Communication in Nursing

This assignment will cover the theory on the importance of communication in nursing, aided by a reflective account of a clinical placement experience. The clinical placement reflection will highlight the importance of how communication had a very relevant role upon a situation encountered on placement, and its support of the communication theory.

The situation that will be addressed was with a patient with whom I had cared extensively for over the course of a six-week placement. For confidentiality reasons, The Code of Professional Conduct (NMC, 2008) will be abided by, and the patients name will be changed to a pseudonym of Mr Peter Jacobs.

The communication process, as Ellis et al (2003) acknowledge; is a process of interacting with one or more people using a basic process of a sender, a receiver and a message set within a particular context, that is used via means of both verbal and non-verbal messages.

Understanding the basic principles of communication should be a fundamental skill of any nurse, and though every nurse will be taught this skill, still a proportion of nurses, as Craven and Hirnle (2006) explain; will forget to communicate with their clients, or colleagues, when undertaking technical tasks, etc.

Whilst maintaining a professional, holistic and efficient means of communication process with a patient, a nurse should not forget that applying the same approach with his/her colleagues is equally important. Assumptions between colleagues should never be advised, as a nurse may have arrived late during the hand-over process, or may not have had time to look at a patients amended care plan, card-ex, etc. This could then lead to inappropriate care given to a patient, which in turn, could lead to all manners of implications.

The importance of communication within the nursing field shall be addressed with obtained theory from professional/creditable researchers. This theory will then be followed by a personal reflection of a clinical experience that will support the theory obtained, leading to an overall conclusion on the importance of communication in nursing.

The Importance of Communication in NursingCommunication is a fundamental aspect of social interaction, and as Riley (2008) explains; it involves the reciprocal process in which messages are sent and received between two or more people. This process can be observed by means of verbal or nonverbal interaction. Many differing models of the process have been explained over the years, though nearly all have the same fundamental aspect of interaction that incorporates the process of communication. Riley (2008) highlights this process by means of, the sender transmits his/her own thoughts and feelings, which are then decoded by the receiver, who then it turn encodes a message and sends it back to the original sender, who then decodes it. This process is then continued until all required information is given or received.

When implementing the nursing process, communication plays a vital role in the continuation of care. Alfaro-LeFevre (2005) defines the nursing process as five interrelated steps that consist of assessment, diagnosis, planning, implementation, and evaluation. Without efficient communication between a nurse and the patient, or colleagues, it would put a strain, or even abruptly end the organization and prioritization of patient care, the patient’s health status or quality of life, as well as the confidence and motivation of a nurse to think critically in a clinical setting.

The ability of communicating effectively with others could be the difference between relationships becoming long term or short, or even the difference between life and death, and in respect to the daily demands of a nurse, time is of the essence. A nurse needs to effectively give, or receive information decisively and correctly, whilst continuing to maintain a positive interpersonal relationship with the patient/client. The nurse has to be approachable and professional, whilst making sure to avoid becoming too personally sociable with the patient/client, otherwise this could deflect the communication away from the information needed or given.

A nurse needs differing types of communication skills to adapt to differing clinical environments or situations. As Potter & Perry (1995) point out, the three main levels of communicating are, intrapersonal, interpersonal, and public communicating. Intrapersonal communication is a process when a nurse uses his/her own self-awareness, experience, and knowledge in deciding whether something needs to be done in a given situation. Interpersonal communicating is encountered most frequently in nursing situations, often by means of face-to-face communication, or in small groups.

Public communication is the form referred to when addressing large groups of people such as students in lecture theatres, or consumer groups in healthcare education (Potter & Perry 1995). A nurse will no doubt encounter all of these situations and will need to adapt quickly and accordingly, though firstly, as Hogston & Marjoram (2007) announce; a person must have knowledge of their own self-concept before they begin to understand another person’s self-concept, this is a skill acquired through maturity and awareness. By understanding one’s own self-concept and self-awareness, one may then be able to empathise and understand other peoples.

Non-verbal communication skills are often overlooked or underappreciated in most aspects of daily living, but for a nurse to utilize communication effectively, this has to be at the forefront of his/her consciousness. As Dougherty & Lister (2004) acknowledge, it is possible to give a verbal message whilst transmitting an incongruent non-verbal message. With a majority of literature stating that at least 70% of communication is non-verbal, it should be easy to acknowledge that body language, facial expressions, etc, could conflict with what is being communicated verbally. If a nurse is giving a verbal message of assurance to a patient/client whilst adopting a facial expression of uncertainty, this could confuse the patient/client into thinking that the nurse is not being truthful, even though the nurse may be thinking of whether to go shopping after his/her shift finishes. This is why a nurse should be adopting a patient centred care approach, and not be thinking of any exterior plans/actions.

A further example of non-verbal communication can be adopted when a nurse enquires about a patient/client’s wellbeing. If a nurse was to ask if the patient/client was in any discomfort or pain, and the response was no, then the nurse may be able to analyse the body language of the patient/client, as to whether it was a truthful response or not. Individuals have differing perceptions of pain, so though a patient may not accept that they are feeling pain, as Roper et al (1996) clarifies; there are physical manifestations of acute pain that can be observed via heavy breathing, tense skeletal muscles, pale and sweaty skin, etc. These are all physical attributes that could be observed through non-verbal communication.

Whilst in conversation, a nurse should always maintain eye contact with the person to whom he/she is communicating. This will amplify the attitude of the nurse being an active listener, as well as showing interest in what information is conveyed. This is confirmed by Crawford et al (2006) when acknowledging that by making continuous eye contact with someone, we truly make them feel visible and involved in dialogue or conversation. This aspect, again, leads weight to patient centred care involving communication skills. Videbeck (2006) acknowledges this theory, but also mentions that cultural beliefs need to be assessed first, as some cultures believe that eye contact can be disrespectful, this is where nurses self-awareness plays a vital role in assessment.

Unfortunately, many people, including nurses, are only (mainly through childhood) subjected to communication skills from their own backgrounds and cultures. This can be a massive hindrance when having to communicate with somebody from a different culture, country, etc. As Roper et al (1990) points out; the ever-increasing problem with communication is that with so many multiracial societies in most countries, the patient or nurse may not speak the national language. This is where huge aspects of verbal and non-verbal communication play a role. Kenworthy et al (2002) imply that it is easy to equate the message with words and overlook other forms of communication, such as posture, gestures, tone of voice, and intonation. Just because a nurse may not be able to understand what somebody is saying, it could be possible to decipher what they mean by their tone of voice or touch.

One of the most vital aspects of communication required in nursing is that of document recording. A nurse needs to be able to document all relevant information regarding a patient/client efficiently and relevantly. It is common knowledge in nursing practice that many abbreviations are used, and by using abbreviations, then this could lead to wrong information being recorded, or information not being understood, certainly regarding newly qualified nurses or students. It is also very important to read the trusts policy, as every trust has different regulations on acceptable/non-acceptable abbreviations that can be used. Again, active listening plays a major part in document recording, and the difference between a Mr Smith/Smyth/Smite, etc, could be life threatening to the patient/client, as well as career threatening to the nurse involved.

In conjunction with the mentioned theories on the importance of communication in nursing, the following reflection used from a clinical placement experience, will both highlight some of the theories obtained, whilst showing the progression of self-awareness that could only be obtained from reflecting upon a relevant experience.

ReflectionThe use of reflection within the nursing context is to bridge the gap between theoretical nursing approaches and the actual implementation of the theory within a clinical setting. Without reflecting upon a situation encountered, a nurse may develop habits that are hard to extinguish, that could also have implications upon the nursing process itself, thus leading to a failure in therapeutic care. As Boud et al (1985) cited in Palmer et al (1994) argues, ‘competency involves not only taking action in practice but learning from practice through reflection.’When using a reflection it is extremely helpful to use a structured model/framework, as this allows a gradual, logical approach of addressing what happened, how the reflector felt about it, why it happened and what could be done if the same situation was to arise again. As Palmer et al (1994) addresses; reflecting on events is a dynamic process and not static, so to acknowledge this process it is desirable to incorporate a reflective framework that is cyclical, which allows knowledge and self-awareness to evolve.

Taking these points into account, the model of reflection that I will use is Borton’s (1970) (appendices 1) “What? So What? Now What?” model of reflection. This will allow me to address the mentioned processes when reflecting upon the situation encountered.

What?During my first six-week clinical placement, I had the privileged opportunity to care for Mr Peter Jacobs (appendix 2). Eight days prior to this instance of care, Mr Jacobs had been diagnosed with suspected Clostridium difficile (C. Diff), and needed to be barrier nursed in a private cubical to prevent the spread of potential infection (Damani and Emmerson, 2003, p148).

During Mr Jacobs’s isolated care, I got the impression that he felt (through intuition) embarrassed about the situation regarding his isolation and barrier nursing. This was a feeling that I had encountered through his non-verbal communication, as he always addressed my entrance into his cubicle with a nervous smile and sadness in his eyes during this period of incubation, though he never said that he had felt this way.

On the eighth day of Mr Jacobs’s isolated care, I had entered his cubicle with disposable gloves and disposable apron already attired, to check if his incontinence pad needed to be changed, I could instantly tell by the smell of faeces that it did. Instead of being met with a nervous smile and sad looking eyes, I was met with a look of what I could only ration was confusion. I took this look of confusion as a part of his dementia, and failed to comprehend that it may have been anything else. I continued to get a new incontinence pad, bowel of warm water and wipes ready in preparation of meeting Mr Jacobs’s elimination and hygiene needs.

As I approached Mr Jacobs with all the items that I needed, it was evident that he still looked confused. At this point, I asked if he was ok, to which he responded ‘not really’. I asked what was wrong, and it was at this point he told me a nurse said he had passed the required incubation period needed to isolate the potential spread of infection, and that he no longer needed to be barrier nursed. I immediately responded that I was not aware of this, and thought, but did not tell him, that maybe his dementia had confused him into thinking so. I told Mr Jacobs that I would continue to wash him and change his incontinence pad with the same infection control procedures, until I was aware of any changed circumstances. I could immediately tell by the look in Mr Jacobs’s eyes, that he was upset. Whilst meeting Mr Jacobs’s needs, he became very withdrawn, and all aspects of verbal communication between us ceased. I could tell by Mr Jacobs’s lack of verbal communication, body language and my own personal intuition, that Mr Jacobs just wanted me to ‘get-on’ with meeting his hygiene and elimination needs, then leave.

I continued to wash Mr Jacobs and change his incontinence pad and no further verbal communications were carried out between us during this process. When I had finished, and was just about to leave, Mr Jacobs shouted out at me; ‘I wish somebody could just tell me the truth’, to which I responded; ‘I will address the situation with the staff nurse now, to which he responded with what I believed was a grateful smile.

When I addressed the staff nurse in regards to Mr Jacobs’s barrier nursing, she made me aware that he no longer needed to be barrier nursed, as he had completed the required time of being asymptomic. I told the staff nurse that nobody had made me aware of this, and that I had just barrier nursed Mr Jacobs, to which he had been upset by and thought he was being lied to. The staff nurse apologised on behalf of her and colleagues for not informing me, and suggested that I read all the patients/clients care plans, whilst she would go and talk to Mr Jacobs. Whilst reading Mr Jacobs’s care plan, it became evident that he no longer needed to be barrier nursed. Upon reading this information, I became very conscientious that I could have read the care plan earlier, and avoided this situation.

So What?My initial feelings at the time of caring for Mr Jacobs, was that I was doing the right thing. I believed that by continuing to barrier nurse him even though he may have been correct, would have been more important in preventing the potential spread of infection, in case that he may have been confused or wrong (Mayhall. 2004). Upon reflection, it would have only taken me a minute or two if I were to go and ask the staff nurse, or read Mr Jacobs’s care plan, to confirm if he was correct or not. By not seeking advice in regards to Mr Jacobs’s care requirements, I had subjected him to personal distress and the belief that he was being deceived by the nursing personnel, this also lead to a communication breakdown between the two of us, and lead to a breakdown in holistic care (Videbeck. 2006). These aspects could/should have been addressed or avoided with basic communication skills from my behalf.

In regards to Mr Jacobs’s withdrawal from verbal communication when washing and changing him, I believed that he just wanted me to complete the process and leave. In hindsight, judging by the fact he gave me a grateful smile after telling him that I would seek advice from the staff nurse before leaving, I now believe he may have just wanted assurance. Assurance could have been given much earlier in the process of care, and could have possibly resulted in Mr Jacobs being more interactive in regards to his psychological feelings (Berger & Williams 1998). My lack of self-awareness at this point made me believe that Mr Jacobs did not want to communicate, but in contrast, he may have felt the total opposite, but did not know how to in fear of being ‘deceived’ again.

When addressing the fact that no members of staff had told me of Mr Jacobs’s change of care requirements, I felt quite resentful at the time that I had not been included, and that I had subjected Mr Jacobs to distress, embarrassment and the feeling of deception. Now that I have had time to reflect on this situation, I now accept that if I were more pro-active and assertive, then I would have checked the care plan or addressed a qualified member of staff upon immediate recognition of Mr Jacobs’s concerns.

Now What?In future instances of a patient/clients concern, I will be more assertive in finding out the relevant information needed with immediate effect upon the clients concerns. I will no longer be ignorant to assume that my beliefs are more knowledgeable or important than the patient/clients. I am now more self-aware and realise that it is my responsibility to find out relevant information concerning a patient/clients care needs, and not assume that I should wait until I am told differently by a member of staff, especially considering how easy it would be to find out for myself.

In regards to a patient/clients non verbal communication, I now believe I am more self-aware in recognising signs, and though I did identify some of these signs when caring for Mr Jacobs, I did not fully comprehend how important they were to his own feelings. This is where I need to improve my decisiveness in asking open questions.

I believe that the whole experience of the situation has helped my own personal awareness in regards to how important communication is in nursing.

ConclusionWith such a broad range of communication aspects within nursing available through theoretical literature, it is evident that the relatively small amount of theory obtained for this assignment has a parallel relevance to the clinical experience that was reflected upon. The reflection confirms that both aspects of verbal and non-verbal communication can evolve, disrupt or abruptly end the nursing process.

All aspects of communication must be at the forefront of a nurse’s conscience; otherwise, s/he may give an impression of disregard to a patient/clients personal feeling, and in turn, display an attitude of an un-caring approach.

It is evident when comparing the theory of communication in nursing and the reflection itself, that to provide acceptable holistic care to a patient/client, a nurse must recognise his/her own self-awareness. This skill, through means of personal reflection and continuation of learnt theory, must be enhanced and developed in means of maintaining a high quality/acceptable level of interpersonal care.

Communication in regards to colleague interaction is also equally relevant. Patient-centred care should be the paramount of a nurse’s concerns, and this could not be achieved without all colleagues working and communicating in unison. A nurse should never make assumptions based upon their own belief/knowledge if they are ever feeling unsure. Instead, they should actively communicate with their colleagues via means of decisive, formal, verbal communication, or require any documented communication that addresses a particular situation/need/requirement. The previously mentioned reflection highlighted an occurrence where this theory is applicable.

The aim of this assignment was to address the theory behind the importance of communication in nursing, with a reflection of a clinical practice that would support it. The writer believes that this has been achieved.

References

Alfaro-LeFevre, R. (2005) Applying Nursing Process: A Tool for Critical Thinking (6th edn). Philadelphia: Lippincott Williams and Wilkins.

Berger, K.J., and Williams, M. B. (1998) Fundamentals of Nursing: Collaborating for Optimal Health. Stamford: Pearson Professional Education.

Craven, R. F. and Hirnle, C. J. (2006). Fundamentals of Nursing (5th edn). Philadelphia: Lippincott Williams & Wilkins.

Crawford, P., Bonham, P. and Brown, B. (2006). Communication in Clinical Settings. Cheltenham: Nelson Thornes Ltd.

Damani, N. N., and Emmerson, A. M. (2003) Manual of Infection Control Procedures (2nd edn). Cambridge: Cambridge University Press.

Dougherty, L. and Lister, S. (2004). The Royal Marsden Hospital Manual of Clinical Nursing Procedures (6th edn). Oxford: Blackwell Science Ltd.

Ellis, R., Gates, B. and Kenworthy, N. (eds). Interpersonal Communication in Nursing: Theory and Practice. (2nd edn). London: Churchill Livingstone.

Heath H B M (ed). (1995). Potters and Perry’s Foundations in Nursing Theory and Practice. London: Mosby.

Hogston, R. and Marjoram, B. (2007). Foundations of Nursing Practice: Leading the Way. Palgrave Macmillan.

Jasper, M. (2003). Beginning reflective practice. Cheltenham: Nelson Thorn.

Kenworthy, N., Snowley, G. and Gilling, C. (2002). Common Foundation Studies in Nursing (3rd edn). Edinburgh: Churchill Livingstone.

Mayhall, C. G. (2004) Hospital Epidemiology and Infection Control (3rd edn). Philadelphia: Lippincott Williams and Wilkins.

Nursing and Midwifery Council (NMC) (2008). The NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics for Nurses and Midwives. London: Nursing and Midwifery Council.

Palmer, A.M., Burns, S. and Bulman, C. (eds) (1994) Reflective Practice in Nursing: The Growth of the Professional Practitioner. London: Blackwell Science Ltd.

Riley, J.B. (2008). Communication in Nursing. Missouri: Elsevier Inc.

Roper, N., Logan, W.W. and Tierney, A.J. (1996). The Elements of Nursing (4th edn). New York: Churchill Livingstone.

Videbeck, S. L. (2006) Psychiatric Mental Health Nursing (3rd edn). Philadelphia: Lippincott Williams and Wilkins.

Appendix 1Bortons’ (1970) model of reflection frameworkBorton’s (1970) What? So what? Now what? model of reflection, found in Jasper (2003), is a good starting point for any new reflective practitioner. Jasper (2003) advocates the use of this model for any student nurse, as it is an evolvable/cyclical framework that addresses three major questions of reflecting on action.

Bortons` (1970) Framework Guiding Reflective Activities:Bortons’ Model of ReflectionWhat?What was the problem?What was my role?What happened?What did I do?So What?What was so important about this experience?What did I learn?Now What?Now what do I need to do?Now what might be the consequences of my actions?Now what do I do to resolve the situation/make it better/improve my patients care?Jasper, M. (2003). Beginning reflective practice. Cheltenham: Nelson ThornAppendix 2Patient: Mr Peter Jacobs*Reasons for Admittance: Recovery from a third stroke and assessment of mental health in regards to Dementia.

Time on Ward: Patient was admitted 3 weeks prior to students start date and remained on ward after students finishing date.

Care Plan details: Mr Jacobs is bed-bound and needs to be aided with all nutritional intakes due his Dysphagia and severe paralysis to left side of body, and mild paralysis to right side of body. Mr Jacobs also needs 100% assistance to meet personal hygiene needs. This includes bed-bathing, oral hygiene and shaving. Mr Jacobs also needs to wear an incontinence pad due to his dementia not addressing his need of elimination.

Patients Personal History: Mr Jacobs had lived alone in a residential complex for 3 years since the death of his wife. He would receive daily visits from a community nurse/or care assistant to check his well-being and to aid with any requirements that may be needed as a result of his mild paralysis after two previous strokes. It was after the third stroke that Mr Jacobs was admitted into hospital due to the stroke leaving him severely paralysed to the left side of his body. Coupled with the onset of suspected Dementia, the severe paralysis left Mr Jacobs needing continuing care.

* Patients name changed to the pseudonym of Mr Peter Jacobs to abide by the NMC (2008) confidentiality guidelines.