Questions may be open or closed. Closed questions are generally those to which there is a limited, simple response, for example ‘what is your name’ or ‘where do you live?’. Open questions are those that aim to extract more detail from the person being questioned and give them freedom to express the answer in their own way. Enabling open questions may facilitate the person to provide the information they feel is most relevant for them. This latter form of questioning, although more time-consuming, is essential for the provision of woman-centred care.
Language
It is important to speak in a language that the other person understands. Where the recipient’s first language is not English, it may be appropriate to employ the services of a professional interpreter. The use of a client’s relations should be avoided for this purpose, except in an emergency, as the individual’s culture, age, sex and seniority within a family may influence whether messages are translated verbatum or edited. The client whose first language is not English may be able to understand English very well as long as the midwife speaks clearly and without haste; there is no need to raise one’s voice.
How you speak to your family or friends in familiar terms may not be appropriate when talking to clients. Similarly, how professionals speak to each other, using jargon and vernacular, is not appropriate in conversations with women and their families. That is not to say that technical terms cannot be used, but that the midwife should check understanding and offer to interpret some terminology so that women can be involved in their care.
The tone and pitch of voice can also convey emotion. Care should be taken to ensure that one’s voice shows interest rather than boredom and concern rather than fear.
Telephone communication
The midwife often communicates with clients or other professionals over the phone. As she does not have the additional information provided by body language she should endeavour to use unambiguous language and a clear voice. She should avoid having three-way conversations, for example if a partner rings in about a woman in labour, as it is difficult to get a true sense of the situation without speaking directly to the woman. Conversations on the phone can lack structure. To ensure that all important information is gathered, for example about a woman in labour or laboratory results, it is useful to have a pro forma or pathway to follow and complete. This should be an aid to care and not applied rigidly in situations where the woman should lead the conversation.
Access the All Wales clinical pathway for normal labour – telephone advice: http://www.wales.nhs.uk/sites3/Documents/327/Part%20one.pdf
Do you have a similar pro forma where you work?
Currently midwives who work in the community carry mobile phones, radios or pagers. However, on many trust premises and surgeries it is requested that mobile phones are switched off. This may prevent some people being able to communicate with their midwives or with their personal support network. Further work needs to be carried out to establish if the use of mobile phones enables enhanced communication between a midwife and her clients.
Physical communication
Body language
Communication does not just involve the use of words, it includes the use of body posture and gestures to express meaning, a concept also known as ‘body language’. A person’s facial expression also conveys the emotion behind the words. The use of the hands in the form of gestures or touch also communicates meaning with or without words.
These activities demonstrate how reliant we are on the use of our bodies when we are giving information and the implications for communication when women have restricted movement due to intravenous infusions, pulse oxymetry or intubation.
How we position ourselves during a conversation may also demonstrate how we feel even if our words are contradictory. For example, when we have our arms folded this can convey aggression and hostility, being closed to what the other person is saying. Thus to convey interest and concern the midwife should adopt an open posture, lean forward slightly and maintain eye contact. However, it should be recognized that for people from different cultures the signs of body language may mean different things. The use of gestures and eye contact may be usual practice within our culture but within others their use may be a sign of rudeness or disrespect (Schott & Henley 1996:72, Thompson 2003:29).
Personal space
Recognizing the need for interpersonal space is also a crucial aspect of effective communication. Being too close to a person with whom we are not normally intimate, during a conversation, can make both parties feel uncomfortable. It has been suggested that the usual nose to nose distance during normal social conversation is between 4 and 5 feet (Rungapadiachy 1999) but that different interpersonal distances are appropriate in different situations. As midwives we need to be aware of the impact of our closeness to clients as we are often in a position to be caring for women in very close proximity.
Touch
The way that we touch another individual can express intense meaning to the other. Skill is required to judge whether it is appropriate (Hall 2001). Laying a hand on someone’s arm or shoulder can convey concern and caring, but not all women are comfortable with this. Kitzinger (1997) demonstrates the potential for touch to be used as a positive tool for communication or one that can cause emotional distress to the persons concerned. Care should be taken that the other person does not misconstrue the messages that are given through touch. It is therefore advisable to ask permission from the client before using touch in a professional situation and essential prior to intimate examinations.
Presence
The issue of the presence of the carer in an encounter with those who are being cared for has been suggested to be the ability to be ‘in tune’ with the other and being aware of the other’s uniqueness as a person (Simons 1987). Different descriptions of ‘presence’ have been described (Osterman & Schwartz-Barcott, 1996):
■ Presence – This is where the carer is physically in the room with another, but totally self-absorbed, and therefore not available to the other.
■ Partial presence – This is where the carer is physically present but focuses her energy on a task rather than on the other person.
■ Full presence – This is where the carer is physically and psychologically present and each client interaction is ‘personalized’.
■ Transcendent presence – This is described as ‘spiritual’ presence and is said to come from a ‘spiritual source initiated by centring’. The presence is felt as peaceful, comforting and harmonious. There are seen to be no limits on the role of the carer and that she is able to recognize ‘oneness’ with the client.
From a midwifery perspective, a study of women’s experiences of their midwife showed that the phenomenon of ‘presence’ is necessary to enable a favourable interaction to occur (Berg et al 1996:15). They suggest that this presence pervades the encounter with the need:
■ To be seen as an individual
■ To have a dependable relationship
■ To have support and be directed on one’s own conditions.
The researchers suggested that some midwives were unable to provide this relationship, and were described as ‘absently present’. It is clear from this that presence of the participants is required for effective communication to take place.
Written communication
Written communication may be used in a number of ways; through letters of introduction, leaflets and information, writing in the maternity record, referral to other professional groups and completion of forms. Professionally it may also include completion of portfolios, reflective activities, essays, articles, completion of records, compilation of reports and statements, completion of charts, or preparing a job application. These activities may need writing in different ways as well as in different mediums. Some will be written by hand while others may require completion through a computer. Whatever ways they are written many are legal documents (Dimond 2004:1159) and therefore care needs to be taken to ensure they are factually correct and do not breach client confidentiality.
Information is often given verbally to women and their families but this should be reinforced where possible through the use of leaflets or information sheets. However, care must be taken as some women may not be able to read or understand the language in which it is written (Smith 2006).
Electronic maternity notes systems have been in place for some time in some areas and a nationwide format is now being developed (Walder 2006). The use of these may change the ways midwives currently document care and enable a more effective strategy, however there may also be anxiety regarding how the data stored will be protected for the wellbeing of the client.
Visual communication
Visual communication may include the use of pictures, such as drawing diagrams to explain issues, the use of graphical representation to replace text, or the use of web based or video material. The use of visual materials is useful to demonstrate situations where women find the verbal explanation difficult or to reinforce what is being said. Examples of visual aids include the use of models in antenatal education or the use of pictures to trigger discussions. Posters placed on walls in clinics are also visual displays of instructions or health promotion information.
Visual communication may also be established through the woman being encouraged to create pictures herself which the midwife may use as a tool to discuss and explore how the woman is feeling about her pregnancy (England & Horowitz 1998, Hall 2007). Further visual communication may be used to help parents communicate with their unborn baby through the use of cards and activities (Lynch & Bemrose 2005).
To summarize, Box 2.1 lists the factors to be considered when communicating with clients.
Box 2.1
Benchmarks of best practice (NHS Modernisation Agency 2003b:02)
Effective interpersonal communication needs to be considered in the context of:
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