After completing this chapter, you should be able to:
• Describe the basic components of communication.
• Identify effective ways of communicating with the health care team.
• Describe an assertive communication style.
• Apply effective communication skills in various nursing activities.
• Identify different types of groups and explain group process.
• Discuss team building, group problem solving, and interprofessional practice.
• Analyze components of interprofessional practice.
Communication is like breathing—we do it all the time, and the better we do it, the better we feel. At times communication can be so subtle that others are not able to comprehend the communicator. Communication between people in everyday life is an exercise in subtleties and interpretations. The more personal the information, the more indirect and obscure the message becomes. In nursing, indirect communications and obscure terminology can be the difference between life and death. When you say, “I want to be clear when I communicate with others,” it is no different from washing windows. The clearer the window, the better we see. Communicating with the health care team and teaching patients what they need to know is part of the foundation of nursing care (Critical Thinking Box 12.1).
Communication in the Workplace
Sharing information with the health care team requires different approaches. This communication on a daily basis may involve delegation of a nursing procedure to nursing personnel, clarification of a physician’s orders, reevaluation of a patient-care assignment of another health care team member, or coordination of various hospital departments (e.g., radiology, dietary, pharmacy, surgery, laboratory) to provide nursing care. Create role-playing situations with your peers by taking turns acting in the supervisor and subordinate roles (Critical Thinking Box 12.2).
How Can I Communicate Effectively With My Supervisor?
Upward communication with supervisors takes on a formal nature. It is important to learn and use the channels of communication. For example, you may share information with your designated team leader on the unit. The team leader shares information with the nursing supervisor or nurse manager, who shares information with the assistant vice president of nursing, who shares information with the vice president of nursing, and so on. From this example, you can see the communication approach taken with the appropriate chain of command.
Do you remember the game you played as a child in which someone whispers a secret to the next person, and each person repeats the secret down the line until the last person speaks the secret aloud? The secret may have started out as “Jenny was out picking berries today so she can bake a pie.” By the end of the line, it may have become “Jenny is so allergic to cherries that she breaks out into hives.” The point is that messages can become very distorted when they travel through the chain of command in the upward flow of communication. Arredondo (2000) says that when communicating with superiors it is important to state needs clearly, explain the rationales for requests, and suggest the benefits to the larger unit. It is also important to listen objectively to the response of the supervisor, because there may be good reasons for granting or not granting the request.
Arredondo (2000) gives the following tips for talking to your supervisor:
1. Keep your supervisor informed of potential or upcoming issues.
2. If a problem is developing, make an appointment to talk it over. Have specific information available, especially written documentation of facts. Focus on resolving the problems, not just the problems.
3. Show that you have important information to share and a sense of responsibility.
4. Be careful which words you use. Avoid blaming others, exaggerating, and using overly dramatic expressions.
5. Do not talk to your supervisor when angry, and do not respond with anger. Use “I” statements, and explain what you think in a professional manner.
6. If you want to present a new idea, give your supervisor a written proposal, and then set up a meeting to discuss it after the supervisor has read it.
7. Accept feedback, and learn from it through self-reflection.
8. Never go above or circumvent the chain of command; this includes your supervisor. Always communicate directly with your supervisor first before going farther up the chain of command.
9. Do not engage in sharing the details of your conversation with others who do not have a stake in the issue.
How Can I Communicate Effectively With Other Nursing Personnel?
When you speak with other professional nurses, you communicate using a lateral, or horizontal, flow of information. This flow is based on a concept of equality, in which no person holds more power than the other. This type of communication is best achieved in a work climate that promotes a sense of trust and respect among colleagues. When nurses work effectively together, their cohesiveness makes success more likely. This takes work and the deliberate use of facilitative messages (Northouse, 2015).
Ideally, professional nurses should view themselves as equals in their interactions with members of other health care disciplines, and their approach to communication should be a lateral one, even with physicians. The basis of this communication is the ability of the nurse to see himself or herself as competent and worthy of being an equal to physicians, social workers, dietitians, and others. Gaining this self-confidence is a major goal of every recent graduate. Using effective communication practices, as described in this chapter, and communication reporting tools (see Chapter 11 for information on hand-off communication) will help you achieve that goal.
Even a recent graduate will soon be providing direction to licensed nursing personnel and unlicensed assistive nursing personnel (see Chapter 14 for further information on delegation). It is important to remember that these people have needs for satisfaction and self-esteem, too. Directions do not need to be given in the form of authoritative commands unless an emergency demands immediate action in a prescribed way. Marquis and Huston (2014) suggest that when you provide direction, you need to think through exactly what you want to be done, by whom, and when. You need to get the full attention of the other person so you know that he or she hears you accurately. You should provide clear, simple instructions in step-by-step order, using a supportive tone of voice. Before the other person goes to do the task, ask for feedback to verify that he or she has accurately heard your instructions. Follow-up is necessary to be sure your directions were followed and to find out what happened, in case something more needs to be done. Involving personnel who are at other levels of nursing care in the planning and evaluation of patient care will increase those associates’ sense of responsibility for the outcomes and will help you to seem less authoritarian. Refer to the checklist in Critical Thinking Box 12.3 to identify areas needed for growth.
What does My Image Communicate to Others?
Unfortunately, we know that most people do not follow that suggestion. People develop impressions about us from the way we look, sound, talk, and act. Often we are less careful about the messages we send with our appearance and behavior than we are when we choose our words. But our image may speak louder than our words. Think about it. Would you feel comfortable accepting nutritional advice from a 300-pound nurse? How would you like it if your instructor criticized your professionalism while wearing dirty shoes, a wrinkled uniform, bright red nail polish, and four earrings in each earlobe? What would you think about a physician whose progress notes contain many misspelled words and poor grammar?
Your credibility is enhanced by good communication. Your image will help you communicate your professional credibility. Maintaining personal hygiene and grooming is essential. Your appearance at work should conform to the norms for professionals in your work setting; save your individuality for your personal time away from work.
Another aspect of your image is your depth and breadth of knowledge of your particular area in nursing. However, you also need to be familiar with a wide variety of subjects so that you can have conversations with people beyond nursing. When people discover common interests, they are more willing to communicate with you.
Flexibility is necessary for effective communication with different kinds of people. This means that you are willing and able to adapt your behavior to relate more comfortably or effectively with others. Flexibility is part of a positive image and says to people that you are willing to accept responsibility for changing your behavior to meet the professional needs or requirements of others. Take an inventory of your appearance, knowledge, and attitude. If you are not sure what kind of image you are communicating, ask several trusted friends.
How Do Gender Differences Influence Communication Styles?
Men and women view their work environments from different perspectives (Vengel, 2010; Mindell, 2001). Men often see the world from a logical, sequential, focused perspective. Women often tend to see the big picture and to seek solutions based on what makes people feel comfortable. Subtle communication differences can create barriers to open, healthy communication between men and women in the workplace. Within the workplace, the dominant communication style is direct, confident, and assertive. This style may be more familiar to men, because they are often raised hearing more aggressive, direct language from their parents, whereas many women may be more used to a soft, supportive tone of voice and choice of words. Cultural values learned in childhood also play a role in the communication style a person chooses. This style may have to be modified to make interactions more successful. A woman who is communicating with a man may need to be more direct and assertive than usual, whereas a man may need to learn to be less aggressive in many situations.
To summarize, men and women have innately different communication styles, often developed from their childhood experiences and environment. To be successful in the workplace, we all have to learn as much as we can about communication differences, identify our own styles, and have the flexibility to use other communication techniques as situations warrant.
What Should I Know About the “Grapevine”?
In addition to formal messages, communication can be informal. This type of communication flows upward, downward, and horizontally and is known as the grapevine. Whereas some people think of this kind of communication as gossip, others say it is the way things really get done. No matter how we describe the grapevine, we know it flourishes in all settings. People enjoy the satisfaction of the social interaction and recognition associated with the grapevine. It also provides information to employees that may not be easily obtained in any other way. It may be the quickest way to find out what the supervisor really values or what new job openings are available (Marquis & Huston, 2014) (Fig. 12.1).
Mindell (2001) provides the following tips for controlling the grapevine:
2. Communicate face-to-face whenever possible. Do not trust the accuracy of messages conveyed through a third party.
3. Whenever rumors are running through the grapevine, hold a meeting to provide information and answer questions.
4. Do not spread rumors. Make sure you have all the facts from their source.
5. Enlist the support of respected leaders to spread the truth.
6. Address significant issues as soon as possible with your manager so that negative feelings can be defused.
7. Make sure what is put in writing is clear and accurately understood.
How Can I Handle Cultural Diversity at Work?
Giger (2013) tells us that culture is a pattern of values and beliefs reflected in the behaviors we demonstrate. Whenever a group of people spends an extended period of time together, that group develops a culture. Each of us comes from a cultural background, and we have beliefs, values, and behaviors that result from that background. In our workplaces, we will encounter many different types of people coming from diverse cultural backgrounds. To communicate effectively, we need to understand our own culture as well as the other person’s culture. In addition, we must acknowledge and adhere to the cultural norms or rules that have developed in our workplace.
We must be aware of stereotypes that may interfere with our ability to see people as individuals. If we view people according to stereotypes, we might limit the way we perceive their communication. Even positive stereotypes make assumptions about people that may be inaccurate and thus may limit the nurse’s ability to use all of his or her work skills effectively (Critical Thinking Box 12.4).
According to Arredondo (2000), communication goes through many filters when a person interacts with someone whom he or she perceives as different. Some of those filters are related to culture, gender, education level, age, and experience. When messages go through these filters, the messages may change because the actual communication symbols are interpreted according to a person’s own cultural values and beliefs. This change may lead to misperceptions and misinterpretations. Communication is improved when we become more aware of the filters we use.
Within the work culture, people often communicate using jargon, inside jokes, or slang unique to the work setting. Acronyms are an example of jargon that health care workers understand but patients may not. It may seem to patients and their families that we are speaking in a code or foreign language. To interact effectively, we need to speak clearly, avoid jargon or slang, and keep our communication short and to the point. Long explanations with lengthy terminology can be confusing to people who are not familiar with the health care culture.
Differences in the cultural backgrounds of workers can be a real asset. Sometimes we may have to provide care to patients who speak languages other than English, and we may need to enlist the skills of co-workers to translate or interpret, especially when cultural values influence the interpretation of the patient’s behavior. We need to understand and respect cultural differences in patients. We can learn how to do this by learning about the differences among our co-workers. Respect and empathy enhance communication with people from other cultures, whether those people are patients or co-workers (Giger, 2013).
Components of Effective Communication
How Can I Communicate Effectively in Writing?
Communication takes place not only when words are spoken but also when they are written and then read by someone else. A big part of a nurse’s overall effectiveness depends on the ability to write effectively. This includes written treatment plans, progress notes, job descriptions, consultation requests, referrals, and memos. Some of you may even write articles for nursing journals or chapters for textbooks!
Mindell (2001) provides some guidelines for writing. First, determine whether you need to write in a formal way. Most upward communication needs to be formal, which means you should use proper titles, format, grammar, spelling, and punctuation. Never allow something you have written to be sent without careful proofreading. Nothing creates a negative impression faster than sloppy work, misspelled words, or poor grammar. If you need to, ask someone else to do this proofreading; be sure it is done well. Take the time to make necessary revisions before sending your written work to others.
Also decide what your purpose is before you write (Marquis & Huston, 2014). This will help you to organize your thoughts so that everything you write helps to meet your purpose. Learn to write exactly what you mean. Choose words that are clear and specific. Often this means simple, small words. Be careful to use technical words only when you are sure you are choosing the correct words and your reader will understand you. Keep your sentences short and simple, with only one idea in each sentence.
When you learn to be clear and concise, you will write the essential information without many lengthy phrases. Your readers will be very grateful if they can follow your thoughts easily. Make sure the first sentence in each paragraph identifies the key point for that paragraph. The reader should not have to guess what you are trying to say. Use a format that guides the reader. This means that main points on each page are easy to locate visually, and concepts are identified by headings or titles. Remember, how well you write strongly influences how you are evaluated. What you put down on paper makes a lasting impression, and people will make judgments about your credibility and professionalism for a long time after you have actually written the words.
How Can I Learn to Speak Effectively?
From giving a change-of-shift report to another nurse, to explaining your plans for a new protocol on the unit, to the organization’s administration, you will have many opportunities speaking to individuals or an entire audience! Even now as a student, you may have the opportunity to make a presentation to your fellow peers.
Many of us let our anxiety intimidate us when it comes to public speaking. However, public speaking can be a great chance to show off our skills, our ability to be creative, and our willingness to be a star entertainer. Think of your presentation as a wonderful opportunity to have the attention of others on just you, even if only for a few minutes (Arredondo, 2000).
A well-planned rehearsal provides the chance to see how long it will take you to say what you want, and it will help you feel more comfortable saying the words easily. Here are some tips on presentation preparation from Kushner (2004) and Peoples (1992).
Analyze Your Audience
What do they already know, and what do they need to know? Have a few objectives for what you want your audience to receive from your presentation.
Do Your Homework
Know enough about your subject to make your talk clear and believable. Make sure you can answer at least a few questions.
Plan the Presentation
This includes making an outline of the content and the teaching strategies you might use. Visual aids or activities may be used to involve the audience in active participation. Visual aids should keep the presentation focused and organized. They should help you hold your audience’s attention (Plus, you are more likely to persuade with visual cues.)
Add Spice to the Presentation
The more active your audience’s participation, the longer they will pay attention. Choose at least one presentation strategy that involves them, such as question/answer, role playing, or small-group discussion. Highlight visually on slides or using other types of media the key points you want your audience to remember. Pecha Kucha is an innovative format for developing presentations. A Pecha Kucha is essentially a slideshow presentation where you show 20 slides, each for 20 seconds (Pecha Kucha, 2016). Check out the following video from University of North Dakota for details on developing a Pecha Kucha (www.youtube.com/watch?v=32WEzM3LFhw) (Fig. 12.2). Use an attention grabber at the beginning to make sure your audience is listening. This may be a friendly greeting, a stimulating question, a startling statistic, a relevant story, or a quote by an expert. Then, in brief and concise words, tell your audience the purpose of the presentation and what it will cover.
Create Cheat Sheets
Cheat sheets are your clues—jot down the first couple of words around a topic to help you remember what to say or what questions to ask, or include small pictures or drawings to jog your mind during the presentation in case you stumble and fumble with your thoughts and words. If the speech or presentation is an important one and is fairly formal, you may want to prepare a script. This means you write out exactly what you will say and have it typed double-spaced, with a wide margin on the left side. Here you can write notes to yourself about when to use your visual aids or when to pass out materials for the audience. Even if you choose to write a script, be sure to memorize the first 2 minutes of what you are going to say!
In your closing, review what you have said, summarize the benefits or implications of what you have said, and reiterate any action you want taken. (Design your closing FIRST, because it is the most important part of the formal presentation. It may sound crazy to work backward, but the closing is what the audience will hear last and remember. Write it out and memorize it!)
Be familiar with the room and equipment you will use prior to the presentation. Determine that everything you need is there before you begin. Make sure the spelling is correct on your visual aids and handouts. Speak with confidence and enthusiasm, while making as much eye contact as you can. Walk around the room and use your hands and arms to make dramatic gestures. They add energy and interest. Most important—relax and have some fun. If you make a mistake, learn to laugh at yourself and move on. Your audience will forgive you. They may not be any more comfortable with public speaking than you are and will generally reach out and be supportive of you.
What Listening Skills Do I Need to Develop?
Listening effectively is one of the most powerful communication tools you can have. It is more than just hearing the words of others. Listening involves concentrating all your energy on understanding and interpreting the message with the meaning the sender intended. Of the four verbal means of communication—writing, reading, speaking, and listening—listening requires most of our communication time. Yet we often pay the least attention to our listening skills (Mindell, 2001). It has been estimated that people actually remember only one-third of the messages they have heard, although they spend 70% of their time listening (Marquis & Huston, 2014).
There are reasons that people are not good listeners (Arredondo, 2000). We simply do not pay enough attention; we hear what we want to hear and filter out the rest. Listening requires concentration, and that means doing nothing else at the same time. Some people think of listening as a passive behavior; they want to be in control by talking more. We think a lot faster than people speak, so we often think way ahead, think about other things, or daydream. Maybe too many distractions are interfering with listening, such as background noises or movements.
One of the most problematic reasons for ineffective listening is that people allow their emotions to dictate what they hear or do not hear. If the message is making demands on us to do more, change what we do, or do better, we may stop listening and start dealing with our own feelings of anger, guilt, or anxiety. We may start planning our own defensive response while the other person is still talking.
Think about situations where you’ve had difficulty listening, understanding, or remembering what was said. Consider these examples:
▪ A psychiatric patient who has recently been admitted displays acutely psychotic thought processes by talking rapidly in pressured speech, using words and phrases so loosely connected that the whole conversation is disorganized and incomprehensible.
▪ A charge nurse spends 5 minutes screaming at her team leader, criticizing everything she has done that day, and then asks the team leader to carry out a very specific and detailed change in the physician’s orders for a patient.
▪ Another nurse asks you to hang an intravenous solution for the patient in Room 1253 while you are writing some progress notes on a patient’s chart. When you finish, you cannot remember the room number where you agreed to hang the intravenous solution.
It becomes essential to develop effective listening skills (Arredondo, 2000). Here are some tips:
Make Sure You Can Hear What Is Being Said
Move closer, eliminate distracting noises, and most important of all, do not talk. You cannot hear someone else when you are talking.
Focus Your Attention on What Is Being Said
Actively concentrate by analyzing the key points as they are being said. Take notes. Do not do anything else while you are listening except to concentrate on hearing and understanding what is being said.
Recognize and Control Your Emotional Response to What Is Being Said
Focus on hearing and seeing accurately what is being communicated. You will have time to ask questions and explore your feelings after the other person finishes. As Vertino (2014) pointed out, if you feel threatened during communication with others, step back, and take a few minutes to calm down before responding.
Make the Decision to Listen and Accept the Other Person’s Needs and Feelings, Whatever They Are
Improved understanding of the other person is gained through listening, and this understanding will help you to be more effective in solving problems and eliminating negative feelings.
Pay Attention to Nonverbal Communication as You Listen to the Words
Much of a message’s meaning is communicated through the sender’s tone of voice, facial expressions, and body movements. You must listen with your eyes and your ears.
Fight Off Distractions
Do not let the speaker’s style of communicating, his or her mannerisms, or other interruptions such as telephone calls or another person vying for your attention break your concentration.
If a lot of factual, important information is being shared, take notes—but just jot down key words or numbers, or the note-taking itself will become a distraction. You may also ask the speaker to put in writing what he or she has said.
Let the Speaker Tell the Whole Story
React to the Message, Not the Person
Ask yourself, “Are my feelings or biases interfering with my listening?” Seek clarification of your understanding by verifying what you have heard.
Respond Positively to the Feelings Being Communicated
Empathy and acceptance will make it easier for the communication to continue. Maintain a positive attitude about listening. Recognize that listening is necessary for success. Allow yourself to hear all sides of an issue.
Identify the characteristics of your listening skills in Critical Thinking Box 12.5.
How Can I Use Nonverbal Communication Effectively?
Nonverbal communication uses movements, gestures, body position, and voice tone to transmit messages (Arredondo, 2000). To convey confidence and leadership ability, it is necessary to learn to use certain nonverbal signals effectively. Here are some tips.
Make Eye Contact With the Person With Whom You Are Talking
This helps the person interpret your message more favorably and says that you are giving your full attention to the conversation.
Stand Up Straight, With Shoulders Back
You may want to lean slightly forward toward the other individual to convey your interest. Stand with your toes pointed slightly outward and slightly apart and approximately 18 inches to 4 feet from the person you are talking to so that you do not invade personal space. Avoid personal contact unless you know the person well and it is a casual conversation.
Use an Assertive Voice Without Pauses to Suggest Confidence
Avoid a whining, nagging, or complaining tone. You may need to listen to your recorded voice to gain some insight into how you sound to others.
Watch for Distracting Behaviors
Avoid negative behaviors that detract from your verbal messages: nodding constantly, yawning, playing with your hair, checking messages on your phone, looking away from the other person, or constantly shifting your weight from one foot to the other. When you use your hands in gestures, keep your forearms up and the palms of your hands open. Avoid making a fist or shaking a pointing finger at the other person.