Communication Skills and Techniques



Communication Skills and Techniques


Katharine C. Cook, Phd, RN, CNE




OBJECTIVES


At the completion of this chapter, the reader will be able to:


• Describe and define the components of effective communication.


• Describe the levels of communication.


• Differentiate between effective and ineffective professional communication.


• Identify the three strategies that enhance interpersonal communication.


• Identify the three types of organizational communication.



PROFILE IN PRACTICE



Nothing is more sacred than the communication between a nurse and a patient. From this interaction, the baseline assessment is laid. Asking sensitive questions is part of taking a complete health history. As nurses we continually learn from our patients how to communicate with them in more effective ways. As a practicing nurse midwife, I became interested in intimate partner violence during pregnancy. I have had opportunity to interview many abused women about their pregnancies and childbirth experiences. These women teach us that better avenues to communicate effectively are always available.


Abuse is a secret that is often kept between a woman and her partner. Breaking that secret by the woman can mean a slap to the face, a hit to the head, or hours of beating. It is incumbent on the nurse to incorporate all his or her communication skills when assessing for abuse.


I want to share with you a lesson learned that represents both intrapersonal and interpersonal communication and the context involved in a communication. Charlotte was a 24-year-old survivor of intimate partner violence. She was pregnant with her second child when I met her. While I was interviewing Charlotte about her pregnancy and birth experience, I asked if any health care professional had questioned her regarding whether she was in a violent relationship and, if so, whether she had shared her abusive history.


Charlotte’s story began when she had her first obstetrical history and physical examination done by a nurse practitioner at a clinic near her home. While doing the exam, the nurse practitioner asked Charlotte if anyone had hurt her at home and whether she felt safe at home. As nurses, we are taught to incorporate sensitive questions regarding abuse within the normal history taking. Although Charlotte was in a very violent relationship, she told the nurse practitioner that she was not in an abusive relationship. This was the first visit Charlotte had had with this practitioner, so she may not have felt comfortable enough to discuss the abuse. However, the reason she did not confide to the nurse practitioner was very revealing. Charlotte’s partner was just steps away outside the examination room. Although the questions were asked in a private environment of the examination room, Charlotte was afraid that when the partner was invited back into the room, the nurse practitioner would confront him about what Charlotte had just said and then her partner would know she had told someone about the abuse—which was not in her best interests.


We do not know the skills this particular nurse had in asking about intimate partner violence, but even if the environment had been perfect, the questions sensitively asked, and the body language open and personal, the communication would still have been halted. Charlotte would not have answered the questions with honesty. We learn from Charlotte that we need to be as specific as possible when asking patients about sensitive information. We learn that we need to tell all our patients that what is said between us is confidential and that only with their permission will the information be divulged. Maybe if this nurse practitioner had expressed this to Charlotte, she would have learned about the abuse.




imageIntroduction


Communication is universal yet parochial. All human beings and, as increasing evidence suggests, most living creatures share and try to understand one another’s feelings and thoughts, even when not intending to do so. Such is the nature of the world; the deepest interaction is that of communication. Rudyard Kipling likened words to drugs and believed them to be even more potent than pills (1928). Although registered nurses are well trained in the administration of drugs and assessment of drug actions and reactions, most nurses do not understand the powerful actions and potential side effects of communication. Effective communication, like effective drug therapy, requires the five rights: right drug, right route, right dose, right time, and right person. This chapter discusses communication (right drug) in all its universality and in all its peculiarities concerning route, dose, timing, and personal interpretation.


What is communication? Webster’s dictionary defines communication as “giving or exchanging information signals or messages … by talk, gestures or writing” (Neufeldt & Guralnik, 1997, p. 282). The Latin root is communicare, meaning “to share.” Thus the key word in the definition is exchanging, which implies a giver and a receiver. Communication theory is based on this construct. Many early theories of human communication were built on a linear model, which assumed one person (sender) sent a message to another person (receiver). This conceptualization, however, simplifies a process that is very complex and makes static a process that is dynamic (Kreps & Thornton, 1984).


Contrary to conventional wisdom, communication is complex. The message is created by a process of interacting components: the meanings people actively create, the time and place of the communication, the relationships established between the receiver and sender, the past experiences of both parties, the personalities involved, the purposes of the communication, and the effects of human communication on people and situations. Meanwhile, as all these components dynamically interact, communication is occurring on many levels: intrapersonal communication, which occurs within the individual; interpersonal communication, in which two people interact; small group communication; and organizational communication. Each level builds on another, and successful communication at all levels depends on success at each communication level (Kreps & Thornton, 1984).



imageIntrapersonal Communication


The foundation of the communication pyramid is formed by intrapersonal communication. This level is within the communicator’s internal environment, where the critical skills of communication begin. Personal translation processes allow the person to constantly encode or create messages and to decode or interpret messages. During translation, the person creates meanings of the messages given and received from an intensely unique perspective. No word, object, or thing has any inherent meaning. The individual brings to bear influencing factors such as past experiences, personality, and relationships to the interpretation of content (Kreps & Thornton, 1984).



CONTEXT


The biggest influence on interpretation of content is the context in which the message is received. Context is much larger and richer than simply the time and place of communication: “It is more than background; it is the total frame that gives a message its meaning” (Maxwell, 1993, p. 1). Work by language theorists (Clifford & Marcus, 1986; Gergen, 1991; Maxwell, 1993) have led to the belief in a social construction of reality. Instead of one unmitigated universal external reality, what an individual thinks and understands is the result of interaction with others. Each person individually constructs reality; nothing is universal and neutral. All individuals do not necessarily share the same perceptions and conceptual frameworks. One readily given explanation for these phenomena is the traditionally understood differences in culture, but one must be careful not to fall into a static and unchanging viewpoint of culture. Cultural diversity is only a piece of what contributes to multiple understandings of the same word, object, or content. As Maxwell (1993) states, “Postmodern approaches instead stress how emergent such understandings are as people interact with others, especially in multicultural environments where people have access to interaction with such varied others” (p. 2). Culture and context both help and hinder communication. Language is ambiguous and depends on understanding implicit meanings and nuances of a situation. Returning to the drug metaphor, something as routine as receiving a message that a patient is in pain is ambiguous. Is the patient assigned to you? What kind of pain? Has the patient recently received pain medication? Did something happen that caused the pain? The list of questions is endless and automatic for an experienced nurse. It requires further communication, relying on shared meanings, and incorporating nuances of the situation. Linguists call this experienced communication response pragmatic competence in communication (Hearnden, 2008).



SELF-AWARENESS


Given that communication is the underpinning that forms a person’s reality, an understanding of the self—and how it is influenced by many external factors—is imperative. How does a person come to such an understanding of self?



Johari Window


One helpful framework is the Johari window (Table 8-1), a conceptual framework of the self that is named after its creators, Joseph Luft and Harry Inglam (Luft & Inglam, 1955). The metaphor in this theory is that of a window with four panes—one open, one blind, one hidden, and one unknown. The open pane represents what is personally known and also known to others. When interacting for the first time with a person, the size of this windowpane is small because each person knows little about the other person. This window becomes more open as a relationship develops and people self-disclose. The second pane reveals what an outsider knows about another but is unknown to the self; therefore it is called blind. This might occur when nonverbal and verbal messages are incongruent and the receiver chooses to believe the nonverbal message, of which the sender may be unaware. The third pane is hidden. This is information that is known to the self but not known to the outsider. The last pane is the unknown, about which neither the person nor others know. This unconscious area can be revealed to one or both as conversation takes place.



The ideal for effective communication is to raise the shade on the open pane of glass so that the self is more transparent to others. However, one should use caution in deciding what information to share with others. In personal relationships it is often not desirable to reveal things that could undo the balance of power in the relationship (e.g., past indiscretions in sexual behavior, mental health problems, life-altering failures). In professional relationships, self-disclosure needs to be in the best interest of the patient. Nurses can encourage reciprocal self-disclosure by revealing the nurse’s self as open, honest, and human (Gordon & Edwards, 1995). Storytelling, for instance, is a powerful means of connection, allowing caregiver and patient to understand commonalities and differences (Heilker, 2007).


A good rule of thumb, however, is to withhold any unresolved information. Unresolved information can shift the focus from the patient to the professional and can become an undue burden. This can be especially tempting when interacting with someone who is close to one’s own age. Even when teaching adults, the professional must be wary of sharing too much personal information. For example, consider a nurse who shared ongoing personal problems with the orientees she was coaching in a clinical setting. The new nurses tried to understand and be supportive but eventually asked for less self-disclosure from the mentor because it had become a source of worry and distraction.



Values Clarification


Another method for increasing self-awareness is values clarification. Simon, Howe & Kirschenbaum (1972) set six criteria that must be met for full value development: freedom in choosing, awareness of alternatives, awareness of consequences for each alternative, happiness with the choice, acting with the choice, and consistently incorporating the choice in one’s actions. Values evolve over a lifetime in response to changing circumstances. During values clarification the aim is not to change values but to become aware of what those values are and the priority assigned to each. Only then can the nurse separate his or her values from that of the patient. Box 8-1 provides a list of common values.



BOX 8-1   Values Clarification Exercise


Below is a list of values that people commonly hold. Rank these values in order of the priority each holds for you, with 1 being your top priority and 10 being your last. After completing the list, share your top three values with your peers. Discuss how these priorities affect your interpretations and decisions.



Modified from Simon, S., Howe, L., & Kirschenbaum, H. (1972). Values clarification: A handbook of practical strategies for teachers and students. New York: Hart.


Personal values are an important influence on how meaning is assigned to interactions and therefore decisions. The inherent tension between time freedom and economic security is one example. If someone must work to make a living but highly values free time, the person is likely to choose a lower-paying job if it is more flexible than a job with assigned office hours.



imageInterpersonal Communication


The next level of communication takes place interpersonally between two individuals. Receiver and sender become both intrarelated and interrelated. As one is encoding or creating messages to be sent, the other is already decoding or interpreting the messages being sent. Human beings have an ability to selectively perceive at any given time the information most important to them.


In everyday life, especially in the 21st century, people are barraged by constant external messages. To cope with this noisy environment, three strategies are inherent to the cognitive process. The first, selective attention, is reinforced and made possible by the process of habituation. During selective attention, the most important messages are given more cognitive space than less-important messages. Habituation enhances this adaptation by blocking out extraneous external and internal messages.


Both selective attention and habituation are constantly in a state of flux. What is important to a new nurse in conversation with a patient might be vastly different from the selective attention of an experienced nurse, who might be more attuned to subtle clues about the patient’s health status. Both nurses, however, can be influenced by internal messages that interfere with their ability to listen actively. This is especially true in today’s health care environment, in which fatigue from 12-hour shifts or too many patients can interfere with communication. To survive in such an environment, habituation allows the nurse to block out fatigue and problems at home to listen to critical messages sent by the patient (Kreps & Thornton, 1984).


One final skill inherent in human beings is the ability for closure. During closure, people make sense out of the messages to which they attended. Educated assumptions are made to fill in the gaps about the message based on the receiver’s logic and past experiences. Thus reality is relative and inexorably connected to past experiences (Kreps & Thornton, 1984). The nurse needs to develop particular skills to avoid premature closure, the most important of which is active listening.



ACTIVE LISTENING


Active listening is a learned skill in which the nurse suspends personal beliefs and values, resists categorization, and stays in the present, minimizing the influence of past experiences and self-directed current and future problems. The focus is entirely on the patient. The nurse, however, is not passive but is actively examining the content of the patient’s message, sorting the relevant from the irrelevant, and seeking clarification from the sender. Selective attention and habituation undergo change as the nurse identifies themes from the conversation and educated assumptions are voiced for patient validation. Often nurses perceive listening to clients as “doing nothing for them.” Active listening properly done, however, provides care and can require as much energy as the nurse expends during physical care of the patient (Pagano & Ragan, 1992; Sheldon, 2004; Williams, 2004).


Silence is an inherent part of active listening. Most nurses are uncomfortable with the use of silence in communication, deeming a pause in conversation as a patient’s need for reassurance and a cue for a nurse to “fill in the blanks,” often bringing the interaction to premature closure. Silence serves a critical role in communication, allowing both nurse and client to reflect on the interaction and its meaning. Often, letting the patient break the silence is important because it indicates to the sender (patient) that the nurse is willing to listen to the patient’s feelings, thoughts, and insights. Occasionally, however, the nurse will need to respond, either by performing a therapeutic technique, moving the conversation in a different direction, or concluding the conversation. The essential interpretation on the part of the nurse is to ascertain carefully whether the silence is uncomfortable for the patient or for the receiver (the nurse); that determination should guide the nurse’s actions (Northouse & Northouse, 1998; Sheldon, 2004; Williams, 2004).



THERAPEUTIC RESPONSES


In addition to silence, active listening is enhanced by verbal communication strategies that help the listener accurately receive the sender’s intended message. The names of verbal communication strategies vary from author to author. The principal focus should be on the rationale for using any one particular technique and the effectiveness of the response in keeping the receiver selectively attending to the message sent by the receiver and keeping the communication open until closure is truly achieved.


Restatement is a communication approach that has been variously described as repeating verbatim the last few words a patient says or paraphrasing the patient’s words. Regardless, the goals of restatement are to let the patient know he or she is being listened to and to encourage the patient to elaborate without asking direct questions. This response technique should be used sparingly because overuse leads to an air of insincerity and could be misconstrued as parroting the patient (Arnold & Boggs, 2003; Sheldon, 2004). Box 8-2 provides an example of restatement.



BOX 8-2   Restatement



Related posts:

  1. Genetics and Genomics in Professional Nursing
  2. Ethical Dimensions of Nursing and Health Care
  3. Historical Development of Professional Nursing in the United States
  4. Socialization to Professional Nursing

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Oct 26, 2016 | Posted by in NURSING | Comments Off on Communication Skills and Techniques

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