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Clinical Development: A framework for effective communication skills

This article outlines a framework for nurses to further develop their communication skills during interaction with patients. It also shows how to implement this framework in nursing practice.

Keywords: Communication, Patient education

Authors Stephen J. Hamilton, MSc, PG Dip, BSc, RMN, is lecturer in health communication; David J. Martin, PG Cert, Adv Dip Management of Psychological Trauma, Dip Specialist Practice, BSc, RMN, is a dual diagnosis worker and part-time lecturer; both at the University of Ulster.

Abstract Hamilton, S.J., Martin, D.J. (2007) A framework for effective communication skills. Extended version of Nursing Times; 103: 48, 30-31
This article outlines a framework for nurses to further improve and develop their communication skills during interaction with patients. It also shows how to implement this framework in nursing practice, and nurses’ role in communication skills is further outlined through the use of an acronym.

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Introduction
The use and benefits of effective communication skills in nursing have been extensively researched and documented over the years. For example, Dougherty and Lister (2007), Kihlgren et al (1993), Boore (1978) and Hayward (1975) all highlighted potential pain-reducing implications and increasing recovery rates when patients are provided with additional information/communication about their diagnosis, prognosis, care and treatment.

Harrison and Hart (2006), Northouse and Northouse (2004) and Robb et al (2004) discussed the range of communication skills available to health professionals. Nurses can facilitate successful and therapeutic patient contact through questioning, listening, summarising, reflecting, paraphrasing, set induction and closure. Nurses use these skills on a daily basis to: gather information; reassure; facilitate patient expression; harness attitudes, views and opinions; encourage critical thinking; reduce anxiety; facilitate liaison with other disciplines; and promote continuity in patient care (Berry, 2007; Murray et al, 2006; Bury, 2005; Bayne et al, 2002; French, 1994; Hargie and McCartan, 1986).

In this article, we advocate a communication skills framework within which the use of these various skills can be contextualised and applied by registered nurses and those in training alike, in hospital and community settings. The purpose of the suggested framework is to reinforce and complement not only the scope of nursing practice but also to encompass the wide range of nursing duties, activities and responsibilities.

Box 1 provides a breakdown of the different features of the suggested framework and is then followed with examples of how the framework could be used during contact time with patient groups. The communication skills role of nurses is then further illustrated in Box 2, using the acronym EDUCATE. The acronym itself serves as a guiding mechanism, mnemonic and future point of reference.


Background
Cutcliffe and McKenna (2005) and Long (1999) reported that during treatment, hospital and community patients interact more with nurses than with any other health professional in the multidisciplinary team. These authors also highlighted that nurses are continuing to expand their role into medical and even surgical practice.

Nurses’ expanding practical role and its consequent negative impact on the interpersonal dimension of patient care has also been well documented in recent years (Northouse and Northouse, 2004; Hunt and Wainright, 1995; Baly, 1995; Sinclair and Fawcett, 1991; Cox, 1983; Gillis, 1980). These authors said that nurses are only too willing to accept changes to their role from outside the profession which, it can be argued, undermines the sense of ownership they have in relation to their own unique interpersonal patient contact.


The framework
Therefore, the communication skills framework outlined here intends to capture and complement the varied, eclectic, multi-dimensional and challenging role of nurses in contemporary healthcare.

We wanted to couch the delivery of communication skills in nursing within a ‘framework’ rather than in a ‘model’. We felt that the term model has a rather slavish and inflexible connotation. The term infers something to be imitated, copied and followed to the letter; such inflexibility is incongruent with the necessarily fluid nature of communication in the healthcare context. The use of the word framework, however, denotes openness, flexibility and versatility, which we conclude are the essential qualities of an effective nurse and an effective communicator.

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Box 1. A framework for effective communication skills practice (the five Is)

(1) INTERACT with the patient;

(2) Establish the INTENTION of the interaction;

(3) Decide on the INTERVENTION to be used;

(4) Assess the IMPACT of the intervention/s;

(5) Evaluate the IMPLICATIONS of the subsequent information obtained and then act accordingly.

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Nurses should try to interact with patients by using the full range of communication skills at their disposal, to help patients realise that practitioners are there to help as much as they possibly can, both physically and psychologically, in light of patients’ vulnerable state of health.

Simultaneously, however, nurses must always remember that they are responsible to, and not for, patients in their care. Patients must be given time and space to express any fears, anxieties, concerns or worries they may have. Therefore, patient expression can be facilitated by the very presence of nurses, and by nurses’ willingness to engage, interact and communicate.

Nurses should establish what the intentions of the interaction are. When defining ‘social skills’, Hargie and McCartan (1986) highlighted that behaviours used in person-to-person interaction are usually goal directed, inter-related, situationally appropriate and under the control of the individual. Communication skills are the lifeblood of any interaction whether personal, professional, social or otherwise, but structure must be present in order to maximise the likelihood of effective interaction (Murray et al, 2006).

Nurses also need to decide on the most appropriate interventions. These interventions may take physical or psychological form, depending on the overall aim and purpose of the interaction, for example: administering an injection; carrying out physical observations; assisting an elderly person with their activities of daily living; or reassuring an anxious patient using their communication skills.

Nurses should then proceed to assess the impact of the selected interventions. Has the practitioner achieved what they set out to achieve? In other words, did the selected intervention or interventions work? If not, why not? What could be done differently the next time to maximise the likelihood of a successful interaction?

The final step is to evaluate the implications of the interaction for professionals and patients alike. For example, acquiring information from a patient during an assessment-type interview is one thing but what should nurses actually do with that information? Other members of the multidisciplinary team may need to be informed and be more specifically involved in patients’ care and treatment, contingent of course on the information received from patients.


Putting the framework into practice
An integral part of nurses’ role is patient assessment on initial contact, following GP referral or admission to an inpatient facility, for example. At this stage of contact, nurses should attempt to reassure patients, convey a sense of warmth and put them at ease by using communication skills such as questioning, reflecting, listening, summarising, paraphrasing and so on.

A practitioner’s intention may be to gather as much patient information as possible, ranging from the type of allergies patients may have to their previous medical/psychiatric history and hospital admissions.

This interaction also has the potential - if managed skilfully - to instil confidence and a sense of safety in the service offered.

The ongoing use of effective communication skills at this delicate and sometimes challenging stage will inform and underpin subsequent nursing intervention. For example, patients may require close observation and/or supervision by a member of staff in light of acute agitation, aggression or life-threatening medical condition.

As the interaction unfolds, nurses should then assess the impact of their communication skills. In other words, are they acquiring the relevant patient information, and if not, what could they do differently to achieve that essential goal? Information acquisition is not the end point for practitioners by any means at this stage. Having the information is one thing but deciding on the implications of it and on what to do with the information is the essence of professionalism in nursing. Perhaps other members of the multidisciplinary team need to be involved to meet patients’ physical and psychological needs. For example, patients may need some kind of social services input depending on their home circumstances and particular situation.


An example in practice
To contextualise the practical nursing application of the suggested communication skills framework, here is another example of how a working knowledge of the framework could contribute positively and therapeutically to patient care.

Nurses are often called on to relay complex information to patients in relation to the management of long-term conditions such as diabetes. Human contact is integral to nursing practice and can be therapeutic in itself. Therefore, we believe that information provided to patients is best delivered in the context of a one-to-one interaction.

Undoubtedly, written information such as leaflets has its place in nursing as a vehicle through which to reinforce the spoken word. However, face-to-face interaction provides opportunities for practitioners to obtain valuable feedback, to check patient understanding and reassure them. There are potential pitfalls in relying solely on written information. Limitations include reduced cognitive capacity, level of literacy, poor motivation and perhaps visual impairment; all of these can be avoided by the simple act of talking to patients.

Essentially, we feel that providing important information to patients should be a goal-directed activity. Nurses need to be clear about what they hope to achieve as a result of the time and effort put into the interaction. Giving thought to the intentions beforehand leaves practitioners in a better position to assess the effectiveness of their subsequent patient contact.

Taking information-giving as the selected intervention, there are a number of areas to address. It makes sense to plan the intervention to maximise the likelihood of effective communication. Paying attention to where and when the information is delivered and actively considering who needs to be involved (for example, relatives and carers) will pay dividends.

Using a broad range of communication skills such as questioning, reflecting and listening, will be key. Asking open questions allows nurses to obtain information, facilitate patient expression and indicate concern for patients (Murray et al, 2006). An example of this could be: ‘Can you give me some idea of what you understand about diabetes?’ Through reflecting and listening, practitioners can assess the emotional impact of a long-term condition. For example: ‘I am sensing you are finding it difficult to cope with your diabetes,’ and then remaining silent to encourage patients to respond.

Assessing the intervention’s impact will involve nurses building in frequent opportunities for feedback. Again, through the use of questioning and reflecting, practitioners can ascertain whether patients have understood the message conveyed. For example: ‘Is there anything else you want to ask me about managing your diabetes?’ Or perhaps: ‘My impression is that you are very clear about how to test your blood sugar,’ or even: ‘How confident do you feel about doing your own injections?’ Remember, the intervention will be planned to include written communication to colleagues in the form of progress notes stating that nurses have provided the intervention.

The final stage will be for nurses to reflect on the interaction - in other words, what are the implications for my future nursing practice? Nurses should ask the following questions: What skills did I use? What was my rationale for using them? Did I achieve my intended goals? What could be done differently in the future to maximise the likelihood of successful patient interaction?


Nurses’ role in communication
Nurses of all grades and disciplines have an ethical, moral and professional responsibility to disseminate their unique skills and knowledge not only to patients but also to colleagues, peers and fellow professionals.

To highlight fully the communication skills role of nurses in hospital and community settings, we put forward the acronym EDUCATE as a guiding mechanism and future point of reference.

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Box 2. The communication skills role of nurses

E = ENGAGEMENT and ECLECTICISM
D = DEMONSTRATION OF SKILLS
U = UNDERSTANDING
C = CLARIFICATION, COMMUNICATION, COLLABORATION and CONFIDENTIALITY
A = ASSESSMENT and the ability to ADAPT
T = TEACHING
E = EVALUATION

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In relation to engagement and eclecticism, nurses routinely make intimate physical and psychological contact with patients, in ways that not only complement the multi-dimensional nature of their professional role and responsibilities but also meet patients’ changing needs. By engaging and interacting with patients, whether this is in hospital or community settings, what nurses are actually doing is instilling a sense of safety and a sense of being protected. This is particularly important, for example, when a patient is in the acute phase of a psychiatric illness, as this may compromise their ability to stay relatively safe and free from physical harm.

Regarding the demonstration of skills, nurses must demonstrate not only interpersonal proficiency with patients, colleagues and peers but also the ability to carry out a variety of medical/nursing procedures as and when required, such as: administering injections; taking blood; dealing safely and effectively with aggression and violence; carrying out physical observations such as temperature, pulse, respiration; and so on.

With reference to understanding, practitioners should endeavour to understand and relate to patient experience as much as possible by imagining what it would be like if they themselves were receiving treatment. The overall purpose of this is to assess their own professional performance, giving an opportunity to make behavioural changes in light of internal and external feedback. In other words, nurses should imagine they are the patient and then ask: ‘Would I like to be cared for by someone like me?’.

In relation to clarification, communication, collaboration and confidentiality, nurses: must remember and if necessary clarify their role and scope of professional practice with patients and colleagues alike; should be proficient in verbal and nonverbal communication; should remember they are part of the multidisciplinary team and so liaise with other health professionals to meet patients’ physical and psychological needs; and must adhere to the boundaries of confidentiality in the Code of Professional Conduct (NMC, 2002).

With reference to assessment and the ability to adapt, practitioners must assess and observe patients, keep their eyes and ears open as well as be sensitive and responsive to professional and training needs. They also operate in a variety of hospital and community settings, often at short notice, bringing with them those generically transferable interpersonal and medical skills.

Regarding the teaching element, nurses need to educate and inform patients, colleagues and trainees alike by giving others the benefit of their unique experience, knowledge and insight.

Lastly, in relation to evaluation, nurses should evaluate the impact and success of various short- and long-term nursing/medical interventions to make the necessary changes that will optimise patients’ physical and psychological recovery. In other words, they should evaluate the impact of various interventions via the following formula:

  • What interventions or skills did I use?
  • What was the purpose of my using those skills and interventions? In other words, what was my goal?
  • Did I achieve what I set out to achieve?
  • Lastly, what would I do differently in the future to maximise the likelihood of success?

Evaluation of this type is therefore very much a process and not an event. It relies heavily on the openness, flexibility and versatility of individual practitioners.


Conclusion
Nurses are resourceful in that they can draw on a variety of physical and psychological skills and interventions to facilitate the care and treatment of individual patients and their families, in hospital and community settings. They are nomadic in that they are able to move from ward to ward, sector to sector, community to hospital and vice versa. They are suitably equipped with a generically transferable set of medical and interpersonal skills designed to meet the needs of a variety of patients, with a range of physical and psychological problems. The letters RN stand for ‘registered nurse’ but they could equally stand for ‘resourceful nomad’, with the essential qualities and attributes of openness, flexibility and versatility.

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