Carol Wurzell, RN

Putting communication skills into practice

Effective communication is essential for productive nursing practice. Communi- cation occurs constantly, whether we are aware of it or not. Every day we communicate with patients; with the surgical team and staff; and with fam- ily, friends, and strangers.

A key to becoming a more effective communicator is to move beyond un- planned interactions and ensure that your communication is purposeful and consciously motivated. Studying the communication process will enable you to examine what and how you com- municate, to develop a sensitivity to how others communicate, and to dis- cover new ways to be more effective in your own communications.

What happens when we communi- cate? The basic elements are the sender, the message, the receiver, and the envi- ronment or context in which the mes- sage is sent. Because it influences both the sender and the receiver, the envi- ronment plays an important part in any interaction.

Communication is a complex process, with many factors that influence the transmission of a message. How the sender formulates the message will

Carol Wurzell, RN, M S , is assistant professor in the College of Nursing at Arizona State Uni- versity, Tempe. She received her baccalaure- ate from Chico (Calif) State College and a Mas- ter of Science from the University of Maryland, Baltimore.

affect its transmission. Even such a straightforward statement as, Yt’s raining,” can be sent in several ways. If the rain makes the sender gloomy or depressed, those elements can easily be transmitted along with the words them- selves. Or if it were the first rain after a long drought, that aspect of the message can also be quite clear. How the mes- sage is sent will be affected by the sen- der’s attitudes, values, knowledge, cul- ture, social system, and even general state of health. The communication skills the sender possesses will also have a great deal to do with how effec- tively the message is sent. The receiver also has values, attitudes, and other fac- tors that affect how that person hears and responds to the message. These fac- tors become a screen or filter through which the message must pass before it is understood by the receiver.

With all these things happening to a message, it’s a wonder that understand- ing takes place at all. Consider a situa- tion in which the OR nurse in a small community hospital has set up a new practice of preoperative assessment and teaching with patients the day before surgery. She must approach the head nurse of the surgical unit to explain the new procedure developed by the OR staff. The OR nurse thinks about the new procedure, how good it will be for the patient, and when should it be done. She thinks about the head nurse. Will she like it, or is it infringing on her

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territory? Does the head nurse respect her abilities, and does she respect the head nurse’s abilities? She thinks about how nervous she is about talking to the other nurse. What if the head nurse will not allow her to come to the unit a t es- tablished times?

All of these thoughts will have a di- rect effect on the choice of words the OR nurse uses. They will affect her tone of voice, the speed of her conversation, and her general way of interacting with the head nurse. These thoughts will also in- fluence what she hears the head nurse say and how she responds generally to the head nurse. Being aware that these factors exist in any interaction will im- mediately begin to improve your com- munication with others. M iscom m u n icat ion. This occurs

through our perceptual screens, allow- ing us to change a message to hear what we want to hear, to send “hidden mes- sages,” and to say things nonverbally that we don’t feel comfortable saying verbally. Miscommunication also can occur frequently in the hospital setting, where the language used may be dif- ficult for the patient to understand.

Astudent taking care of a patient who was to have surgery for a nonmalignant tumor of the uterus was surprised when the woman began talking about cancer treatments after surgery. Recognizing an increase in the patient’s anxiety, the student asked her what was upsetting her so. The student then found out that the patient had been told she was to have a tumor removed, and to the pa- tient a tumor meant cancer. This sit- uation should never have occurred and was a result of ineffective communica- tion.

As a sender, it is our reponsibility to be sure the receiver of the message un- derstandsour meaning. As a receiver, it is also our responsibility to try to under- stand what the words of the message mean to the sender. As a sender. never

just assume the receiver understands you. And as a receiver, never assume you understand what is meant by the sender.

Validation. There are several ways to make sure understanding takes place. Once you have some idea of what you think is going on, find out for sure if you are right. It’s easy to say, “I think you’re telling me. . . ” or “You’re saying to me t h a t . . . ” or “Do I understand that

When you make an observation, check it out before you assume you’re right. A patient who is experiencing pain may frown and have a wrinkled brow and clenched fist, but so may a patient who is angry and frustrated. Your nursing actions depend on under- standing the patient’s behavior. Too often we assume we know without checking. The only person who can con- firm your interpretations of behavior is the individual you are observing. Vali- dation is an essential aspect of effective communication.

Listening. Probably the most impor- tant skill in communication is listening. Listening is more than hearing. It is an active process in which the listener hears and understands what is being said. Understanding is the key. How often do we “listen” to someone and then five minutes later cannot describe what was said. The process of selectively tun- ingout occurs all the time and depends a great deal on our attitude and feelings at the moment.

To listen effectively, one must con- sciously and actively work a t under- standing the other person. This active process takes effort and practice. To be an effective communicator, it is your responsibility to listen attentively. O’Brien has identified common listen- ing problems. Ask yourself these ques- tions and evaluate your own listening ability.

*Are you able to listen to another

you. . . . ”

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any nurses feel M inadequate and avoid listening to patients.

without being distracted into think- ing of someone or something else?

0 Do you engage in an activity while someone is speaking-writing, doodling, watching another situa- tion (such as television), listening to the radio or stereo, reading the newspaper or a report, signing pa- pers, etc?

0 Are you so concerned with having an answer to the situation or ques- tion that you do not hear the prob- lem?

0 Are you committed to your ideas to such a degree you do not listen to the responses of another?

0 Are you negative about viewpoints that differ from yours and so reject new ideas or trends? Do you feel that most people are valuable and that communication with them is important?

0 Are you abrupt with people, inter- rupting them to tell your story? Do you strive to accent the positive attributes of the speaker or do you look for flaws in his presentation?

.Can you summarize the ideas of another without asking him to re- peat the dialogue again? Do you break in to complete the thoughts of another, either because you feel he is too slow in getting to the point or because you feel more capable?’

Listening itself can be an effective tool in helping others. Often persons

value the opportunity just to share their concerns and do not expect solutions to their problems. Many nurses, however, feel inadequate and avoid listening to patients for fear they cannot “help them” or “know what to say” in return. The process of listening is a therapeutic tool that nurses do not use enough in their interactions with patients and others. But i t is a skill we all possess and need only to refine.

Asking questions. Many interactions between a nurse and patient involve ob- taining information through question- ing. Often the focus is on how to get the most information in the least time. Ask- ing questions effectively is another communications tool that requires some thought. Questioning has many pur- poses in addition to obtaining factual information from the patient. Questions can (1) elicit descriptions of feelings, (2) clarify perceptions, (3) interpret mean- ings, and (4) validate observations-all necessary aspects of the nursing proc- ess.

Closed questions, questions that re- quire a yes, no, or a one-word response, are efficient most of the time. If only closed questions are used, however, the patient, or any receiver, is left dissatis- fied with the interview. The receiver has no way of getting feedback from the questioner, and no way to explain his answer. We convey the feeling that we are too busy to listen. Another difficulty with closed questioning is that because

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the nurse only gets a direct answer to her question, she is limited in the amount of information she receives.

Open-ended questions allow the pa- tient to elaborate, discuss, or describe what he is thinking. These questions take more time, but the patient feels much more satisfied with the interview, and the nurse gets more information from the patient. Sometimes open- ended questions result in the patient rambling on and on. If that occurs, the nurse can acknowledge what has been said and ask a direct question to get the patient back on track. Most people don’t realize they are rambling and don’t mind getting back on the topic.

The key to an effective interview is balance between open-ended and closed questions. Open-ended questions are best used in the beginning. We can con- vey early that we care about the patient and his thoughts and feelings, and we can get more information to use in mak- ing assessments. Closed questions are useful when we need some specific in- formation. With patients of limited vo- cabulary, closed questions can also be useful because elaborate responses are not expected. Generally, though, closed questions are not as effective as open- ended questions. The nurse can often obtain more pertinent information from a few thoughtful open-ended questions than a whole list of closed ones.

In addition tojust asking questions, it is important to convey that we are lis- tening and interested in what the per- son is saying. Maintaining appropriate eye contact, asking relevant questions, being attentive, and focusing on verbal and nonverbal actions will al l ac- complish that purpose. Showing signs of being in a hurry to leave, repeating questions already asked, or asking for information about something a person has already told you will quickly de- stroy the person’s confidence in you.

Nonverbal communication. All com-

munication has both content and feeling. Content is usually contained within the verbal message, while feelings are primarily expressed nonverbally. The nonverbal part of a message is the most believable. Research has shown that of the total impact of any message, 65% is reflected in nonverbal behavior and only 35% in verbal.2 For that reason, it is important that we develop skills of observation so we can be aware of the whole person we are communicating with and not just his words. Once we can make these observations and read the person’s nonverbal cues, we are much more able to understand the whole mes- sage. Knapp has identified that nonver- bal behavior is generally used to (1) elaborate on the verbal message, (2) contradict the verbal message, (3) at times substitute for a verbal message, or (4) just repeat the verbal me~sage .~ Nonverbal behavior expresses emotion, conveys attitudes such as like or dis- like, and reveals personality. It also gives cues for managing such aspects of the communication process as feedback, taking turns, showing attention, and indicating closure. These aspects al- ways occur in an interaction, but we are usually not aware of them.

Nonverbal behavior encompasses seven major areas: (1) body motion, in- cluding facial expression; (2) physical appearance; (3) use of space; (4) how we say what we say, ie, rate, volume, tone, pitch, articulation, and choice of words; ( 5 ) use of objects to convey messages, including clothes, jewelry, and objects on our desk; (6) use of touch; and (7) the environment, such as seating arrange- ments, the use of barriers, and use of color.

Certain nonverbal behaviors are used to convey specific messages. For exam- ple, studies of status have found that, in the presence of a lower status person, a high status individual will have less eye gaze, a more relaxed posture, a louder

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voice, more frequent use of arms, and more expansive movements than the lower status p e r ~ o n . ~ Becoming experi- enced at observing all aspects of the communication process will give us much clearer understanding of what is being communicated.

Collaboration. This is often a key to better patient care. Nurses frequently must collaborate with each other and with other health team members to en- sure comprehensive patient care. A major part of collaboration is under- standing what is being communicated and taking individual responsibility to enhance the communication process. Most conflicts will occur because of faulty communications.

There are several steps to successful collaboration. First, it is important to recognize the contributions of the other person and accept those contributions as valuable. An open mind is essential. Next, listen to the other person’s ideas and thoughts without judgment. Often we are so intent on sharing our own ideas that we don’t hear others’ or are quick to find negative aspects. Finally, take responsibility for ensuring an ef- fective communication process. That is, make sure the other person under- stands what you are trying to say, and make sure you understand the other person’s point of view. Comments such as, “She didn’t even listen,” “She cer- tainly didn’t understand what I was saying,” and “I sure couldn’t make sense of what she said,” can easily be turned around to “I don’t think I really got her attention or interest,” “Maybe I didn’t make myself clear or give her a chance to ask questions,” and “I might have understood better if I had asked some questions.”

Taking personal responsibility in communication is the only effective way to ensure understanding. In any con- versation, if you are not sure the other person understands you, then accept the

reponsibility for that lack with a state- ment such as, “I’m not really sure I’ve made myself clear. Tell me what you don’t understand so I can clarify.” By doing so, you could eliminate misun- derstanding, resentment, and possibly anger later on, and the receiver of your message will probably have a good feel- ing about talking with you.

Consider the following situation. Mary, an OR nurse, wants to interview her preoperative patients the day before surgery. She comes to Jane, the head nurse of the surgical floor, to arrange a time when she can do her preoperative assessments.

Mary: You know, we have this new program where we interview the pa- tient the day before surgery. (States purpose for the interaction)

Jane: Yes, I heard about it. (Acknowledges)

Mary: Well, I’d like to do my inter- views about 2 pm every day. (States needs)

Jane: That’s not possible. We have meds and charting to do before we leave at 3:30. Everyone is really busy then. (Responds with own needs)

Mary: (becoming nervous) That’s the only time I can come-I’m in surgery until 1. (As anxiety increases, does not listen; defends need and choice of time)

Jane: (raising her voice) Well, we have to get all the admissions done plus meds-I just don’t see how it can be done. (Does not listen; restates own needs)

If not stopped by one of the participants, this type of interaction can continue for a long time.

Mary: I think we are stuck here. I understand you have a lot to do around 2 and 3, and my coming then might just add to your work. (Stops the interaction

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because it is getting nowhere; restates Jane’s position, letting Jane know she understands her point of view)

Jane: Yes, that’s right. I j u s t don’t see h o w we can manage it. (Responds to Mary’s attempt to understand)

Mary: I wil l usually need t o in terv iew only two patients. A r e al l the preop pa- t ients involved with staff a t t h a t t ime? (Begins to solve the problem with Jane)

Jane: No, but most are. (Still some hesitancy)

Mary: What if I called each day and set up a specific appointment for the patients I need t o talk with? (Offers a solution that is a compromise of sorts)

Jane: That wou ld work . T h e n we could plan our t ime around you.

The elements o f th is dialogue show that it’s easy t o l is ten t o our own needs and n o t understand the other person’s po int of view. Had Mary started out l is- ten ing and understanding, she might have accomplished h e r tasks sooner, but she did recognize the need to show un- derstanding before she could get any- where. A l though th is method does n o t always work, the in ten t i s to i l lus t ra te the difference between understanding the other person’s communication and only paying attention to your own con- cerns. Understanding always enhances communication.

E f fec t i ve communica t ion can en- hance your practice, especially in the perioperative role. T h e t w o k e y ele- ments are l is ten ing and understanding. Str ive for mastery o f these, and other techniques o f communication wi l l n o t be dif f icult to develop. 0 Notes

1. Maureen O’Brien, Communications and Rela- tionships in Nursing (St Louis: C V Mosby Co, 1974) 35.

2. Stewart Tubbs, Sylvia Moss, Human Com- munication, 2nd ed (New York: Random House,

1977) 217. 3. Mark Knapp, Non-verbal Communication in

Human Interaction, 2nd ed (New York: Holt. Rinehart 8. Winston, 1978) 21-26.

4. lbid, 228.

New treatments can ease menstrual pain A new era of treatment is at hand for menstrual cramps, says a report in the Journal of the American Medical Association. New medications are proving highly effective in relieving the pain that often accompanies the menstrual period.

For decades, the accepted approach to dysmenorrhea has been minor tranquilizers, mild pain relievers, and an automatic diagnosis of “psychogenic” pain, the report says. Psychological factors may be strong in some cases of menstrual pain, but in many there are bodily changes causing the cramps, changes that can be offset by medications.

Gynecologists are taking menstrual pain seriously these days. The pain is known to cause loss of many hours from work and school. Menstrual pain is a complex process in the body, but an important factor is a high bodily production of prostaglandins during the period of menstruation. The new medications reduce the excess prostaglandin production, and thus relieve pains.

Prostaglandin inhibitors are effective for relieving pain of dysmenorrhea in 65% to 100% of patients, W Y Chan, professor of pharmacology, Cornell University Medical College, New York City, said. However, says Chan, the prostaglandins represent a “shotgun” approach to the problem, and more selective drugs are sought for use in the future.

One problem, the report declares, is to reach physicians with the message that new tools are available for relief of menstrual pain. One family physician who treats many dysmenorrheic patients told JAMA, “So many of the women come to me after seeing other physicians who have told them, ‘It’s all in your head.”’

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