Communication in Nursing
The basic communication elements are (1) the sender, (2) the channel, (3) the receiver, and (4) the message. All of those elements need to be unambiguous to achieve effective communication, which means that the sender must send a clear message to the receiver through an appropriate channel. Effective communication is critical in healthcare because it affects patient safety, treatment outcomes, conflict resolution, and job satisfaction. However, various factors other than the basic communication elements affect the quality of communication in healthcare. Those factors include the organisational structure, leadership and management styles, organisational culture, staff motivation, and the organisational goals.
The simplest type of organisational structure is a structure with a unity of command, which means that all employees report to and receive input from one manager only. The benefit of this approach is that it minimizes the amount of manager-employee relationships, which reduces the chances for communication errors and improves productivity. However, that type of structure is inappropriate for larger healthcare organisations for two reasons. First, medical interventions often require multidisciplinary interventions managed by different professionals. Second, a hospital consisting of hundreds of employees cannot be managed by a single manager because a high span of control (i.e. the number of people reporting to a single manager) delays communication and the decision-making process.
Because the optimal span of control is estimated between 3 and 50 people, large hospitals will often implement several layers of management, so the employees can communicate only with the manager one layer above them in the chain of command (Marquis & Huston, 2012). For example, the department supervisor nurse will be responsible for overlooking specific functions and tasks of several staff nurses. Those staff nurses develop a manager-employee relationship only with their supervisor nurse, who can communicate on their behalf with middle managers when necessary.
The formal communication channels within the chain of command require the staff nurses to report to their supervisor nurse only. However, staff nurses can still experience various difficulties despite the organised chain of command. Their immediate boss is the supervisor nurse, but because of the multidisciplinary nature of medical interventions, nurses often find themselves working with multiple bosses, including the patients, physicians, and the central administration (Marquis & Huston, 2012).
The lack of unity in that complex organisational structure can often lead to various communication issues. For example, working with multiple bosses can result in contradictory input from different sources, which increases the chances of conflicts and reduces productivity (Marquis & Huston, 2012). While large organisations and multidisciplinary teams cannot achieve unity and build a sustainable system based on centralised decision-making, they can implement various policies to resolve conflicts and improve productivity.
For example, organisations can implement the shared governance model in their care delivery because it empowers nurses in their decision-making, and empowering individual employees improves workplace collaboration and treatment outcomes (Scherb, Specht, Loes, & Reed, 2011). The participation of staff nurses in daily decision-making can improve productivity because it eliminates the delays associated with communication through the chain of command. In order to resolve conflicts when they arise, communication training for nurses can help them remain assertive in communication, which is an appropriate response to colleagues and supervisors who are aggressive in their communication because it facilitates conflict resolution (Marquis & Huston, 2012).
Even though the chain of command needs to be respected, some situations might require the nurses to bypass the chain of command. For example, if a staff nurse considers that the practices of the supervisor nurse are unethical, that nurse can bypass the chain of command and communicate with the department director or somebody higher on the chain of command. It is still recommended to communicate with the person in question before taking such actions because it might be possible to prevent the event from escalating (Marquis & Huston, 2012).
Leadership and Management
While nursing has high burnout and turnover rates among staff and management, proper communication can improve nurses’ job satisfaction and resolve those issues. According to Parsons and Stonestreet (2003), communication is one of the most important determinants of nurse manager effectiveness and retention because the manager-employee communication quality directly influences performance, productivity, and job satisfaction. The subcategories of communication associated with performance and job satisfaction include manager availability, clear expectations, and feedback (Parsons & Stonestreet, 2003).
However, the quality of the communication among nurses is also dependent on leadership styles and nursing models implemented by the organisation. For example, the self-scheduling model removes a part of the nurse managers’ responsibility in decision-making by empowering the staff nurses to actively communicate and collaborate to reach desired treatment outcomes. Healthcare facilities that place more trust and responsibility on the staff nurses with a decentralized decision-making structure showed a significant improvement in the well-being, job satisfaction, and retention rates of both the nursing staff and nursing managers (Parsons & Stonestreet, 2003).
The differences in leadership styles also affect communication. Transactional leaders want their followers to obey instruction while maintaining the status quo. Transformational leaders use a different approach that focuses on enhancing staff morale and performance by allowing them to exercise creativity, develop self-identity, and implement new ideas. Both leadership styles have strengths and weaknesses, and effective communication determines whether they become detrimental or effective.
For example, transactional leadership is a useful style in acute care delivery because creativity and incoherent interventions can cause errors that could be fatal. The ability to follow proven practices without question is critical in those scenarios. However, because transactional leadership focuses on maintaining the status quo, there is a possibility of ineffective communication because of the lack of input from staff nurses. On the other hand, transformational leadership can improve job satisfaction by giving the staff nurses a sense of empowerment, allowing them to think independently, and developing their professional competencies. However, certain professional boundaries must be communicated effectively to prevent role confusion and inconsistency in care delivery, and consistent communication between the staff and managers is required to maintain those boundaries. Therefore, both leadership styles can be useful in different settings, but clear and consistent communication is required regardless of the leadership style to maintain the quality of care and avoid interpersonal conflicts.
Even though studies identified the most desirable communication practices in nursing, it is important to consider that effective communication skills are not equally developed in all healthcare workers, so instances of ineffective communication can often appear in practice. For example, managers who want to avoid conflict resolution will often use evasive communication strategies, such as asking irrelevant questions and using excessive compliments to change the subject of the conversation (Marquis & Huston, 2012). That behaviour is detrimental to staff morale and damages the integrity of the organisational culture because the managers and leaders in nursing are responsible for empowering the staff and promoting an ethical value-based workplace (Parsons & Stonestreet, 2003). While it is possible to confront those managers with assertive communication strategies and refuting their attempts at changing the subject, consistent incidences involving poor communication strategies are indicators that leaders are not able to effectively promote a positive organisational culture.
The organisational culture is a collection of norms, beliefs, values, and behaviours that determines the behaviour and well-being of nurses and other employees of the healthcare facility. While policies and procedures in hospitals change, the core values create a consistent foundation that facilitates a positive workplace. The most common types of organisational culture in healthcare are the role culture, task culture, and person culture, but the foundational values of a positive organisational culture are consistent across different types of culture and include trust, empowerment, delegation, consistency, and mentorship (Kane‐Urrabazo, 2006).
Communication has a significant role in building those values. For example, trust can be built only with open, honest communication and transparent, ethical practices (Kane‐Urrabazo, 2006). In order to exercise empowerment and delegation, the managers must be able to communicate effectively to avoid ambiguity, and communication must be frequent to ensure the employees receive the information, resources, and support they need to carry out tasks autonomously. Finally, mentorship programs have a variety of practical implications in nursing, such as alleviating anxiety in new employees and providing continuing competence to existing employees. In choosing mentors, the nursing managers must consider that communication skills facilitate the mentoring process, but the mentors must also serve as role models through their traits and behaviours (Kane‐Urrabazo, 2006).
Apart from the standard components of organisational culture, the evidence-based practice (EBP) culture is currently highly valued in nursing. Some hospitals have been testing EBP policies that support the sharing of EBPs through collaboration and communication among staff nurses. They found a significant improvement in EBP adherence and treatment outcomes (Rolfe, Segrott, & Jordan, 2008). Communication between nurses is essential for sharing and creating an EBP culture because care delivery improvement becomes a team effort.
An organisation that supports and uses the aforementioned values is setting up a culture that satisfies the conditions that contribute to successful communication. According to a focus groups study by Robinson, Gorman, Slimmer, and Yudkowsky (2010), successful communication is determined by the clarity of messages, calm behaviour, and mutual respect in the workplace. Calm behaviour and mutual respect can exist only in an environment that emphasises trust and collaboration. Considering some patients or colleagues less valuable than others was associated with ineffective communication, but fostering a positive organisational culture can reduce those issues and facilitate their resolution (Robinson, Gorman, Slimmer, & Yudkowsky, 2010).
The relationship between staff motivation and communication is reciprocal. Ineffective workplace communication can reduce staff motivation, and staff motivation can affect the way they communicate with colleagues and patients. For example, ineffective communication between colleagues can result in frequent conflicts. Consequently, unresolved conflicts can result in poor workload management, mistakes in patient allocation, and workplace harassment, so the nurses required to deal with the consequences of unresolved conflicts are at a high risk for burnout (Eagar, Cowin, Gregory, & Firtko, 2010). Burnout is a condition in which nurses are no longer able to empathically connect with their patients, and they distance themselves from their workplace obligations to patients and interactions with colleagues. They no longer have the motivation to provide quality care to patients or improve organisational care delivery, which could have been prevented with conflict resolution strategies and open communication.
The nurses’ motivation can also negatively affect patients’ perceptions of effective communication. The study by Jones, Woodhouse, and Rowe (2007) explored the patients’ perception of nurses’ communication effectiveness in the Neonatal Intensive Care Unit (NICU) and found that the patients differentiated between two types of nurses’ motivation in communication. In effective communication, the nurses’ motivation was to treat patients as equals and collaborate with their needs during conversation. Ineffective communication was characterized by the nurses’ motivation to position themselves above the patients and treat them as if they were ignorant or irrelevant.
In order to improve the patients’ satisfaction with the care provided, various communication strategies can be implemented. From the patients’ perspective, emotional expressions during communication and empathy were considered the most important characteristics of effective communication. Discourse management (e.g. asking follow-up questions and encouraging patients to ask additional questions) was considered the most desirable communication skill (Jones, Woodhouse, and Rowe, 2007). Most importantly, the nurses must remember that their role is to collaborate with patients rather than position themselves as their superiors because collaboration is the only way to establish rapport and emotionally connect with the patients. Their personal motivations and perceptions of their role during discourse can significantly affect the patients’ perceptions of communication quality.
The Achievement of Organisational Goals
The most important goal for healthcare organisations is improving care delivery. A direct impact on the quality of care delivery can be achieved by improving nurse-patient communication and modifying formal documents to explain medical terms in plain language. For example, nurses could be trained to avoid medical terms when disclosing information to patients, and the organisation can create discharge papers using plain language to improve the patients’ understanding of their diagnoses and prognoses (Huff, 2011).
For other organisational goals, the communication strategies between the employees are dependent on whether the goals are long-term or short-term. Long-term goals (e.g. hiring strategies, changing in-hospital models of care delivery, home-based nursing program implementations, etc.) require deliberate planning on a larger scale, so the employees involved in planning include mainly top-level and mid-level managers. If communication barriers result in conflicts, the appropriate strategy for overcoming those issues is seeking consensus because it resolves all important issues before implementing strategies and changes on a large scale that require a team-wide support (Marquis & Huston, 2012).
Short-term organisational goals require less planning and time for implementation than long-term goals because they are specific and can be evaluated quickly. For example, it is possible to immediately implement a policy that requires reviewing all acute care interventions and restricting individual interventions to determine whether that model improves treatment coherency and outcomes (Reader, Flin, Mearns, & Cuthbertson, 2009). In order to achieve short-term goals, planning will usually involve communication between staff nurses and their department supervisors. Avoiding difficulties in communication can be achieved by setting clear strategies for implementing, measuring, and evaluating the goal. Consistent feedback is critical for managing short-term goals to change strategies and objectives if necessary.
Effective communication in healthcare settings is consistently associated with various personal traits (e.g. empathy, trust, empowerment, etc.) and communication skills (e.g. conflict resolution, assertive communication, providing feedback, seeking consensus, discourse management, etc.) that can be applied to any conversation in different circumstances. However, various factors can affect the effectiveness of communication in healthcare, and they can be both personal and organisational. The most significant problems in communication can occur because of the complex organisational structure and poor organisational culture. Personal issues and incompetence can also interfere with communications at all layers of management and in nurse-patient relationship. Therefore, communication training should be an essential requirement for all healthcare professionals to facilitate conflict resolution, hasten the decision-making processes, and improve care delivery.
Eagar, S. C., Cowin, L. S., Gregory, L., & Firtko, A., 2010. Scope of practice conflict in nursing: A new war or just the same battle? Contemporary Nurse, 36(1/2), pp. 86-95.
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