Caring relationships formed among a nurse and those affected by a nurse’s practice are at the core of nursing (see Chapter 7). Communication is the means of establishing these helping-healing relationships. All behavior communicates, and all communication influences behavior. For these reasons communication is essential to the nurse-patient relationship.

Nurses with expertise in communication express caring by the following (Watson, 1985):

A nurse’s ability to relate to others is important for interpersonal communication. This includes the ability to take initiative in establishing and maintaining communication, to be authentic (one’s self), and to respond appropriately to the other person. Effective interpersonal communication also requires a sense of mutuality, a belief that the nurse-patient relationship is a partnership and that both are equal participants. Nurses honor the fact that people are very complex and ambiguous. Often more is communicated than first meets the eye, and patient responses are not always what you expect. By giving all of your attention to a patient, you attend to the patient’s needs and aid the healing process (Tavernier, 2006). Most nurses embrace the profession’s view of the holistic nature of people and experience synergy in human interaction. When patients and nurses work together, much can be accomplished.

Therapeutic communication occurs within a healing relationship between a nurse and patient (Arnold and Boggs, 2011). Like any powerful therapeutic agent, the nurse’s communication can result in both harm and good. Every nuance of posture, every small expression and gesture, every word chosen, every attitude held—all have the potential to hurt or heal, affecting others through the transmission of human energy. Knowing that intention and behavior directly influence health gives nurses tremendous ethical responsibility to do no harm to those entrusted to their care. Respect the potential power of communication and do not carelessly misuse communication to hurt, manipulate, or coerce others. Skilled communication empowers others and enables people to know themselves and make their own choices, an essential aspect of the healing process. Nurses have wonderful opportunities to bring about good things for themselves, their patients, and their colleagues through this kind of therapeutic communication.

Gaining expertise in communication requires both an understanding of the communication process and reflection about one’s communication experiences as a nurse. Nurses who develop critical thinking skills make the best communicators. They draw on theoretical knowledge about communication and integrate this knowledge with knowledge previously learned through personal experience. They interpret messages received from others, analyze their content, make inferences about their meaning, evaluate their effect, explain rationale for communication techniques used, and self-examine personal communication skills (Balzer-Riley, 2007).

Critical thinking in nursing, based on established standards of nursing care and ethical standards, promotes effective communication. When you consider a patient’s problems, it is important to apply critical thinking standards to ensure sound effective communication (Chitty, 2010). For example, curiosity motivates a nurse to communicate and know more about a person. Patients are more likely to communicate with nurses who express an interest in them. Perseverance and creativity are also attitudes conducive to communication because they motivate a nurse to communicate and identify innovative solutions. A self-confident attitude is important because a nurse who conveys confidence and comfort while communicating more readily establishes an interpersonal helping-trusting relationship. In addition, an independent attitude encourages a nurse to communicate with colleagues and share ideas about nursing interventions. Such an attitude often involves risk taking because colleagues sometimes question suggested nursing interventions. At the same time, an attitude of fairness goes a long way in the ability to listen to both sides in any discussion. Integrity allows nurses to recognize when their opinions conflict with those of their patients, review positions, and decide how to communicate to reach mutually beneficial decisions. It is also very important for a nurse to communicate responsibly and ask for help if uncertain or uncomfortable about an aspect of patient care. An attitude of humility is necessary to recognize and communicate the need for more information before making a decision (Paul, 1993).

It is challenging to understand human communication within interpersonal relationships. Each individual bases his or her perceptions about information received through the five senses of sight, hearing, taste, touch, and smell (Arnold and Boggs, 2011). An individual’s culture and education also influence perception. Critical thinking helps nurses overcome perceptual biases, or human tendencies that interfere with accurately perceiving and interpreting messages from others. People often assume that others think, feel, act, react, and behave as they would in similar circumstances. They tend to distort or ignore information that goes against their expectations, preconceptions, or stereotypes (Beebe et al., 2010). By thinking critically about personal communication habits, you learn to control these tendencies and become more effective in interpersonal relationships.

As communication skills develop, competence in the nursing process also grows. You need to integrate communication skills throughout the nursing process as you collaborate with patients and health care team members to achieve goals (Box 24-1). Use communication skills to gather, analyze, and transmit information and accomplish the work of each step of the process. Assessment, diagnosis, planning, implementation, and evaluation all depend on effective communication among nurse, patient, family, and others on the health care team. Although the nursing process is a reliable framework for patient care, it does not work well unless you master the art of effective interpersonal communication.

The nature of the communication process requires you to constantly make decisions about what, when, where, why, and how to convey a message. A nurse’s decision making is always contextual (i.e., the unique features of any situation influence the nature of the decisions made). For example, the explanation of the importance of following a prescribed diet to a patient with a newly diagnosed medical condition differs from the explanation to a patient who has repeatedly chosen not to follow diet restrictions. Effective communication techniques are easy to learn, but their application is more difficult. Deciding which techniques best fit each unique nursing situation is challenging. Communication about specific diagnoses such as cancer or end of life and dealing with patient and family emotions can be challenging, and some nurses struggle to cope with their own reactions and emotions (Sheldon et al., 2006).

Throughout this chapter brief clinical examples guide you in the use of effective communication techniques. Situations that challenge a nurse’s decision-making skills and call for careful use of therapeutic techniques often involve the types of persons described in Box 24-2. Because the best way to acquire skill is through practice, it is useful for you to discuss and role-play these scenarios before experiencing them in the clinical setting. Consider who is involved in the situation to decide which communication will be most effective.

Intrapersonal communication is a powerful form of communication that occurs within an individual. This level of communication is also called self-talk, self-verbalization, or inner thought. People’s thoughts strongly influence perceptions, feelings, behavior, and self-concept. You need to be aware of the nature and content of your own thinking. Self-talk provides a mental rehearsal for difficult tasks or situations so individuals deal with them more effectively and with increased confidence (Gibson and Foster, 2007; White, 2008). Nurses and patients use intrapersonal communication to develop self-awareness and a positive self-concept that enhances appropriate self-expression. For example, you improve your health and self-esteem through positive self-talk by replacing negative thoughts with positive assertions.

Interpersonal communication is one-on-one interaction between a nurse and another person that often occurs face to face. It is the level most frequently used in nursing situations and lies at the heart of nursing practice. It takes place within a social context and includes all the symbols and cues used to give and receive meaning. Because meaning resides in persons and not in words, messages received are sometimes different from intended messages. Nurses work with people who have different opinions, experiences, values, and belief systems; thus it is important to validate meaning or mutually negotiate it between participants. For example, use interaction to assess understanding and clarify misinterpretations when teaching a patient about a health concern. Meaningful interpersonal communication results in exchange of ideas, problem solving, expression of feelings, decision making, goal accomplishment, team building, and personal growth.

Transpersonal communication is interaction that occurs within a person’s spiritual domain. Study of the influence of religion and spirituality has increased dramatically in recent years, and ongoing research helps us understand the role of nurses in addressing a patient’s spiritual needs (Pesut et al., 2008). Many people use prayer, meditation, guided reflection, religious rituals, or other means to communicate with their “higher power.” Nurses have a responsibility to assess a patient’s spiritual needs and intervene to meet those needs (see Chapter 35).

Small-group communication is interaction that occurs when a small number of persons meet. This type of communication is usually goal directed and requires an understanding of group dynamics. When nurses work on committees, lead patient support groups, form research teams, or participate in patient care conferences, they use a small-group communication process. Small groups are most effective when they are cohesive and committed and have an appropriate meeting place with suitable seating arrangements (Arnold and Boggs, 2011). A nurse’s role varies with the function of a group. He or she frequently coordinates the group, provides recognition and acceptance of the contributions of each group member, and provides encouragement and motivation to help the group meet its goals (Townsend, 2009).

Public communication is interaction with an audience. Nurses have opportunities to speak with groups of consumers about health-related topics, present scholarly work to colleagues at conferences, or lead classroom discussions with peers or students. Public communication requires special adaptations in eye contact, gestures, voice inflection, and use of media materials to communicate messages effectively. Effective public communication increases audience knowledge about health-related topics, health issues, and other issues important to the nursing profession.

Nonverbal communication includes the five senses and everything that does not involve the spoken or written word. Researchers have estimated that approximately 7% of meaning is transmitted by words, 38% is transmitted by vocal cues, and 55% is transmitted by body cues. Thus nonverbal communication is unconsciously motivated and more accurately indicates a person’s intended meaning than the spoken words (Jones, 2009). When there is incongruity between verbal and nonverbal communication, the receiver usually “hears” the nonverbal message as the true message.

All kinds of nonverbal communication are important, but interpreting them is often problematic. Sociocultural background is a major influence on the meaning of nonverbal behavior. In the United States, with its diverse cultural communities, nonverbal messages between people of different cultures are easily misinterpreted. Because the meaning attached to nonverbal behavior is so subjective, it is imperative that you verify it (Stuart, 2009). Assessing nonverbal messages is an important nursing skill.

Good communication requires awareness of symbolic communication, the verbal and nonverbal symbolism used by others to convey meaning. Art and music are forms of symbolic communication used by nurses to enhance understanding and promote healing. Lane (2006) found that creative expressions such as art, music, and dance have a healing effect on patients. Patients reported decreased pain and a greater sense of joy and hope.

Metacommunication is a broad term that refers to all factors that influence communication. Awareness of influencing factors helps people better understand what is communicated (Arnold and Boggs, 2011). For example, a nurse observes a young patient holding his body rigidly, and his voice is sharp as he says, “Going to surgery is no big deal.” The nurse replies, “You say having surgery doesn’t bother you, but you look and sound tense. I’d like to help.” Awareness of the tone of the verbal response and the nonverbal behavior results in further exploration of the patient’s feelings and concerns.

Helping relationships are the foundation of clinical nursing practice. In such relationships you assume the role of professional helper and come to know a patient as an individual who has unique health needs, human responses, and patterns of living. Therapeutic relationships promote a psychological climate that facilitates positive change and growth. Therapeutic communication between you and your patients allows the attainment of health-related goals (Arnold and Boggs, 2011). The goals of a therapeutic relationship focus on a patient achieving optimal personal growth related to personal identity, ability to form relationships, and ability to satisfy needs and achieve personal goals (Stuart, 2009). There is an explicit time frame, a goal-directed approach, and a high expectation of confidentiality. A nurse establishes, directs, and takes responsibility for the interaction; and a patient’s needs take priority over a nurse’s needs. Your nonjudgmental acceptance of a patient is an important characteristic of the relationship. Acceptance conveys a willingness to hear a message or acknowledge feelings. It does not mean that you always agree with the other person or approve of the patient’s decisions or actions. A helping relationship between you and a patient does not just happen—you create it with care, skill, and trust.

A natural progression of four goal-directed phases characterizes the nurse-patient relationship. The relationship often begins before you meet a patient and continues until the caregiving relationship ends (Box 24-4). Even a brief interaction uses an abbreviated version of the same preinteraction, orientation, working, and termination phases (Stuart, 2009). For example, the nursing student gathers patient information to prepare in advance for caregiving, meets the patient and establishes trust, accomplishes health-related goals through use of the nursing process, and says goodbye at the end of the day.

Creating a therapeutic environment depends on your ability to communicate, comfort, and help patients meet their needs. Comfort is a critical value inherent in the practice of nursing. Therapeutic interactions increase feelings of personal control by helping a person feel secure, informed, and valued. Optimizing personal control facilitates emotional comfort, which minimizes physical discomfort and enhances recovery activities (Williams and Irurita, 2006).

In a therapeutic relationship it is important to encourage patients to share personal stories. Sharing stories is called narrative interaction. Through narrative interactions you begin to understand the context of others’ lives and learn what is meaningful for them from their perspective. For example, a nurse uses narratives to understand a patient’s perception of risk and the meaning of risk when taking medication that increases the risk of bleeding (Andreas et al., 2010) and to explore patient experiences of dignity in care (Dawood and Gallini, 2010). It is important to listen to patient stories to better understand their concerns, experiences, and challenges. This information is not usually revealed using a standard history form that elicits short answers.

Many nursing situations, especially those in community and home care settings, require you to form helping relationships with entire families. The same principles that guide one-on-one helping relationships also apply when the patient is a family unit, although communication within families requires additional understanding of the complexities of family dynamics, needs, and relationships (see Chapter 10).

Communication with other members of the health care team affects patient safety and the work environment. Breakdown in communication is a frequent cause of serious injuries in health care settings (World Health Organization, 2007). When patients move from one nursing unit to another or from one provider to another, also known as hand-offs, there is a risk for miscommunication. Accurate communication is essential to prevent errors (Cronenwett et al., 2007).

Use of common language when communicating critical information helps prevent misunderstandings. SBAR is a popular communication tool that helps standardize communication among health care providers. SBAR stands for Situation, Background, Assessment, and Recommendation (Pope et al., 2008). Research indicates that effective communication between health care providers and other members of the health care team ensures patient safety and promotes optimal patient outcomes (Amato-Vealey, Barba, and Vealey, 2008). Evidence identifies nursing actions that increase effectiveness of nurse-to-nurse interaction and interprofessional communication (Box 24-5).

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