How you communicate

5.1 Introduction

In this chapter we add another layer of knowledge, skills and insight to your repertoire of clinical attributes. We describe how you can make meaningful contributions to the clinical environment and to the patients for whom you care through sensitive attention to the way you communicate. In the first section we also describe the ways in which nurses can define and promote their profession by effectively using their ‘nursing voice’. Later in the chapter we discuss the implications of electronic forms of communication for students, nurses and patients.

5.2 What is a nurse?

In this section we draw on the work of Bernice Buresh and Suzanne Gordon, two journalists who have written extensively about the importance of nurses being able to define and promote their profession.

The public holds nurses in very high regard. Opinion polls indicate that nurses are the most highly rated profession in terms of honesty and ethics, rating significantly higher than pharmacists, teachers and doctors. Yet studies indicate that when people think of registered nurses they are more inclined to dwell on their kindness and caring than on their knowledge, expertise or professionalism. The public’s image of the nursing profession is linked to nurses’ ability to articulate their experience, skills and expertise:

The job at hand for nurses is to help the public (as well as other health care professionals) to construct an authentic meaning of the word ‘nurse’ that conveys the richness and uniqueness of nursing. This means not misconstruing nursing as something commonplace, but deepening the public’s comprehension of nursing as deeply complex, skilled and essential to patient care.

Buresh & Gordon (2000, p 17)

Coaching Tips

How do you introduce yourself?

Nurses have a choice about the way they present themselves to patients, families, doctors, other clinicians and the general public. They can present themselves in ways that assert their personal and professional identity, or they can remain part of the wider, undifferentiated healthcare services industry. They can highlight their clinical knowledge and competence, or they can conceal it. Each day in the workplace, what nurses say and do can elicit the respect and collegial treatment their professional standing deserves, or undermine it. While caring for patients and families, or interacting with other members of the healthcare team, nurses convey messages about their own respect for the status of nursing. Some of these messages are implicit; others are more explicit, delivered through presentation, body language, tone of voice and conversational style.

Some examples to think about

If a nurse thinks it advisable to consult a doctor, she or he can inform the patient by saying, ‘I’ll discuss this with the doctor.’ By using these words nurses imply that they have clinical knowledge and judgement, and see themselves as doctors’ colleagues. Alternatively, nurses can act in a subservient way by saying, ‘I’ll have to ask the doctor.’

When contacting a doctor, a nurse can establish collegiality by beginning the conversation with the words ‘Hello Dr Smith, this is Sarah O’Shea, Mrs Johnson’s nurse. She is experiencing chest pain and I think …’ Alternatively, she can cast herself in an inferior role by beginning ‘I’m so sorry to bother you Dr Smith, but this is Sarah, Mrs Johnson’s nurse …’

The way that nurses introduce themselves to patients and their families can also have a significant impact on how they are perceived. You can introduce yourself with a firm handshake, provide your full name, inform them that you are a student nurse and explain your role in the patient’s care. Or you can simply say, ‘Hello, I’m John’ and leave it at that.

Most patients meeting you for the first time have few visual cues about your identity and role. Your introduction is your best opportunity to let people know that you are a student nurse, a serious professional with clinical skills and knowledge. Being serious and professional is not the same as being distant and aloof. It simply means presenting yourself as a knowledgeable caregiver. This presentation tends to reassure patients rather than alienate them.

First name basis?

In some clinical contexts it has become common for nurses to use only their first names when introducing themselves to patients, visitors or doctors and some name badges bear only first names. Although the use of first names may vary depending on the context of practice and the policies of the institution, can you imagine doctors introducing themselves by their first names only? Why, then, is there an imbalance between these two professions? If nurses continue to uphold and reinforce these identification practices, it suggests that nurses regard doctors as superior in the healthcare environment. We know that this is not the real intention of nurses who use only their first names. Mostly, they are doing it to develop a friendly and informal relationship with their patients, and to show them that they are ‘on their side’ or ‘an equal’. Unfortunately, this often misconstrues what patients really want and need from a nurse. They don’t want a friend; they want a nurse with knowledge and skill. ‘A really good nurse will establish the context for a professional relationship. They will communicate to a patient: This is what I do. This is what you do. This is what I know. I will make sure that everything will be all right for you’ (Buresh & Gordon 2000, p. 52).

5.3 Therapeutic communication

Something to think about …

Words have a magical power. They can bring either the greatest happiness or deepest despair

Sigmund Freud

Communication connects people and creates social bonds, which in turn facilitate survival. A baby learns to cry to elicit a response from their mother when they are hungry or uncomfortable. Over time they develop words to communicate specific needs. Across the lifespan, we communicate not only our basic physical needs and wants, but also our most complex, intimate and psychological needs.

No doubt you have chosen a career in nursing because you relate well to people and enjoy communicating. You may think that you already have excellent ‘people skills’ and you may wonder why we have included a section on therapeutic communication in our book. Few nursing students understand the real meaning of therapeutic communication, how it differs from social communication and the impact that it has on the people for whom they care. Few realise that effective communication can be a form of therapy. Effective communication impacts on patient outcomes in many ways. Studies have demonstrated a relationship between therapeutic communication and compliance with medication and rehabilitation programs, reduction in stress and anxiety (Harms 2007), pain management, self-management, mood and self-esteem (Goleman 2006) to name a few. As with all forms of therapy, therapeutic communication requires knowledge, a defined skill set and practice (lots of practice).

So how is therapeutic communication different to how you communicate in your everyday life? Therapeutic communication occurs when the nurse effectively uses communication techniques and processes with a patient in a goal-directed way (Table 5.1). Therapeutic communication focuses on the patient’s needs not the nurse’s; it is not a mutual sharing of feelings or thoughts. Thus, self-disclosure on the part of the nurse is limited. The nurse responds not only to the content of the patient’s message, but also to the feelings expressed through verbal and non-verbal communication. Therapeutic communication requires active listening, attending to the patient, hearing what is being said and what is not being said, and communicating back to the patient that the nurse has heard and understood the message. This type of communication requires emotional intelligence (see Chapter 4; Goleman 2006), energy and concentration. It conveys an attitude of caring and concern. Therapeutic communication requires a broad range of skills and techniques, for example (Day & Levett-Jones 2009, p. 493–494):

• probing using open-ended and closed questions

• touch

• paraphrasing or restating

• seeking clarification

• providing information

• encouraging and acknowledging

Table 5.1Characteristics of a therapeutic relationship

A THERAPEUTIC RELATIONSHIP:

Is a partnership between a patient and a nurse, focused on the patient’s healthcare needs or goals

Considers people to be autonomous individuals capable of decision making

Considers the person’s culture, values, beliefs and spiritual needs

Respects patient confidentiality

Focuses on the promotion of self-management and independence

Is based on trust, respect and acceptance

Day & Levett-Jones (2009, p. 497)

Coaching Tips

Therapeutic communication does not just happen. As with all forms of therapy it is a learnt skill that takes work to learn and practice to master. However, the benefits for your patient are worth the investment.

While a full explanation of therapeutic communication is beyond the remit of this book, you will undoubtedly have opportunities to learn more about this essential nursing skill at university and you will have plenty of opportunities to practice it when undertaking placements. You should also refer to the Australian Nursing and Midwifery Council (ANMC) National Competency Standards for the Registered Nurse(ANMC 2006), Collaborative and Therapeutic Practice Domain, Competency 10, where the expectations of the nursing profession in relation to communication are clearly explained.

Resources useful to your learning include:

• Day J & Levett-Jones TP (2009) Communicating, in Berman A, Synder S, Levett-Jones T et al. (eds) Kozier and Erb’s Fundamentals of Nursing, Ch 27, pp 482–516. Pearson, Sydney.

• Harms L (2007)Working with People. Oxford University Press, South Melbourne, Victoria.

• Stein-Parbury J (2008)Patient and Person: Interpersonal Skills in Nursing, 4th edn. Elsevier, Marickville, Sydney.

Something to think about … improving patient endurance with comfort talk

Seriously injured patients undergoing lifesaving procedures after trauma often experience pain that is overwhelming. They vocalise their distress, withdraw from painful activities and may be combative towards members of the healthcare team. In this context, the goal of care is to stabilise the patient, minimise the effect of injuries and maximise survival. Comfort behaviours used by nurses are described by patients as their lifeline. ‘Comfort talk’ combined with the nurses’ posture, touch and gaze enable patients to endure extraordinary pain associated with trauma care. Comfort talk keeps patients focused on the minute-by-minute progression of the care (‘Nearly finished … then we’re done’). It enables patients to prepare for the next procedure and orients them by providing information about their condition and the necessity for care (‘You’ve got a real bad cut here … we’ll have to clean it’). Critical care is able to be given quickly and safely by assisting the patient to remain in control and endure through the use of comfort talk.

Morse & Proctor (1998)

5.4 Welcome to Australia or New Zealand

This section is related to the topic of cultural competence as discussed in Chapter 3. It is written especially for international students, although it will undoubtedly be of benefit to local students who want to better understand and support their international nursing colleagues. We hope that this brief overview complements what you learn in class about contemporary practice cultures and helps you to become accustomed to the clinical learning environment and the diverse factors that affect your learning experience. Without this knowledge, miscommunication is common and learning possibilities sometimes reduced.

Firstly, and most importantly, we’d like to say welcome to Australia or New Zealand. The increasing numbers of international students in academic programs such as nursing have had a positive impact on our ability to appreciate and understand different cultures. The diversity and richness that international students bring to the academic and clinical environment enhances the learning opportunities of all students and staff.

While most students may, at some stage, experience difficulties related to their clinical placement, these may be exacerbated by language and cultural differences. If you experience problems, it is important to reflect upon them and try to analyse the root cause of the problems so that appropriate support, guidance and teaching can be provided. Try to identify your fundamental issues of concern from the coaching tips below (adapted from Remedios & Webb 2005).

5.4.1 Receptive communication

Do you sometimes find it hard to understand what your patients or nursing colleagues are saying to you? Local accents, shortened, fast speech and the use of colloquialisms may cause significant difficulties for international students from a non-English speaking background. Misunderstandings between you and others may occur if you do not readily acknowledge when you have not understood or have only partially understood a conversation. Most importantly, patients’ safety may be jeopardised if you are not perfectly clear about what is being asked of you. Initially, it may be culturally difficult for you to do this, but keep in mind that in Australia and New Zealand it is not considered disrespectful to question an individual in authority or to ask someone to repeat what they have said. Nor is it considered a ‘failure’ on your part if you have not understood something. On the contrary, clinicians will expect you to ask questions, and to ask for clarification whenever you need to.

Coaching Tips

• If you want to confirm your understanding of an instruction or discussion, try paraphrasing: for example, ‘Can I confirm that you’d like me to take Mrs Smith to the shower on a commode, because of her low blood pressure [BP]?’

• Ask someone to explain any colloquial language you do not understand (fellow students are usually willing to do this).

• If you are unsure of healthcare terminology related to the patient mix on the ward where you are undertaking your placement, ask questions and be prepared to do some research.

• Remember, nodding or silence following a conversation may be taken to indicate that you fully understood what was being said, even if the reverse is true.

5.4.2 Expressive communication

Do you sometimes find it difficult or frustrating trying to make yourself understood by patients or nursing colleagues? During your studies you will be expected to become increasingly fluent in the English language, familiar with colloquialisms and conversant with the professional language used to report and communicate with health professionals, but still have the ability to switch to less formal language when needed—for example, when conversing with patients.

Coaching Tips

• Observing nursing staff communicating effectively with one another and with patients will allow you to clarify expectations and build upon what you already know.

• Reflect on these observations carefully. Ask yourself what made the interactions effective. How and why was humour used? What colloquialisms and terms need clarification?

• Make the most of opportunities to practise communicating with patients and staff.

• Do not hesitate to ask your clinical educator or mentor to observe you and provide detailed feedback on your progress.

• Most educational institutions have student-support services that provide English language tuition. Avail yourself of this opportunity if you require additional help. Alternatively, seek English language tuition from external providers such as community colleges.

5.4.3 Written communication

Is it difficult to understand what is written or to find the English words for what you want to write? Both international and local students can experience difficulties with reading and writing. Patients’ notes, referral letters, medication charts and other forms of professional documentation may be especially problematic as students try to find and use appropriate language and grammar.

Coaching Tips

• Develop a glossary of terms and their definitions (professional terminology as well as more conversational terms); add to it regularly and use it often.

• Practise, practise, practise! Try writing a nursing report on notepaper and asking someone you respect and trust to critique it for you before you write in a patient’s notes.

• Reading nursing journals will help you to develop your fluency in English and your professional vocabulary, and will build on what you already know.

• Even reading good-quality English-language novels set in your new country will improve your literacy and grammar, and help you to better understand colloquialisms and local culture. Ask your librarian to recommend appropriate novels.

• Remember that in nursing reports you must always sign your name in English.

5.4.4 Cultural issues

Are you finding the clinical culture in Australia or New Zealand confusing and stressful? If you have no previous experience with these healthcare systems, it may be difficult at first to understand the complexity of the structures and values that operate within the system. The interactions between you and patients or fellow students may present unique issues. This not only applies to international students, but also to local students who care for patients from diverse cultures. Misunderstandings may involve religion, gender and age-related issues, as well as language. Sometimes a lack of understanding and tolerance on the part of some clinical staff and fellow students may have a negative impact on the ability of international students to fit into and feel accepted in the clinical environment.

Coaching Tips

• Many educational institutions have dedicated courses, or at least an orientation program, to prepare international students for the cultural differences they may encounter. Local community colleges also provide programs to assist with reading, writing and speaking. Make the most of these learning opportunities as well as the opportunities to interact with local students.

• Join local sporting, musical or recreational clubs to increase your opportunities for socialising with people from different backgrounds.

• During your clinical placement experience it is important that you express any concerns you have, even though it may be difficult to do so. Sharing your worries with someone you trust will mean that you can be supported and guided. Sadly, not all students, staff or patients will be sensitive to different health beliefs, customs, cultural and religious practices. If you experience discrimination, subtle or obvious, you need to discuss it with your educator or academic staff member. All Australian educational and healthcare institutions have policies regarding discrimination and your concerns will be taken seriously.

• Seek out a peer mentor to work with during your studies. This should be a person who can support your development in the English language. Spend time together focusing on language development and understanding.

• Review the section on cultural safety in Chapter 3.

• Everyday English for Nursing(Grice 2003) is an excellent resource to help you develop your English language skills and Hally (2009)has also written an informative guide for international nursing students studying in Australia and New Zealand.

5.5 Using professional language

Nurses must be able to describe the care they give and the clinical decisions they make (Buresh & Gordon 2000). In discussions with colleagues, patients, their significant others and the public, the language that nurses use reflects on their professional standing. Nursing students are recognised as a part of this group of professionals and are expected to behave according to the conventions of the nursing profession.

You will accumulate a lot of professional and jargon-based words and statements that will become a normal part of your practice language. Nursing jargon refers to words that are used by nurses when they talk about their practice. These words may exclude people who are unfamiliar with their use, so choose your words carefully when you speak to people who do not have a nursing background. Distinguish between what you say to health workers and what you say to the lay person. Colloquial language, or slang, is often referred to as conversational speech without constraint. While appropriate in some contexts, its use should be minimised in the practice environment.

As you progress through your nursing program, you will develop a wide repertoire of professional terminology. Give careful consideration to your audience to ensure that you use the most appropriate language in each situation. The inappropriate use of nursing terminology will completely change the meaning of your message. Abbreviations must be approved by the institution in which you are undertaking your placement. Some words that are commonly abbreviated can have very different meanings within various contexts of practice (for example, ‘SB’ may be an abbreviation for ‘seen by’ or ‘short of breath’). Clinical errors can occur as a result of this type of miscommunication.

For some nurses, it is not unusual to address their patients, particularly if they are elderly, using endearments such as sweetie, cherub, darling, dahls, angel, lovey, etc. (Gardner et al. 2001). However, this is not person-centred language and many people will be offended by being addressed in this manner, so don’t assume that it is acceptable. A good rule is to simply ask a patient if he would prefer you to use his given name (e.g., John) or address him more formally (Mr Smith).

Coaching Tips