To speak is to articulate sound by pushing air out of the lungs, through the trachea and into the larynx where vocal cords take up one of two positions. When the vocal cords are drawn together like a stiff pair of curtains, the air from the lungs has to push them apart, and this causes a vibration which can be experienced by placing a finger on the top of the larynx and producing sounds like [z]. Sounds made this way are described as ‘voiced’. When the vocal cords are left apart, however, air passes silently to make ‘voiceless’ sounds such as [s] or [f]. In its journey onwards, the air passing through the larynx moves into the mouth and/or nose where sounds are formed by changing the shape of the oral cavity, notably with the tongue. Many of the sounds produced in this way form words, but a significant proportion form what have been termed ‘guggles’ or paralinguistic cues – expressions of surprise, support, ‘um hmm’, ‘ah ha’ and so forth which may be used to support and encourage a speaker or to indicate that a person wishes to interrupt. They are an informative part of the ‘music’ of conversation (Scherer et al 2002). Once sounds have been made, they must be perceived for communication to take place. In the ear, sound waves – a kind of ‘compression wave’ in the air – are converted into nervous impulses and enter the brain via the cochlear nerve. The basic anatomy of the ear is shown in Figure 2.2. Sound waves enter the ear via the pinna and outer ear canal and vibrate the eardrum or tympanum. This transmits vibration via the bones of the ear (the hammer, anvil and stirrup) to the cochlea, which is rich in nerve endings that are able to detect the minute deformations in the tissues caused by the vibrations and turn them into nerve impulses. These impulses then pass along the auditory nerve to the midbrain and then to the auditory cortex of the temporal lobes. The processing of sound into meaningful units of communication is not well understood, but it is possible that different brain cells or groups of cells specialize in the recognition of certain sounds.

If the sensory processes themselves are impaired, this can lead to communication difficulties. There are a variety of techniques which can be used to compensate for these impairments. For example, as well as mechanical aids such as implants and hearing aids, deaf and hearing impaired people can use a number of strategies to communicating which rely on the hands. A variety of techniques such as sign language (Fig. 2.3) and finger spelling may be employed (http://www.british-sign.co.uk) to convey meaning. There are also a variety of aids to help visually impaired people communicate, including: glasses, Braille, large print, books and magazines on tape, dark lined writing paper or even a grooved writing board, through to electronic aids such as label readers or voice recognition phone diallers. One critical aspect of non-verbal communication is the interpretation of facial expressions of emotion, and children with learning difficulties have been found to be less accurate than non-disabled children in making such interpretations. As Bandura (1986) has pointed out, the ability to read the signs of emotions in social interaction has important adaptive value in guiding actions toward others.

The ability to use language is located in the brain, and debate has ensued about the locality for this specific function. The role of Broca’s area in the human brain in the production of speech and Wernicke’s area in understanding the significance of content words in speech has been appreciated since the 19th century (Dronkers 2000; Fig. 2.4). These two areas are linked by a bundle of nerve fibres called the arcuate fasciculus. These two main areas have been studied closely in relation to various forms of brain damage and how such lesions affect language production. Damage to Broca’s area is related to difficulty in producing speech, while damage to Wernicke’s area is related to speech comprehension difficulties. In addition, a part of the motor cortex, close to Broca’s area, controls the muscles that articulate the face, tongue and larynx – all key to language production – which when damaged also affect communication.

If a client were to hear a word and repeat it, this suggests a simple transmission of a word being heard and understood in Wernicke’s area; this area transfers a signal via the arcuate fasciculus to Broca’s area, where production of the word is set up with a signal being sent to the motor cortex to put it out in a physical form by moving particular muscles, etc. Yet there is evidence that a large number of different areas of the brain are used for the production of spoken utterances (Posner & Raichle 1997) and that different areas of the brain are activated for different aspects of speech. Hence, a rich variety of anatomical and physiological mechanisms and senses lie behind human communication, and scientists are still examining this complex phenomenon, just as they still have much to understand about consciousness itself. Thus, in contrast to a localized view of language functioning in particular parts of the brain, it appears that this human skill is wrapped up with interdependent aspects of brain function.

Sometimes people’s predispositions may make them less likely to interpret cues in a particular way. For example those who are apt to be cynical or hostile are likely to misattribute happiness (Larkin et al 2002). Research has also revealed gender differences in the accuracy of decoding facial expressions of emotion, with males being less accurate than females (Pell 2002).

It is extraordinary how children acquire language. As well as becoming competent users of a complex syntax, on average English-speaking children acquire a vocabulary of about 60 000 words by the age of 18. The early stages of children’s communicative learning are outlined in Table 2.1. During peak vocabulary development periods during childhood this means learning a new word approximately every 2 hours. This has led some theorists, such as Chomsky, 1976 and Pinker, 1994, to suggest that there are somehow inbuilt – or as cognitive scientists sometimes say, ‘hard-wired’ – cognitive and neural structures that enable the grammar and lexicon to be learned so readily: in Chomsky’s phrase, a ‘language acquisition device’. This is debatable, however, and critics charge Chomsky and Pinker with paying insufficient attention to the sheer diversity of the world’s languages, or with not considering how difficult it is to explain language in evolutionary terms (Allott 2001). At the present state of knowledge, communication is far more than biology alone can explain, and to make sense of how communication has come to be employed we need to make sense of the evolution of cultural themes too (Oudeyer & Kaplan 2007).

Much human communication is delivered through non-verbal channels or ‘body language’, and is not dependent on sound. Through gestures, postures and facial expressions, people convey rich vocabularies to others. Early attempts to study these phenomena identified about 20 000 different facial expressions (Birdwhistell 1970), which, when combined with gestures and movements yield about 700 000 different possibilities, which may or may not be meaningful (Pei 1997). Non-verbal communication involves a variety of issues (Patterson 1983). Some functions concern how an individual feels towards another person. That is, non-verbal communication may express feelings such as like or dislike; it can establish dominance or control; or it can be used to express intimacy, perhaps by touching and mutual eye contact. Non-verbal signals can be used to regulate interactions, for example by signalling the approaching end of an utterance or the desire to speak, or they may facilitate goal attainment, for example by pointing. Facial expressions add to this visual richness, especially through changes to the eyes and mouth. In interaction in contemporary Western cultures participants typically spend about 60% of the time gazing at one another and these gazes typically last about 3 seconds (Argyle & Ingham 1972). Mutual gazes take up 30% of the time, with the actual gaze lasting about 1 second (Kleineke 1986). The eyes often signal that a person is ready to speak or to end communication. The use of body space – how close people position themselves to others (proximity) – and the shape or posture they adopt affect how messages are sent and received. Whether individuals touch others, and how they do this, and what clothes they choose to wear signal messages such as status and bring yet more dynamics to communication. The issue of how well-attuned a healthcare professional is to the client’s communicative preferences is therefore important. If healthcare professionals make decisions or communicate in a way that fails to account for clients’ cultural beliefs and preferences, then the client’s self-care, adherence to advice and overall outcome may well be poorer (Stewart et al 1999).

Drawing and graphical communication can be an important tool in the hands of nurses and their clients. Indeed, it may be especially useful when communicating with people from different language groups or with people who suffer sensory or communicative impairments. For example, there are cases of people who have been severely communication-impaired following a stroke but who have become functional communicators once more through drawing (Rao 1995). Some authors have also noted the way that drawings provide a useful window into the emotional lives of children who have suffered a traumatic event such as bereavement (Clements et al., 2001 and Wellings, 2001).

Nursing communication takes place in a context informed by wider political and economic directives, and involves communication with other healthcare professionals and patients. As such, it is caught in a web of powerful conceptions and ideologies of what society should be like, how it is constructed and what is important. According to Fairclough (1989), nursing is shaped by powerful ideologies of bureaucratic ‘cost-effectiveness’ and ‘efficiency’, and nurses’ training tends to promote acquisition of communication or social skills ‘whose primary motivation is efficient people-handling’ (Fairclough 1989: 235). This may tempt nurses to communicate in a way which has more to do with economics, politics and the public image of the institution for which they work than with their profession’s or their own value systems. The increasing conviction on the part of policymakers in the UK that there has been a power imbalance between patients and health care providers has led to a number of initiatives to try to ensure that patients’ voices are heard. Of particular interest in the UK is the Commission for Patient and Public Involvement in Health (http://www.cppih.org), established in January 2003 as an independent public body, sponsored by the Department of Health, to ensure public involvement in decision making about health services. Across England there are over 400 Patient and Public Involvement (PPI) forums comprising volunteers in local communities who are involved in helping patients and members of the public to influence local healthcare delivery (Commission for Patient and Public Involvement in Health 2006). In an effort to strengthen the ‘local voice’ further, the UK government plans to replace these with Local Involvement Networks (LINks) (Department of Health 2006a). This reflects a belief on the part of policymakers that:

To ensure that voices are heard at an individual level, within the NHS there is the Patient Advice and Liaison Service (PALS; http://www.pals.nhs.uk/), which was introduced to ‘ensure that the NHS listens to patients, their relatives, carers and friends, and answers their questions and resolves their concerns as quickly as possible’ (Patient Advice and Liaison Service 2007). While the bodies involved and their jobs are dynamic and the sketch presented here simply represents the current situation at the time of writing, the focus on getting patients’ needs taken seriously in the health services remains at the heart of policy and practice for the foreseeable future, and communication will play a central role in this process.

The American Telemedicine Association (2006) defines telemedicine as ‘the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status’. Telehealth covers a variety of activities in which information and communication technologies play a part. The term:

This can involve activities as simple as the use of the telephone to real-time monitoring of vital signs and online consultations. In the case of videolinks, a nurse can, for example, conduct an examination of a patient while at the same time being in audiovisual communication with other specialists who may assess the patient’s problems remotely. In the UK, there is acknowledgement of the benefits of so called e-medicine, especially in rural areas where there may be isolated or elderly clients. However, barriers can be encountered, especially where there is limited training, or where providers baulk at the initial cost of setting up facilities and associated increases in workload (Richards et al 2005).

Language can be a means of socializing a client into a particular kind of role, as a patient, a victim, as someone who is in pain or as someone who is incapable. There has been considerable research about the role of language styles and plot structures in enabling the roles of healthcare professionals and patients to be performed. Proctor et al (1996) studied how nurses in a trauma centre in a US hospital talked to injured patients. By video-taping interactions between nurses and patients in pain, the ‘Comfort talk register’ was identified, which included the following functions:

The authors suggest that because comfort talk is regularly used, it has a rhythmical, sing-song quality aimed at getting patients to endure the situation for longer. This highlights the importance of the style and content of communication in managing treatment.

As nurses deal with clients, some features of their language can be a source of complaint. Caregivers interacting with elderly clients have been observed using high-pitched baby talk, controlling institutional talk, short utterances, simple grammatical structures, interrogatives (questions) and imperatives (commands) (Ambady et al 2002). Moreover, there is some evidence to suggest that use of patronizing speech styles does not depend on the status of the patient – the confused are no more likely to be patronized than those who are alert and oriented. Rather, the speech style seemed to depend on the attitudes of the caregiver (Caporael et al 1983). The features of speech and non-verbal behaviour – for example high pitch, pats on the shoulder and expressions like ‘That’s a good girl’ – are perceived by the elderly patients themselves as patronizing, and are seen as unfavourable by observers (Ryan et al 1994). It is important that those working with elderly people are aware of such behaviour and that instruction is incorporated into the education of caregivers (Ryan et al 1994).

Hollinworth et al (2005) note fragmentary care from a variety of practitioners who may each seem ill prepared to deal with patients’ problems. Also, practitioners who talk down to patients or who talk among themselves can contribute to feelings of exclusion on the part of patients and carers and may prompt an angry response. Equally, fear, physical illness and disability, confusion and pain may all present as anger.

Institutional care encourages dependency, by means of both open (overt) and secret or disguised (covert) strategies on the part of care staff (Ryan & Scullion 2000). Although the situation is changing slowly, being a ‘good patient’ traditionally involved being passive, compliant and docile. The language of the institution is thought to be more important in producing dependency than the disability itself. Moreover, despite the ethic of care in such institutions, the experience of being cared for is often profoundly dehumanizing:

The role of language may be to offer comfort and to enlist clients in the rituals of health care in a way that will ultimately benefit them. It is important, however, to be aware of how language might just as easily patronize or incapacitate clients and place them in a position where they are disadvantaged.

Fundamental ideas about medicine are embedded in culture and language. Within the UK in the 21st century, most people think that they know what a sick person is. Everyday complaints like the common cold and gastrointestinal upsets have a set of symptoms that are expected to co-occur. However, history suggests that the way illness is defined depends a great deal on recent changes in patterns of sickness and health. Contemporary illnesses are different from those described in the 18th century – people no longer claim to suffer from ‘seizures of the bowels’ or ‘rising of the lights’. Nevertheless, in all centuries, the coherence of an illness is an important part of the sufferer’s experience of it. Concern with narrative emerges from the everyday observation that when we find out about someone, we usually do so by means of a story that they tell or which someone else tells about them. These stories are important because they do not merely describe experience but constitute or make it. Nurses narrate both their own stories of care and the stories told to them by clients. This does not mean that the stories nurses tell are pure fictions, but much of what happens between nurses and patients is to do with narration. This idea has been developed in psychology, sociology, anthropology and in the study of medical and nursing activities and the experiences of clients.

Narratives also reflect the interests of the teller. For example, Hyden (1995) describes how in cases of domestic violence, male perpetrators favour words that emphasize purpose (why they acted as they did) whereas female partners emphasize agency (how they were beaten) and the physical and emotional consequences. This kind of storytelling reveals another important feature – the communicators are often at pains to manage their ‘stake’ and ‘interest’ in the piece. A critical comment about a patient may be prefaced with the claim ‘I usually try to be on the patient’s side, but …’. Everyday speech is littered with similar examples. Homophobic comments are often accompanied by statements like ‘Some of my best friends are gay’ or potential accusations of ethnic prejudice are headed off with ‘I’m not racist but …’. In narratives of illness encountered by nurses, it is important to consider the role that culture has in helping to make sense of these phenomena. In European or North American white majority cultures, the degree of correspondence between the stories told by clients and professionals makes it easy to take signs, symptoms, syndromes and illnesses for granted. However, it is important to realize that if this cultural frame of reference is moved, the problems people express may seem at odds with dominant Western medical notions of health and illness.