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Communication and the 6Cs: the patient experience

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One patient’s story highlights the importance of nurses and staff communicating effectively, and how poor communication can have a negative impact on patients


Patient experience is a factor in the measurement and metrics of the quality of NHS healthcare. This article, based on a short case study, explores the care of a patient with complex needs who was admitted to hospital. It relates the care to the 6Cs and the Nursing and Midwifery Council’s Code, with a focus on the role of communication between the nurse and the patient. It provides useful points to reflect on for NMC revalidation.

Citation: Barber C (2016) Communication and the 6Cs: the patient experience. Nursing Times; 112: online issue 1, 4-5.

Author: Christopher Barber is full-time informal care giver and part-time associate lecturer (learning disability nursing), Birmingham City University.


The quality of patients’ experience in hospital is an issue in healthcare. In 2010 the coalition government made a commitment to put patients at the heart of all the NHS does to improve their experience of care (Department of Health, 2010). This article highlights the experiences of a patient with complex needs on a hospital ward and in an outpatient department in a large hospital, and is discussed in the context of the 6Cs (NHS England, 2012; Box 1) and Code for nurses and midwives (Nursing and Midwifery Council, 2015). The patient described in this article gave permission for her personal experiences to be used as a case study.

The role of the 6Cs

The 6Cs set out the values and standards for nurses to work towards and were included in the chief nursing officer for England’s consultation paper in 2012 (NHS England, 2012). The purpose of the 6Cs was to ensure patients are looked after with care and compassion, by professionals who are competent, communicate well, have the courage to make changes that improve care and can deliver the best and commit to delivering this all day, every day (NHS England, 2012). They represent an attempt to ensure all patients receive high-quality care. I would argue that communication is perhaps the most important principle.

The patient experience is a recognised indicator of the quality of care (Darzi, 2008), with communication being a major aspect. The NMC Code supports this and notes that nurses should:

  • Put the interests of people using or needing nursing or midwifery services first;
  • Make their care and safety your main concern;
  • Make sure their dignity is preserved and their needs are recognised, assessed and responded to.

Box 1. the 6Cs

  • Care
  • Compassion
  • Courage
  • Communication
  • Commitment
  • Competence

Source: Cummings and Bennett (2012)

The patient experience

Mrs Windsor was in her late 50s, had cerebral palsy, sleep apnoea and myasthenia gravis (a neuromuscular condition that leads to fluctuating muscle weakness and fatigue). She was taking medication

(pyridostigmine) for this condition and was admitted on to the ward with atrial fibrillation. As a result of her disabilities and complex needs she has an advance directive not to undergo resuscitation in the event of a stroke or heart attack.

Mrs Windsor experienced frequent communication issues during her stay on the ward, including a lack of communication between ward staff on opposite shifts and between ward staff and herself. She was able to communicate but, as a hospital patient with complex needs, felt vulnerable and her husband had to advocate for her on several occasions. She felt the breakdown in communication stemmed from staff’s inability to listen, understand, and empathise, and to report, record and give information appropriately and accurately. For example, Mrs Windsor needed to take the medication for her myasthenia gravis regularly to achieve a therapeutic benefit, so she asked ward staff to administer it at specific times. Her request was not passed on and this exacerbated her symptoms and increased her anxiety and frustration.

Mrs Windsor thought information about her advance directive would be recorded in her nursing and medical notes for care staff to read but she repeatedly had to inform staff about it.

Towards the end of her stay she was seen by a senior staff nurse at the anti-coagulant clinic, who gave her a lot of information regarding atrial fibrillation and treatment such as warfarin and digoxin. However, the nurse raced through the information without stopping and did not consider Mrs Windsor’s needs.


Care is defined as: “the vehicle through which nurses interact with patients and assist them to cope with suffering, to find meaning in their experiences, to promote health and wellness and to die with dignity” (Roach, 1997).

For effective interaction and engagement with both the patient and the person behind that label, communication is vital. Care may be compromised if nurses do not communicate well. Such communication must involve:

  • Listening to what patients say;
  • Answering their questions in ways they can understand and process;
  • Relaying information from patients to colleagues, and vice versa.

Mrs Windsor’s experience illustrates how communication issues have a real effect on patients’ experiences. The NMC Code makes explicit nurses’s responsibility to listen, work with and act on their patients’ concerns and give treatment in a timely manner (Box 2).

Without the ability to listen and communicate, delivering the 6Cs and meeting the requirements of the Code would, at best, be “watered down” and compromised and, at worst, may not be internalised and made real or concrete. This is illustrated by the failure of staff to acknowledge the importance of Mrs Windsor’s advance directive and pass the information on to the team. Mrs Windsor had to repeat her wish not to be resuscitated, which suggests individual nurses and the nursing team were not able to understand her wishes – as such, their competence in meeting her care needs were compromised.

The ongoing communication issues around the timing of drug administration and the information given in the anticoagulant clinic resulted in a lack of confidence in the staffs’ ability to provide compassionate and competent care.

The Agency for Healthcare Research and Quality (2004) highlighted the importance of health literacy, and the need for information to be tailored to the right level for an individual’s needs. Health Literacy (2016) note that “Health information in current circulation is written at too complex a level for 43% of working-age adults (16-65 years)” and this figure rises to 61% if the health information includes numeracy.

Given Mrs Windsor’s potential vulnerability due to her complex healthcare needs, the nurse in the anticoagulant clinic should first have assessed her communication needs, then amended her approach accordingly. Without this, Mrs Windsor’s ability to give informed consent was compromised.


The 6Cs are likely to have a crucial impact on how patients and service users experience nursing care for many years to come, with communication being pivotal to this experience. The importance of communication is also emphasised in the NMC Code, which should be used to guide nurses’ day-to-day practice. They have an obligation to listen to patients’ concerns about communication and reflect and consider how they interact and engage with them.

Box 2. Using the NMC Code for reflection

 You can use sections 2 and 7 of the Code to reflect on this case study:

2: Listen to people and respond to their preferences and concerns

To achieve this, you must:

  • 2.1 Work in partnership with people to make sure you deliver care effectively
  • 2.2 Recognise and respect the contribution that people can make to their own health and wellbeing
  • 2.3 Encourage and empower people to share decisions about their treatment and care
  • 2.4 Respect the level to which people receiving care want to be involved in decisions about their own health, wellbeing and care
  • 2.5 Respect, support and document a person’s right to accept or refuse care and treatment
  • 2.6 Recognise when people are anxious or in distress and respond compassionately and politely

7: Communicate clearly

To achieve this, you must:

  • 7.1 Use terms that people in your care, colleagues and the public can understand
  • 7.2 Take reasonable steps to meet people’s language and communication needs, providing, wherever possible, assistance to those who need help to communicate their own or other people’s needs
  • 7.3 Use a range of verbal and non-verbal communication methods, and consider cultural sensitivities, to better understand and respond to people’s personal and health needs
  • 7.4 Check people’s understanding from time to time to keep misunderstanding or mistakes to a minimum
  • 7.5 Be able to communicate clearly and effectively in English

Key points

  • How can communication affect the patient experience?
  • Can you think of a situation when better communication could have prevented a patient becoming frustrated, upset or receiving inappropriate care?
  • What should health professionals bear in mind when giving patients information about their condition or treatment?
  • How can you check whether patients have understood everything they have been told?
  • How can health professionals improve their communication skills?
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