Nursing standards in global and local contexts

Care providers’ communication capabilities are valued from international and national perspectives. Across the globe, nursing’s scope of practice incorporates the competencies and accountabilities of the nurse’s capacity to respond to change (ICN, 2013). Individually, a nurse’s scope of practice is not limited to tasks, functions or responsibilities, but rather relies on a combination of knowledge, judgement and skills (ICN, 2013). Nurses’ responsibilities include coordinating the inputs of the interdisciplinary healthcare team members to determine a comprehensive plan for patient care (Dempsey, Hillege & Hill, 2014). The range of responsibilities means the nurse needs to be a versatile and emotionally intelligent communicator.

Various international health organisations, both globally and locally, emphasise the importance of teamwork in their policies as an important ingredient of patient safety. For example, the World Health Organization (WHO) has a mandate to strengthen the capacity of the nursing and midwifery workforce through strategies to forge strong interdisciplinary health teams (WHO, 2014). This includes being able to function effectively in a healthcare team made up of professionals from multiple disciplines. The International Council of Nurses (ICN, 2013) recognises that nursing is known to be allied to other professions through collaborating, referring and coordinating healthcare activities.

In Australia, the national competency standards for registered nurses work in conjunction with the Nursing and Midwifery Board of Australia (NMBA) registration standards, and are used as the criteria to determine a person’s right to be registered or enrolled as a practising nurse (NMBA, 2014). Australian nursing standards are broad, and cover professional issues related to continuing professional development, criminal history disclosure, English language skills, professional indemnity arrangements, recency of practice, various endorsements and eligibilities (NMBA, 2014). The competencies are more specific to an individual’s professional practice, and their capability and capacity to demonstrate, under the domains of professional practice, critical thinking and analysis, provision and coordination of care and collaboration and therapeutic practice (NMBA, 2006).

Communication is a core ability mentioned in each of these competency domains in terms of the nurse demonstrating skills in protecting human rights, and appraisal of and feedback about self and others through reflective practice. Coordination and delegation of care with and for others, and establishing successful therapeutic and professional relationships, are also core competencies (NMBA, 2006). Competency standards in New Zealand also include specific indicators related to establishing rapport and relationships based on trust, respect and empathy (Nursing Council of New Zealand, 2014).

Beyond the professional requirements of nursing is the need to understand how nurses’ behaviours and communication styles affect their patients’ perceptions of their healthcare experience. As nurses are ever-present in the healthcare setting, it is their responsibility to consistently provide physical, psychological and emotional support to people receiving healthcare services. This recognition is coupled with the knowledge that effective interpersonal communication is crucial if nurses are to respond to changes in the contexts of contemporary healthcare while balancing the often competing demands of advancing work practices and complex client needs (Glass, 2010).

Interpersonal communication in healthcare settings

Interpersonal communication is at the heart of nursing. It can be defined as a ‘cyclic, reciprocal, interactive, and dynamic process, with value, cultural, and cognitive variables that influence its transmission and reception’ (Arnold & Underman Boggs, 2011, p. 13). Nurses encounter numerous communication challenges in their work. The consequence of this is that in a typical shift nurses interact with patients about a variety of issues concerning their health. For example, nurses collaborate and negotiate with other healthcare providers; they manage and lead members of the healthcare team; and they delegate and instruct health service staff. Nurses therefore need the mental agility to cope with and respond to the bombardment of messages they receive over the course of a shift. Logical and critical thinking is also required to prioritise the messages so that appropriate clinical decisions can be made. Advanced verbal, non-verbal and written communications techniques are then needed to disseminate and communicate the decisions reached. Nurses develop these communication and critical thinking skills throughout their careers, but their awareness of the need to develop such skills is established as early as their first year of study as nursing students.

The understanding of the extent and complexity of the communication, as well as the type and frequency of interpersonal communication that occurs for nurses, is reflected in some research studies – for example, in a UK emergency department, researchers measured the number of communication events with which a head nurse had to deal in a shift. They found that the head nurse had over 1000 separate communication events over a 10-hour shift (Woloshynowych et al., 2007). This seems an extraordinary number, but they uncovered even more sobering facts: 14 per cent of these communication situations were simultaneous and 30 per cent were interruptions to a task. This research illustrates that nurses have to mentally juggle a host of competing pressures in an emergency department, where attention needs to be focused on urgent emergency situations. In stressful circumstances where expectations are high and there are many demands, nurses need both robust and dynamic communication skills to negotiate these demands successfully. To achieve this, they need to learn the skills and be prepared to practise them as they progress through their degree and clinical placement experience.

Nurses encounter and engage with many different people in the course of their day. They also need to prioritise the messages as they receive them – which can be challenging, because they are subject to competing demands. For example, a patient may need analgesia, a doctor may be demanding assistance, a ward clerk needs bed availability and the hospitality staff want to know where to take a patient’s meal. Conflict arises if the clinical decisions or priorities of the nurse are impacted by these differing needs. Some of these stresses can sometimes erupt into aggressive behaviour – indeed, aggression and violence in the emergency department are common. Nurses are exposed to it more than other healthcare and emergency services workers (Hodge & Marshall, 2007), as patients presenting to emergency departments have expectations that their injury or illness will be reviewed and managed quickly.

Building self-awareness and self-concept

Previous chapters have identified how personal beliefs and biases influence the way we think and communicate with others. It is important for nurses to gain insight and to understand the personal perceptions and prejudices that might affect the therapeutic relationships they are expected to establish with patients. Self-awareness and experience contribute to the development of effective communication skills. Stein-Parbury (2014) suggests, for example, that if nurses are authentic, sincere and genuine with patients, they will develop a more open and meaningful relationship with them.

A level of self-awareness is integral to identifying weaknesses, building strengths and overcoming ‘blind spots’ – for example, in coordinating patient care in clinical contexts. Blind spots are those places where communication gaps occur that are potentially harmful to patients, and to organisational objectives and outcomes. The Johari window (created by Luft and Ingham in the 1950s and still relevant today) is a self-awareness model created as four quadrants displaying aspects of levels of self-awareness. The quadrants are: known to self, known to others, hidden and unknown to self. The Johari window (see Luft, 1984) outlines the progressive nature of self-awareness from unknown to open. The two quadrants that are important to the discussion in this chapter are the known to self and unknown to self (or blind) quadrants. The more self-aware we become, the fewer blind spots we have, and if we act on this knowledge we can improve our interpersonal communication.

To transition from the blind spot to a place where personal characteristics are known to self and others requires a deep understanding of the self. Nurses who already have a realistic understanding of themselves have a useful starting point in their communication and behaviour. For example, if a busy shift consistently makes a nurse short-tempered, but there is self-realisation about this, then there is a strong basis for change. Insight can provide nurses with information from which to enhance or halt specific ways of behaving. Conversely, nurses who are oblivious that their behaviour is negatively affecting colleagues and patients will be hampered in terms of improving the situation.

It can be difficult for most people to alter long-standing behaviours, but in circumstances where there is limited insight, it is very difficult and might require feedback from others to inspire a change. Behavioural change is dependent upon the inspiration and motivation of the individual. Motivation contributes to and is a key attribute of self-awareness (Dempsey, Hillege & Hill, 2014). The nursing competency standards are strong external motivators for seeking to gain personal insight and being alert to improvement opportunities. The care and safety of the patient are also powerful external motivators. Internal motivation is required when attempting to improve interpersonal capabilities in nursing practice, and this can be the most challenging thing of all. For example, the nurse may feel strongly motivated purely to improve the level of care they give to the patient.

Reflective practice

Self-awareness is a component of reflective practice, which is central to changing behaviour for improving nursing practice. As Chapter 3 outlined, reflection involves thinking about one’s nursing practice and communication, and how these affect others or can be improved. There are certain conditions that help reflective skills to flourish. These conditions, according to Mann, Gordon and McLeod (2009, cited in Devenny & Duffy, 2013, p. 38) include:

• intellectual and emotional support
  
• an authentic context (that is, within an organisational climate that promotes respect between professionals)
  
• access to mentoring
  
• time for group discussion and reflection
  
• freedom of expression of opinions.

Reflective practice is made up of purposeful actions and exercises, and is a creative process. Glass (2010) offers a model for reflecting on self to increase personal awareness. This includes listening to the substance of the messages you communicate to yourself. Sometimes, the substance of what we say to ourselves can be positive and at other times can be negative and detrimental to the self-concept. For example, if a nursing student were treated badly by a patient, the student could look at it in a negative light which could damage the student’s self-concept; however, if the student chose to look at it as a learning opportunity rather than a personal failure, then the self-concept could actually be enhanced. This approach reflects Glass’s (2010) recommendation about reframing such troublesome or counterproductive self-talk into positive responses. Improving one’s self-perception in this way will promote self-efficacy (see below) through an enriched self-concept.

Your response to the learning activity is most likely negative, and may sound something like, ‘This is terrible. I failed. I should have studied more.’ Negative self-talk is harmful rather than helpful. Alternatively, more realistic and positive dialogue might include, ‘This result is not what I hoped for. Does the course offer supplementary work? It means I may have to do the course again. I need to make an appointment with the examiner to discuss my options. If necessary, another attempt at the course will help me to get better grades next time.’

Self-efficacy and assertiveness

Self-efficacy is a valuable attribute that contributes to effective communication. People who practise self-efficacy recognise and value their strengths and abilities, and can motivate themselves towards meeting challenges by regulating their thoughts and feelings (Moyle, Parker & Bramble, 2014). Self-awareness is therefore strongly associated with self-efficacy (Arnold & Underman Boggs, 2011). As noted previously, reflection is a way by which nurses can improve their competency in these and other aspects of their practice.

Assertiveness is an important skill because it is based on respect for self and others. It does not reflect a ‘win at all costs’ mentality, but rather respects and accounts for the rights of individuals. An assertive nurse or nursing student can use skills to try to resolve the problem. If there is a dispute between healthcare practitioners, the assertive skills of the nurse will be useful. Respecting your rights and those of others sounds counter-intuitive when you are in a dispute; however, you need to be aware that the other person may have a different perspective and that you need to negotiate a common understanding. The key to assertiveness is to take the emotion out of the situation, as emotion usually exacerbates the problem. The person needs to calmly state the problem, articulate its impact and try to look at the problem from the other person’s point of view. A solution should then be offered. (Chapters 2 and 3 include some of the practical strategies for being assertive.) Some of the hallmarks of assertiveness include being able to provide constructive feedback, having the confidence to ask for feedback and being able to say ‘no’ without feeling guilty. This is an important tool in the nursing context – particularly when there are competing demands from colleagues and patients.

Non-verbal communication

Types of non-verbal communication

The nurse’s non-verbal communication has a powerful and important impact on the delivery of care. Non-verbal communication can be defined as communication without words, but this simple definition belies its complexity. Non-verbal communication is more than body language; it incorporates many different elements, some of which are:

• kinesics (body language), including movement, gestures, facial expressions and gesticulations)
  
• oculesics – linked to kinesics, this refers to the study of eye behaviour
  
• haptics – communication through touch
  
• chronemics – relates to use and perception of time
  
• paralinguistics – the tone of our voice.

An understanding of the different types of non-verbal communication can help nurses to identify and consider where adjustments might be made to positively contribute to patient care. The non-verbal communication methods applicable to the nursing context are discussed below.

Kinesics and oculesics are two types of non-verbal communication that are closely linked. A nurse’s alertness to these non-verbal messages can help to progress the nurse–patient dialogue so that common understanding is achieved. The patient may say one thing but the non-verbal cues could undermine the spoken message.

Kinesics is body language. It denotes how we move, what gestures and gesticulations we use, our deportment and the way we walk. Our body language can betray our words at times. For example, on inquiring about a patient’s health, an answer of ‘Fine, thank you’ could be accompanied by slouched shoulders and a downward gaze. The body language here is contradicting the spoken language. Even people who are aware of the impact of body language and try to ‘match’ their spoken and non-verbal aspects by smiling and appearing cheerful will be exposed by incongruent or conflicting cues. A nurse who is aware that monitoring for this incongruence can provide valuable information for guiding necessary patient care will respond and question the patient further.

Oculesics relates to how people use their eyes, and can be a way to regulate and progress the communication as well as closing the psychological distance between people. Eye contact can also stall communication – particularly when there are variables such as culture, gender, age and status inhibiting its effectiveness. In Australia, eye contact is regarded as a measure of a person’s confidence and honesty. However, some cultures avoid eye contact as a sign of respect to the status of the person. If the nurse is unaware of this, it can be misinterpreted and complicate care. This is where the negotiation of meaning is so important (see Chapter 2 and Chapter 5). The nurse can clarify confusions or concerns respectfully if this occurs.

Gaze and eye contact between the nurse and patient can be a key source of information and comfort. There are some patients who cannot speak because of conditions such as stroke, who rely on non-verbal communication to try to convey their feelings. Their eyes may be the only channel of communication. By paying special attention to the eyes of a patient during all interactions, the nurse has the opportunity to collect information that can contribute to comprehensive care. For example, squinting might indicate pain or discomfort, so further investigation at this point is warranted.

Coupled with verbal messages such as greeting by name and use of gesture, eye contact is recognised as a positive communication behaviour. A lack of eye contact by the nurse is a significant variable determining how successful the communication exchange is perceived to be by the patient (Happ et al., 2011). Nurses therefore need to be aware of the importance of using the eyes to gauge information and to help allay anxiety. However, cultural differences can affect the interpretation of eye contact, as in some cultures eye contact is determined by status. Children, for example, are trained not to look directly at their elders when speaking to them (Maier-Lorentz, 2008). These cultural differences may seem to be insurmountable, as there are so many variations. However, Maier-Lorentz (2008, p. 39) states that ‘nurses must be cognizant that several meanings may be attached to direct eye contact in order to communicate effectively with their patients’. It is therefore worth building knowledge as both a nursing student and a nurse. And it is worth remembering that not all people conform to a cultural expectation, which further complicates the issue.

Haptics is a type of non-verbal communication that relates to touch, and is sometimes viewed with suspicion in professional contexts. For example, teachers often modify their initial response to comfort a distressed child by hugging the child because of concern about using inappropriate touch. The use of haptics by nurses, however, is generally not viewed suspiciously, as most people see it as necessary and therapeutic. Therapeutic touch can be a powerful tool when used at the right time (Hillege, Hardy & Glew, 2014). Nurses practise in the intimate space of patients, and providing care by gently touching the patient’s hand or patting the shoulder can be encouraging and comforting for some. However, touch can also be quite confronting for the patient, even though they know it is necessary. Because healthcare practices involve nurses entering the personal and intimate space of others, there are inherent risks of patients becoming uncomfortable despite the sensitivity of the nurse (Glass, 2010). Therefore, the way a patient is touched by the nurse is extremely important and must be congruent with the intervention required. When used appropriately, touch is an effective form of communication; however, touching another person can have a multiplicity of interpretations for the receiver. Some factors that influence the way someone interprets the touch of another are family, religion, class, culture, age and gender (Hillege, Hardy & Glew, 2014, p. 119). Some cultures, for instance, have a more tactile and less inhibited approach while others have strong values and beliefs that prohibit, for example, male nurses touching females. It doesn’t necessarily have to be intimate touch, as in some Asian countries touching of the head is not welcomed because the head is seen to be the source of a person’s strength (Maier-Lorentz, 2008). If nursing students learn about such cultural differences during their studies, they will become sensitised to these differences and try to be culturally sensitive where possible (see Chapter 5).

Chronemics is a dimension of non-verbal communication that is different from the types discussed above because it doesn’t relate to one-on-one interaction with the various cues given and interpreted. Chronemics relates to time – that is, a message is conveyed about a person by their use of time. For example, a university student who arrives late to class every week may be judged as being uninterested, rude or even lazy. The fact that the student may not be able to get there because of a clash of class times or bus schedules is not considered by the observers. This kind of misunderstanding can be present in healthcare. How we use our time sends a message to others that can contain value judgements. In the nursing context, the amount of time spent with a patient may not be as much as the patient would hope. The patient may interpret this as them being less valued by the nurse. However, the reality may be that resources are stretched and the nurse could be overwhelmed with work pressures. It is disappointing that these stretched resources can affect the time spent with patients and their families, as these discussions could actually help to save time in the long run; time spent talking to patients and relatives can help nurses to recognise nuances in individual treatment responses (Chan, Jones & Wong, 2013, p. 2026). Nurses often need to have discussions about their capacity to deliver care. Openly communicating with the patient can help to avoid misunderstandings by establishing expectations. Nurses in the emergency department are frequently responding to inquiries about perceived delays in treatment from patients with non-urgent conditions. Talking to those involved about the realities of the nurse’s time constraints can help to lower expectations and anxiety.

Paralinguistics (or vocalics) refers to the tone of the voice. It can reinforce the spoken message or it can undermine it. When an impatient or hostile tone is used, it has the potential to increase anxiety in a patient. The patient is already in a vulnerable position. ‘It is important for healthcare providers to be aware of the power of voice tone and consider how their emotions may be inadvertently leaked through their voice tone.’ (Haskard et al., 2008, p. 18). Healthcare is a complex and busy environment, and some non-verbal messages can be (unwittingly) detrimental to patient care (see Thomas’s story on page 143). For example, if anger is conveyed to the patient, it could serve to weaken the trust that is so pivotal to the healthcare setting. Consider the nurse who disregards a patient’s requests for analgesia because the nurse does not believe the patient requires the medication.

An understanding of the different types of non-verbal communication can help nurses to identify and consider where adjustments might be made to positively contribute to patient care.

The relationship between verbal and non-verbal communication

Nurses’ awareness of their non-verbal messages may help to convey a sense of confidence, warmth and empathy to the patient, particularly when the non-verbal behaviour is positively linked to verbal communication. Problems emerge, however, when there is a lack of congruency between the verbal and non-verbal messages. For example, the nurse may use positive and encouraging words, but the message could be undermined by incongruent non-verbal messages such as hostile tone of voice or less than gentle handling of the patient. Much of our non-verbal behaviour is seemingly inherent, and it takes a concerted effort to change the way we use particular cues. Patients may exhibit stoic or bravado behaviours when in fact they may be deeply anxious about their circumstances. A nurse who is astute at detecting this by actively listening and observing can gather a great deal more information that could then generate new directions in patient–nurse conversations, which in turn could ultimately help guide patient care. For example, incongruence of facial expressions and body language with spoken responses is a sign for the nurse to ask more questions to gain greater insight.

Case study Brad’s Story

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