Nursing 619 – Communication Barriers In Nursing

Communication is an essential part of the nursing process. A good nurse uses communication in all forms to teach her patient, to educate family members, and to collaborate with other members of the healthcare team. For the purpose of this paper, we will focus on the communication barriers between nurses and their patients.

Nurses impose their own barriers on communication. Because of the nature of the nursing job, it is easy to become too attached to a patient. If things turn out badly for a patient the nurse cares about, this causes pain and makes it more difficult for the nurse to perform her job. To avoid this pain, nurses put a barrier between them and their patients, focusing on task-oriented communication rather than patient-centered communication.

Communication barriers can also arise because of the patient’s situation. Without proper education, the nurse can have difficulty communicating with a patient who is developmentally delayed. The nurse may feel uncomfortable communicating with a deaf person in the absence of a sign language translator. With the elderly, communication can be difficult because of their slow speech, hard hearing, and other results of aging.

To provide the best care for the patient, the nurse must overcome these barriers and practice good patient-centered communication. With good communication, the nurse can express empathy for the patient, promoting an atmosphere of healing and comfort. With good communication, the nurse can properly educate her patient, leading to better care in the hospital and in the home. With good communication, the patient feels well cared for, and the patient feels confident that the nurse is on his side. Their questions get answered and their experience in the hospital is improved.

CLINICAL EXPERIENCES

In my clinical this past semester, I have experienced difficulty communicating on two occasions. In school, we learn that communication is important, but when put in a situation that requires a little adaptation, I couldn’t help but feel that my skills were inadequate. While I struggle each week with the first introduction to a patient, wondering what to say, how to say it, and how I can best appear confident in my skills and abilities, the week I was assigned to Mrs. S, a deaf patient, I was especially nervous to go into the room for the first time. While I had some basic communication strategies in my head, I had no idea what to expect. Eventually I worked up the courage to go in the room, and luckily she read lips. She had a white board that I was able to use when she couldn’t understand what I was mouthing, and we got along okay until a translator could be found later in the day. But I couldn’t help but feel like Mrs. S was missing half of what I had been trying to communicate. I got her to understand all my words, but she couldn’t hear the tone of my voice. When she was in pain, I couldn’t be sure that I had appropriately conveyed my empathy, because she could only see or read the words I was saying, not hear them. While Mrs. S was able to see my body language, I still wasn’t sure that she knew how sorry I was that the flu shot I gave caused her pain.

In my last week of clinical, I was assigned to work with Ms. A, a patient who was developmentally delayed. For most of the morning working with her, her support staff was absent, so I was on my own to figure out what she could understand, and what her responses meant. At first, I wasn’t even sure that she could talk, because she wasn’t responding to my queries. It wasn’t until the nurse came in to help me with something that I heard Ms. A speak. Communication with Ms. A was especially important, because she was experiencing an emergency situation. Her broken leg was losing blood flow and sensation, but her potassium was critically high at 6.5, so there was a parade of surgeons and ultrasound techs and lab techs and nurses and administrators coming in and explaining what was going on, but it was clear that she was becoming overwhelmed and I wasn’t sure how much she understood beyond the fact that everyone was worried. I tried my best to reassure her, but her face remained creased with worry. It wasn’t until her caretaker came in and explained what was happening that I saw her relax. It was clear to me that my communication had been ineffective.

OBSERVATIONS

On the other end of communication, nurses put up their own barriers. In my clinical experience, as a student I had more time to spend with my patient, because I was only assigned to one per shift, rather than four like the nurses. When I would talk with my patients, many of them expressed surprise at my having time to talk to them and others commented that they felt a disconnect with their nurses. When pressed for further details, they would reveal to me that the nurses seemed too busy to really care. They would blow in, give pills or listen to lung sounds and then rush off to another patient. Curious about what could be done to remedy the situation, and whether this was common, or just a part of my hospital, I conducted a review of the literature.

LITERATURE REVIEW

When thinking about what I wanted to write for this paper, I first thought of Ms. A. She as a patient had the most profound impact on me this semester, and I wanted to research communication strategies to use with developmentally delayed patients so that the next time I encountered such a situation, I would have the tools available to reassure my patient, rather than having to rely on someone else. However, when I searched the Cumulative Index to Nursing and Allied Health Literature (CINAHL), I was only able to find one or two articles pertaining to the subject. Accordingly, I broadened my search and changed my topic to include communication difficulties and strategies for nurses to use with any patient population.

After identifying the articles that I would shape my paper around, I identified several themes. Communication difficulties are prevalent in all areas of healthcare, and all nurses are likely to experience difficulty communicating with a patient at some point in their practice (Bryan, Axelrod, Maxim, Bell, & Jordan, 2002). There is a need for good hands on training to change the attitudes with which healthcare workers approach these patients and to give them tools to improve communication (Bryan, Azelrod, Maxim, Bell, & Jordan, 2002; Tracy & Iacono, 2008). Communication barriers on the part of the nurse are usually the result of the ward environment and a sense of task-orientedness rather than a patient centered attitude (Cleary, Edwards & Meehan, 1999; McCabe, 2004). Finally, a person’s condition (intellectual disability, deafness, age) is not necessarily indicative of their communication abilities. Within each condition, there is a wide range of communication abilities, and the nurse should assess each patient as an individual before making assumptions (McLean, Brady, McLean, & Behrens, 1999).

APPLICATION

Both nurses and patients have a sense that nurses are too busy to really connect with their patients. McCabe (2004) found that after interviewing patients regarding their perceptions of the nurse-patient communication while they were in hospital, it became clear that while nurses had the ability to engage in therapeutic communication with their patients, “health care organizations do not appear to value or recognize the importance of nurses using a patient-centered approach when communicating with patients to ensure the delivery of quality patient care” and thus nurses continue to use the task-oriented approach that is approved by their managers. While this may ensure that all the nursing interventions get completed, the patients are left feeling “that the tasks were more important than they were” (McCabe, 2004). At the end of the study, McCabe (2004) suggests that it is up to the management to change the attitude of their ward. The nurses agree with the patients. Cleary, Edwards, and Meehan (1999) found that nurses “often expressed regret at the lack of time available to spend with individual patients.”

To be a better communicator, each nurse should try to find a few minutes of uninterrupted time with each patient that is focused on the patient’s concerns and not the task at hand. In this way, the patient can experience good care. In my own experience, the patients truly seem to appreciate the students, not because they are good at performing tasks or getting their medications to them on time, but because the students take the time to really talk with the patient. While this may be difficult with the current way a hospital ward is organized, changes should be made to accommodate real face-to-face communication between nurses and their patients.

When the nurse does find time to sit down with her patient and discuss health issues, there can be challenges presented by the patient’s condition. While each individual has different communication needs, there are several strategies that can be applied to any situation to improve communication. Arthur (1999) identified four essential skills for communication: attending, listening, empathy, and probing. By attending to the client, the patient feels confident that the nurse wants to understand what they are saying. It is only by actively listening, paying attention to verbal and nonverbal cues, that the nurse can understand her patient. Arthur (1999) considers empathy “communicating to clients understanding of what they are saying” so the nurse should occasionally rephrase the patient’s words or check for clarification. By probing, the nurse can help the client identify feelings and explore where they are coming from, and accordingly get to the heart of the matter. When communicating with a patient who has a communication disability, McLean, Brady, McLean and Behrens (1999) suggest discussing patient-specific strategies with the patient’s typical caregivers to get an idea of what to expect. Even armed with these particular strategies, Bryan, Axelrod, Maxim, Bell, and Jordan (2002) recommend allotting more time for each interaction, as the patient may communicate more slowly, or it may take you longer to understand what they are saying.

When communicating with a patient who has difficulties, it is important to do so in a non-judgmental manner. Effective communication can only happen when both participants are comfortable and confident that what they are saying will be received appropriately. To increase the confidence of healthcare workers, Tracy and Iacono (2008) recommend practicing communicating with these special patients in a controlled environment. Bryan, Axelrod, Maxim, Bell, and Jordan designed a program called Communicate intended to educate nurses and other direct care professionals about working with patients who have communication difficulties. Hospitals and agencies can greatly increase the communication skills of their employees by hosting such a program.

CONCLUSION

As nurses, communication is a major part of the care we give our patients. The environment in which we work is not set up for ideal communication. Nurses are busy, patients are vulnerable, and management encourages staff to focus on completing measurable tasks rather then spending time with patients, which may not have a readily measurable benefit. Despite this environment, it is the task of the nurse to take the time for meaningful conversation with her patients.

Educational programs, especially those that allow practice and exposure to the kind of patients being discussed, can greatly increase the confidence of nurses. It would be especially helpful to offer this type of program to nursing students. As a student, I would have benefited from this type of program. It would have made me more confident approaching Mrs. S, and I wouldn’t have to rely on others as in Ms. A’s case.

Therapeutic communication is essential in the nurse-patient relationship, and the nurses who take these strategies to heart will greatly improve the care of their patients.

References

Arthur, D. (1999). Assessing nursing students’ basic communication and interviewing skills: the development and testing of a rating scale. Journal of Advanced Nursing, 29(3), 658-665. Retrieved from CINAHL Plus with Full Text database.

Bryan, K., Axelrod, L., Maxim, J., Bell, L., & Jordan, L. (2002). Working with older people with communication difficulties: an evaluation of care worker training. Aging & Mental Health, 6(3), 248-254. Retrieved from CINAHL Plus with Full Text database.

Cleary, M., Edwards, C., & Meehan, T. (1999). Factors influencing nurse-patient interaction in the acute psychiatric setting: an exploratory investigation. Australian & New Zealand Journal of Mental Health Nursing, 8(3), 109-116. Retrieved from CINAHL Plus with Full Text database.

McCabe, C. (2004). Nurse-patient communication: an exploration of patients’ experiences. Journal of Clinical Nursing, 13(1), 41-49. Retrieved from CINAHL Plus with Full Text database.

McLean, L., Brady, N., McLean, J., & Behrens, G. (1999). Communication forms and functions of children and adults with severe mental retardation in community and institutional settings. Journal of Speech, Language & Hearing Research, 42(1), 231-240. Retrieved from CINAHL Plus with Full Text database.

Tracy, J., & Iacono, T. (2008). People with developmental disabilities teaching medical students–does it make a difference?. Journal of Intellectual & Developmental Disability, 33(4), 345-348. Retrieved from CINAHL Plus with Full Text database.

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