Communication is a process in which information, perception, and understanding are transmitted from person to person. As an integral part of any relationship, communication is important to nurses. Nurse leaders and managers can view communication as a tool to accomplish work and meet goals. The significance of communication revolves around its effectiveness and the climate in which communication occurs. Effective communication is enhanced by clear, direct, straightforward, and frequent message transmission. Trust, respect, and empathy are the three ingredients needed to create and foster effective communication.
For leaders, communication is a key element of the role. Leaders are in charge of vision, and the vision needs to be communicated as a compelling image. Such a compelling image is thought to induce enthusiasm and commitment in others. Thus a major part of the leader’s role is to communicate a vision. Leaders shape values and norms in a way that binds and bonds individuals and groups. Communication is key to this effort. Visions are communicated by means of managing meaning and creating understanding, commitment, and ownership of a vision. Leaders use communication as a tool for building trust. Trust is the glue that holds leaders and followers together.
• Humanizing Nursing Communication Theory: A nursing theory describing the manner of communicating that acknowledges the unique characteristics of the holistic human being. The communication patterns of interaction (communing, asserting, confronting, conflicting, and separating) are conveyed with an attitude that can be identified on the humanizing-dehumanizing continuum (Battey, 2006, 2007; Duldt, 2008; Duldt & Giffin, 1985). Humanizing Nursing Communication Theory (HNCT) is based on “normal” as opposed to “therapeutic” and includes not only professional-client but also inter- and intra-professional communication.
• Interpersonal communication: Communication between two or more individuals involving face-to- face interaction while all parties are aware of the others on an ongoing basis. Each person sends and receives information while continually adapting to the other actors.
• Persuasion, negotiation, and bargaining: Persuasion is the conscious intent by one individual to modify the thoughts or behaviors of others (Bettinghaus, 1968). Negotiation is a dialogical discussion between two or more parties to arrive at an agreement about some issue. To bargain is to make a series of offers and counteroffers about what each party will do, give, receive, and so on, until an agreement is reached to the satisfaction of all. All three of these involve communication. Persuasion uses argumentation and appeals to logic, whereas negotiation and bargaining may involve some sense of compensation and perhaps coercion, such as bullying or condescending behaviors.
• Spiritual assessment: Information needed by nurses resides within each patient, and the professional nurse seeks to use the patient’s own definition in developing individualized plans of care. This information may be obtained through informal conversation or a formal assessment interview.
• Spiritual care: Interpersonal communication. It exists in the relationship between the caregiver and the care recipient. Whether the spiritual care exists at all is determined by the perceptions of the one receiving the care. The implication of this definition is that nurses need specific communing skills to establish and maintain the relationship.
• Spirituality: A dimension of all human beings that is relational in nature, with a higher being and/or with other human beings; may include spiritual and religious practices, perhaps within an organized faith community.
Communication is a basic and essential skill for leaders and managers. Communicating, along with diagnosing and adapting, is one of the three basic competencies of influencing and leadership (Hersey et al., 2013). It is a critical and important tool for effectiveness in engaging and motivating people and in getting work done through others. Structuring messages so that people understand them clearly and avoiding emotion-laden triggers enhance the communication effectiveness of a manager. For example, the communication of accurate (correct, truthful, precise), adequate (sufficient, consistent, repetitious), and applied (useful and appropriate to the nurse’s individual needs) information was necessary for directing managed care changes (Apker & Fox, 2002). These communication techniques can foster stronger organizational affiliation while maintaining nurses’ strong identification with nursing.
Acquiring interpersonal relationship skills, including the ability to communicate, is as essential to a leader’s personal set of leadership skills as psychomotor skills are for a clinical nurse. Leadership and management ability is predicated on a facility for communication. In nursing leadership and management, skillful communication is essential for effective implementation of the change process. It is an intervention that leaders and managers in nursing use to accomplish their goals. Communication also is a key component of case management practice.
Language is used by leaders to give meaning to work. Communication problems may be a source of dissatisfaction. Research has indicated that a positive communication atmosphere, positive communication between staff nurses and immediate superiors, and personal feedback on job performance are related to nurse job satisfaction (Pincus, 1986). Farley (1989) identified six areas of organizational communication that can be assessed for communication problems (Box 7-1).
Leaders and managers always communicate in basic ways, whether they want to or not—they always communicate their attitude and their goals and expectations. Trust or distrust is communicated. Leaders communicate a vision, subtly or directly, and a sense of where they are going and what they expect from their followers.
One technique used for interpersonal effectiveness in groups, collaborative teams, and interdisciplinary work situations is persuasion. The tactics of persuasion are useful when an authoritarian leadership style is not appropriate and the nurse has to convince colleagues to work together.
Harvey (1990) suggested that skillful, positive questioning can persuade people to accept change. People are more willing to commit themselves when they see personal benefits. Positive questioning capitalizes on this fact to establish hopeful, affirmative attitudes. Inviting agreement, commitment, and realization of benefits facilitates necessary changes. Setting a positive and cooperative tone within a work group is each member’s responsibility. Nurses frequently may be in situations in which they need to persuade others to cooperate. Therefore they will need to use strategies of persuasion and negotiation.
The work of successful nurses and managers depends on the ability to negotiate. Nurses need to be able to articulate needs, positions, and justification for resources. The different techniques of conflict resolution and influencing in nursing include bargaining and negotiation as one method of gaining power and persuading others to grant autonomy by using individual and collective action. The use of collective action at both the work group and the larger profession levels can make a difference in terms of autonomy in professional practice, job satisfaction, and a general positive feeling about the profession of nursing.
Human interaction issues are the general arena in which leaders and managers spend most of their time. Power and conflict become important focal points of human interaction in organizations that may need management or resolution through persuasion or negotiations. Both conflict resolution and negotiation techniques can and should be used to manage change. As nurses are confronted with the impact of mergers, downsizing, restructuring and reengineering, and alterations in skill mix, negotiation skills are needed. These skills can help improve relationships and aid managers to function in their designated roles.
Negotiation is used to educate clients and other professionals about nurses’ roles and contributions, to get a fairer exchange in decision-making autonomy, to interact with vendors, to deal with client complaints, to interact with integrated health systems and group health care purchasers, to deal with unionized employees, to respond to the media, and to negotiate with medical staff and managed care groups to consolidate contracts (Sherer, 1994).
Nurses work in a complex and highly interpersonal relationship-based work environment. It is known that inter- and intra-professional relationships can be problematic (Duddle & Boughton, 2007). Conflict, poor colleague relationships, decreased job satisfaction, reduced productivity, and quality/safety concerns result. Leaders can help nurses gain insight into their own behavior, how it affects others and the work environment, and how to use strategies to cope, become resilient, and advocate for workplace communication improvements at all levels.
There is a great need in the health care professions to provide holistic care (body, mind, and spirit) to all clients, regardless of religious, ethnic, or cultural characteristics, in a humane (nonjudgmental and compassionate) manner. Yet today’s American health care system emphasizes certain business and management concepts such as efficiency, accuracy, and economy. This is expected in the use of sophisticated medical terminology and highly skilled specialists who operate modern equipment, but the technical and disease-oriented language that is used is often ineffective in aiding some patients to understand their health conditions.
Health care organizations are complex and exist in uncertain environments. Nurse leaders and managers play a crucial role in the management of information and communication for the purpose of effective care coordination and the avoidance of unsafe and error-prone care situations. Medical errors and patient safety in hospitals have been a focus of the Institute of Medicine (IOM). Clearly, providers need high-quality information and effective communication. Nurse administrators are responsible for developing care delivery systems with adequate structure and an effective communication system that enhances care coordination. These systems of communications need to enable patient rescue and safety by coordinating care, preventing information loss, and improving methods of surveillance (Anthony & Preuss, 2002). Interventions have been initiated to augment nurse and physician collaboration in intensive care units (Boyle & Kochinda, 2004) and to capture communication patterns in OR nurses to facilitate automation to reduce adverse events (Moss & Xiao, 2004).
A related concern for the management of information and communication is how to prevent breaches of patient confidentiality. The Health Insurance Portability and Accountability Act (HIPAA) provisions have heightened awareness about and presented strategies to protect patients’ privacy and data security in health care transactions. For example, fax transmissions need to be secure and security measures need to be taken to protect computerized databases and electronic transmissions. End-user encryption is commonly used for data security. In a series of interviews with 51 patients, Brann and Mattson (2004) identified both internal and external confidentiality breaches, which were categorized into a typology table. Health care providers’ actions that disseminate confidential information can harm patients. Systems, processes, and structures can be altered to prevent many of these situations.
A couple of examples from nursing leadership and management are worth considering. Delivering unpleasant news is one example. In hospital nursing, situations occur in which nurses are sent (pulling, floating, and farming are the terms used) from the unit in which they normally work to another unit. The person who has to deliver the often unpleasant news determines whether to call the unit and leave a brief note on the assignment sheet or go to the nurse to talk directly about the change. Some might offer to take the nurse to the other unit, introduce the person to the charge nurse, and smooth out the transition. There are different ways to structure and deliver the message to be effective in difficult situations.
One leadership situation occurs when a nurse presents a proposal to a committee who must be convinced to release the money for a project that is vital to the care of clients. Strategic planning and a written business plan are used to determine how to maximize the message delivery. This may include knowing how to structure the communication, nonverbally as well as verbally, so that a positive impression is created to set the stage for a full and impartial hearing. The use of the evidence base and expertise can be leveraged for effect.
Communication effectiveness becomes crucial in times of disaster. In fact, often one of the key outcomes of disaster drills is to identify breaks in the communication system so they can be fixed before a real-time event occurs. Argenti (2002) found that in times of extreme crisis, the internal communication to employees took precedence. It was most important for the leader to effectively rebuild the morale of employees so that they could then serve customers. The five strategies he recommended are as follows:
Implementing spiritual care in clinical practice within an agency is an example of communication leadership. Spirituality is in itself complex, unique, and difficult. As a leader, nurses are responsible for their area of knowledge, power, and influence. Nurses cannot expect to change other professions and disciplines but can set realistic goals about major issues within the scope of nursing leadership influence and make a difference in patient care. A plan to address the spiritual dimension of holistic care is offered based on theories, supporting research, and the study of spirituality in healing (Battey, 2006, 2007). This is not to be considered the final answer but merely an initial way to provide one perspective in developing a plan most appropriate to situational leadership needs.
One issue for leaders in nursing is to implement holistic care—the spiritual dimension of this paradigm in particular. Some may just add the word holistic to the mission statement and continue business as usual. This is not enough. The holistic paradigm is becoming the desired mode of health care delivery and needs to be reflected in communication and practice.
In the 2005 manual for hospitals, The Joint Commission (TJC) included requirements about spirituality care (TJC, 2008). Nurses are now charged to define and record social, spiritual, and cultural variables influencing the patient’s health in their initial assessment. Many facilities have pastoral care departments to provide spiritual care.
The proposed definition of spirituality useful for nurses is that spirituality lies within each patient, and the professional nurse seeks to use the patient’s own definition in developing individualized plans of care. Ethically, as nurses strive to deliver just holistic care, they need to keep their own spiritual/religious beliefs to themselves and avoid proselytizing. Although definitions of spirituality are endless, nurses need be responsible for only five dimensions:beliefs, values, meanings, goals, and relationships (BVMGR). The BVMGR rubric is proposed as the most appropriate guide or assessment tool for nurses. Nurses can be alert to the BVMGR topics during routine care of patients.
The core of spiritual care is supporting the following position: the definition of spirituality that is relevant to a particular patient/client can be found only within that person. Therefore it should not matter whether the nurse is a Buddhist or whether the hospital is owned by Jews or Catholics or Adventists or whether this happens to be a public hospital in the middle of the Christian “Bible Belt” of the southern United States. What is relevant to the health care decisions to be made for a particular patient is what he or she Believes, Values, finds Meaningful in life, maintains as life Goals, or has as special interpersonal Relationships. For nursing assessment, it is the rubric of BVMGR—the dimensions of a patient’s spirituality—that forms the basis for spirituality care.
The following definition is drawn from religious rather than health care scholars and offered as a benchmark for nursing. According to Kraus and Holmes (2007), spiritual care is not technique, technology, maps, guidelines, drugs, or directives that make the impact; rather, spiritual care is defined as interpersonal communication. Spiritual care occurs within the relationship between the caregiver and the care recipient. Whether the spiritual care exists at all is determined by the perceptions of the one receiving the care (Kraus & Holmes, 2007). The implication of this definition is that nurses need to develop specific communing skills. Two theories, Humanizing Nursing Communication Theory and Communication Ethics Theory, offer solid direction to nurses for interacting in a compassionate manner with spiritually distressed clients (Battey, 2006, 2007).
If spirituality is defined as relational, and if spiritual care is interpersonal communication, then the spiritual care of the nurses also is important. Extensive documentation in the literature exists regarding the disruptive and distracting communication interactions that occur not only between nurses and between nurses and professional colleagues (e.g., physicians, pharmacists, administrators) but also between nurses and patients. The research, the literature, and common knowledge from reading the daily papers indicate that nursing personnel experience high turnover rates, job dissatisfaction, and burnout; many RNs are leaving the profession. The shortage of nursing personnel in most areas of the United States has had a negative effective on retention of nurses and recruitment of students to nursing (Buerhaus et al., 2005; Buerhaus et al., 2007). The work environment is described as hostile to nurses, and patient outcomes of increased severity of illness and mortality have been directly related to poor communication skills of the staff (Kramer & Schmalenberg, 2003). The clinical ambiance and interpersonal communication received by nurses need to change. Leaders can set realistic goals within the scope of their leadership influence and make a difference where nurses live and work.
The challenge of this issue of leadership and communication, persuasion, and negotiation revolves around who is to change what, when, how, with whom, and with what outcome? How can the leaders (the “who”) who are to implement holistic care—especially spiritual care (the “what”)—throughout the nursing organization somehow (the “how”) involve all nursing professionals (the “with whom”) so that nurses will be able to provide spiritual care to patients (the “with what outcome”)?
Leaders, to a significant degree, are alumni of an educational system that historically did not teach these concepts. If they did, nursing education about spirituality was likely to be an hour’s lecture by a chaplain or minister. In fact, the current literature reveals a wide range of perspectives, including the position that spiritual care is not to be provided by nurses. Fortunately, most nurses are creative, “renaissance” people who are talented in examining, learning, reviving, and adapting to meet new challenges.
For most of the past century, concern for the manner by which human beings are treated has increased, not only on an international and national level but also in business and industry. The need for humane behavior toward people, especially in communication behavior, is particularly important as health care evolves into a larger and more complex industry. In a conference report (Troupin, 2001) from the Durban South Africa meeting of the World Organization of Family Doctors, David Satcher, the former U.S. Surgeon General, reviewed the history of health care for the past 100 years. His message to family physicians was to take an active role in improving the overall quality of health through focused efforts. He noted that health resources can be more equitably distributed if leadership is directed to improving and humanizing problems in the health care system.
It is proposed that if health care personnel, especially nurses, are regarded in a manner that acknowledges all characteristics of human beings, then these personnel will tend to regard the patients, clients, peers, and professional colleagues in a similar manner. Because registered nurses constitute the largest health care occupation in the United States, with 2.7 million jobs of the approximately 4.8 million people employed in hospitals in the United States (U.S. Department of Labor, Bureau of Labor Statistics, 2012), humanizing efforts become important to the fabric of health care.
Numerous theories of communication have been developed for nursing practice, usually in clinical psychiatric and mental health contexts. Attitudes are an important factor. Nurse leaders can become intellectually aware of and sensitive to the wide range of humanizing and dehumanizing attitudes (Box 7-2) that can be used with different patterns of communication interaction (Figures 7-1, 7-2, and 7-3). The list of attitudes was developed by searching the literature for concepts commonly used in promoting relationships and in counseling; then the antonyms were identified using a thesaurus. The patterns of interactions were identified from the discipline of communication studies and are known to be commonly used in everyday communication.