Communication theory and its applications in nursing and healthcare

communication models:

ways of describing communication in a diagrammatic form; for example, the linear, interactive and transaction models

Communication models have evolved from the first rudimentary model by Shannon and Weaver in 1949, which described transmission. This linear model was fairly mechanistic, and basically reflected the idea that the sender and receiver had little to do with the interpretation of the message, which was essentially independent. However, if this were true, every time you went to a lecture, you would be able to understand the many messages conveyed to you without any explanation. Of course, the reality is that if you’re tired, distracted, overwhelmed and uncertain, the message will not be received in the way it was intended. This model also did not reflect the two-way nature of communication. It did, however, introduce the concept of the communication barrier – although only to a limited extent. It included physical noise, which meant anything that interfered with the transmission of a message, such as static on the radio line or your computer crashing.

Clearly, there are problems with the linear model in explaining how communication works, and better models evolved to better represent communication. Nonetheless, the linear model was useful as a critical starting point, and it helped to establish some common terms that have been adapted into other models, including:

  • sender/receiver – source and destination
  • message – the information being conveyed
  • code – the system used to convey the information, words, graphs, non-verbal communication, etc.
  • channel – the way the code is conveyed – for example, it may be easier to present complex information in a graph rather than by using the written word
  • noise – communication barrier.


a set of symbols that are combined to build a communication message – for example, type of language or graphic representations


a communication theory term – any barrier that affects the transmission of a message

As a nursing student, you may already have thought about the code or channel you use when communicating. For example, a patient may not be able to hear well, so you may have to write out the message. Emailing lecturers rather than seeing them face to face may be a choice based on your mode of study, convenience or anxiety, but one that you hope will achieve the best results. You will also need to consider non-verbal communication, as it makes up a significant proportion of communication (see Chapter 6). In the healthcare space, some patients may have to rely on non-verbal communication, depending on their condition. So, when communicating, you need to choose the channel and the code that are most effective at the time.

Thus, while there are some aspects of the linear model that represent what actually happens when we communicate (for example, the code or channel), the linear model does not reflect enough of the elements that describe communication. Unfortunately, some people communicate as if the linear model were accurate. For example, have you been to a lecture where the lecturers don’t ask for questions or take advantage of feedback? It is almost as though they believe they just need to deliver information and that you will receive it in the way it was meant with 100 per cent accuracy. This impedes meaningful and efficient communication.

The interactive model of communication (see Figure 2.1) is an advance on the linear model, as it reflects the communicator’s fields of experience (see below). It also includes more barriers – semantic, psychological and interpersonal. Most importantly, it includes two-way feedback, so it accurately represents what happens when we communicate. The initial impression is that this model provides a clearer explanation of how communication works. It introduces significant improvements: the two-way process and the field of experience. The number of barriers is expanded to include psychological and semantic barriers. However, the main problem is that it looks at communication as if it were tidy and predictable. It suggests that communication happens in discrete stages. ‘A’ asks a question of ‘B’, who then replies and the process is repeated. Unfortunately, this does not reflect the reality of communication, as the way people talk is often messy. They interrupt and talk at the same time, which can make it less of a ‘clean’ process. It could, however, be used to describe communication that does occur in discrete chunks, such as emails, forum discussions, Facebook messages and even (rare now) letters.

Figure 2.1 The interactive model of communication

The transactional model of communication (see Figure 2.2) added some important additional elements: the simultaneous and continuous nature of communication. It also added the interpersonal barrier, which is fundamental to human communication. Communication strategies are also included, which closes off the communication process (see below for a more in-depth discussion on communication barriers and strategies). The field of experience is what people bring to the communication experience, as we do not communicate in a vacuum. It is basically the individual, cultural, psychological and environmental variables that have created the way the person sees the world – these include factors such as values, sex, age, occupation, education, financial status, mood, memory, family background and personal relationships, to name a few. This field of experience shapes the way we perceive the message and ultimately our world-view. Chapters 3, 4 and 5 also discuss perception or world-view and its influence on communication.

Figure 2.2 The transactional model of communication

People’s unique world-views: Perception

As we go through each day, we need some kind of filtering system to help us process the constant assault on our senses by the multitude of stimuli in our environment. If we did not have such a filtering system, we would be exposed to so much information that we couldn’t mentally cope with it. Therefore, we need to make sense of the world: this is our perception, which creates our world-view. Perception is ‘the active process of creating meaning by selecting, organizing, and interpreting people, objects, events, situations, and other phenomena’ (Wood, 2013). The field of experience mentioned in Figure 2.2 contributes to our perception, as do multiple layers of experience. We can have similar viewpoints to others, but there will always be slight variations because each person is unique.

Siblings have similar backgrounds but many variables will affect their perception, such as birth order, different experiences at school and so on. Our perception is not cemented and can change over time – even seemingly intractable beliefs and values can be shifted. Once stereotypes of people are broken down, people may have a more realistic understanding and therefore their perceptions can change. For example, Spiteri’s (2013) study of schoolboys showed that when the boys had contact and open dialogue with young asylum seekers about their traumas and difficulties, the boys’ perceptions and prejudices were reduced and replaced with a more empathetic attitude. Chapter 5 examines the impact of perception in communication. In cross-cultural theory, perception is known as a ‘cultural world-view’ or ‘way of knowing’.

Our perception is affected by another important element of the transactional model: context. Time, place and relationship are important aspects of context, and can affect the success of the message.


the time, place and relationship of something, which can determine the meaning of communication


As time passes, you have different experiences that shape your perspective. As an undergraduate nursing student, your perceptions will change as you progress through your degree and gain knowledge and maturity, so your vision of the world will change. An example that shows how your world-view can change is your choice of career. You may have enrolled in nursing because you had certain perceptions of it. Highly dramatised television programs or other media can often shape these perceptions; students are sometimes attracted to nursing specialisations that are reflected in films and television as being exciting or glamorous, and this affects their initial choice (Birks et al., 2014). As some of the myths are dispelled and the reality is revealed, you will look at nursing in more sophisticated ways. Another aspect related to time is when the message takes place. Your timing can torpedo or enhance the success of the message. For example, as a nursing student, you may need an extension for an assignment, but contacting your lecturer at 5.00 p.m. on the day it is due may not be the most propitious time to ask for it. So time is a significant part of the complex communication process.


Where the communication takes place will determine how well it is received. For example, talking about your weekend when you are involved in an emergency situation at the hospital may not be regarded as the ideal place for such a discussion.


Our relationship with people helps to shape the way we perceive and interact with others. How intimate we are with people has an impact on our expectations. This also relates to our professional relationships. If a nursing student has a good relationship with some patients but not others, a negative attitude will be revealed to the problematic patients, no matter how hard the student tries to hide their true feelings. We betray ourselves by many of the different types of non-verbal communication, such as tone of voice (paralinguistics) and body language (kinesics) (see Chapter 6).

Communication barriers

Think about the following case study.

Case study

Mika (a first-year nursing student) explains how she tried to analyse her problems by using basic communication theory.

According to communication theory, my communication difficulties come from three major barriers. First, my communication issues with flatmates come from gender differences. As a woman, I am concerned about cleaning and noise, but my male flatmates don’t care. This communication problem is an interpersonal barrier which can be created because of different values and perspectives. Second, physical barriers are created by loud music and parties, and this can also lead to problems with my flatmates, which then develop into another interpersonal barrier. As an international student, I am also aware of semantic barriers, as I sometimes don’t have confidence in my English. This in turn creates psychological barriers because it creates anxiety.

Critical reflection

Reflect on the communication barriers Mika is experiencing. Write short notes about how you would solve these problems if you were Mika.

Mika is thinking carefully about her problems, and is applying aspects of the transactional model to them. This is a good example of how something that starts out as theory can have useful applications and be the starting point for problem-solving. As you progress through your studies and nursing career, you can be mindful and analytical about your communication. An understanding of intrapersonal, interpersonal, semantic and physical (or external) barriers can help to increase your emotional intelligence. It is worth noting that many of these barriers are sometimes interdependent and create overlap. For example, Mika’s semantic barriers ended up creating an intrapersonal or psychological barrier: anxiety.

Intrapersonal/psychological barriers

As nursing students and future professionals, you will be confronted by many situations that will make you uneasy, where communication barriers have arisen between you and the people with whom you are communicating. Some of these situations can be based on:

  • assumptions and expectations
  • fear and anxiety
  • stereotyping (leading to bias and prejudice) and labelling.

Intrapersonal/psychological barriers can stem from assumptions and differing expectations. For example, nursing students can make assumptions about staff or patients, thus creating potential problems. A study of nursing students found that assumptions made about a patient’s diet were challenged after astute questioning by a nursing student (Jirwe, Gerrish & Emami, 2010). The patient notes indicated that the patient would eat everything, and the nursing student reiterated this idea to the patient, who confirmed it was correct. However, the nursing student then asked the patient whether she ate pork, and the answer was no. This then led to a useful discussion where clearer information was given and both the patient and the nursing student were pleased with the result. This is an example of where a person did not accept an idea at face value. However, the same nursing student asked another patient (a man from an Islamic country) whether he ate pork (he didn’t) and this unfortunately created offence because of assumptions about religious differences (Jirwe, Gerrish & Emami, 2010), which therefore led to interpersonal barriers. This example illustrates the challenges nursing students face, and reflects the idea that not everyone will respond in a predictable way. It also suggests nurses need to be psychologically robust to deal with the vagaries of nursing life, as confidence can be built and diminished in the same shift.

intrapersonal/ psychological barriers:

barriers within a person, such as bias, anxiety and assumptions, that impede communication

Physicians may have expectations and assumptions about nurses that can also create communication barriers within the team, with potential risks for all concerned. In a study of oncology nursing, Wittenberg-Lyles, Goldsmith and Ferrell (2013) found that doctors sometimes failed to give the full picture about patient care because they assumed and expected that the nurse would already have this knowledge. This can have a potentially dire effect on patient care, particularly in the highly sensitive end-of-life care context, and could negatively affect the new nurse’s confidence when conveying observations that could be useful to the physician. Thus this circle of unresolved communication strands can create a poor communication climate because of these communication barriers.

Personal or political situations can generate fear and anxiety, which can also affect the nurse’s perception of the patient and ultimately patient care. Nursing students may unconsciously (or even consciously) blame the patient for things beyond their control. A climate of fear can often create poor behaviour, even if it is subtle, and this can have a deleterious impact on the patient. For example, some commentators have noted that people of Middle Eastern origin around the world are subject to racism and prejudice in healthcare settings. Unfortunately, this type of issue has real consequences, and affects the health outcomes for patients and creates further psychological problems including lowered self-esteem, social withdrawal and increased marginalisation (Al Abed et al., 2014). Of course, this applies to many other groups in our society, and if nursing students are aware of the causes of prejudice and possible impacts on patient care, it could help to reduce their negative behaviour (even if it is not intentional).

This kind of behaviour could be linked to labelling theory. Price (2013) states that labelling theory relates to the practices that some people construct to disadvantage the less powerful in society. Price’s discussion related to negative attitudes towards older people, who are sometimes perceived to be less productive and therefore less worthy of attention. If other groups are also labelled in a negative way, they can also be the victims of poor decision-making. Doctors and nurses are the gatekeepers and decision-makers for vital services and facilities, and intrapersonal barriers such as assumptions can lead to stereotyping, bias and even prejudice. This could unfairly disadvantage some patients and compromise patient care. Labelling theory is an example of a theory that can be applied to a specific context to help analyse a situation. Being aware of this theory, and taking steps to avoid these kinds of behaviours, can help overcome the intrapersonal barriers related to labelling and stereotyping.

Intrapersonal barriers are present in all human beings; they are part of our cultural and psychological history. Nursing students are no different from anyone else, but because your attitudes could potentially affect the way you treat colleagues and patients, it is important to develop emotional intelligence and take a ‘stocktake’ of these attitudes. As indicated throughout many chapters in this book, self-awareness is a critical starting point to changing perceptions and improving professionalism. Other strategies often stem from awareness, and particularly self-awareness.


Empathy is trying to understand the other person’s perspective, and it is a useful characteristic in human communication. If you really try to see the other person’s position, it helps to create more meaningful conversation, which could result in more creative problem-solving. The starting point for developing empathy is empathic listening, which goes beyond merely comprehending the words and centres on really trying to understand the other person’s situation, feelings or motives (Engleberg & Wynn, 2015). Empathic listening can help to remove you from the picture in order to focus on the other person. This can be difficult for some people, as they think that revealing their own experiences can help. While this may be true later, in the initial stages you really need to understand the problem, and this can only be done by listening carefully and providing encouraging verbal and non-verbal responses.


understanding another person’s point of view

The following questions by Engleberg and Wynn (2015) provide a useful guide to understanding the range of empathic listening:

  • Do you show interest in and concern about the other person?
  • Does your non-verbal behaviour communicate friendliness and trust?
  • Do you avoid highly critical reactions to others?
  • Do you avoid talking about your own experiences and feelings when someone else is describing theirs?

Just attempting to understand will help to minimise the barriers, as the other person will usually appreciate the concern. Bramley and Matiti (2014) studied the impact of empathy and found that patients really appreciated nurses’ empathetic behaviour; this not only related to their own care but also their observations of the care of other patients. They also wanted nurses who displayed little empathy to understand what it felt like to be nursed in an uncompassionate way. Empathy should not be confused with sympathy. Davies (2014) differentiates between them by analysing differences in terms of their impact. With sympathy, a patient will probably feel pitied, but if the patient is approached in an empathetic way, they are more likely to feel validated.


Validation is linked to empathy, and it can be another useful strategy – particularly when dealing with patients and their families. Validation is accepting what people say or do ‘as a valid expression of thought and feelings in that particular circumstance at that particular time’ (Harvey & Ahmann, 2014, p. 143). This does not mean you have to agree with the other person, but simply that you acknowledge how they feel. For example, if you perceived a patient to be malingering, rather than dismissing the complaint you could accept that the patient may generally feel that way and acknowledge it to the patient. This can then help to negotiate the communication until a solution is found.


accepting what another person says as being valid to improve the flow of communication

Jan 30, 2017 | Posted by in NURSING | Comments Off on Communication theory and its applications in nursing and healthcare

Full access? Get Clinical Tree

Get Clinical Tree app for offline access