Chapter 12: Communication and Collaboration in Professional Nursing

(NP RELATIONSHIP) Contract (orientation phase)

An example of a contract that might emerge from the orientation phase of the relationship with a patient with newly diagnosed diabetes is an agreement to work together on the patient's ability to monitor glucose levels and to manage diet using specific guidelines

Listening

Active listening involves focusing solely on a person and acknowledging feelings in a nonjudgmental manner. In active listening, the nurse is communicating interest and attention. It is best accomplished without background distractions, such as the television or chatting visitors. Using an intentionally unrushed manner, making good eye contact, nodding, and encouraging the speaker ("Go on" or "Tell me more") also help to communicate interest. Facing the speaker squarely and using an open posture (leaning forward, relaxed, arms uncrossed) also communicates interest. Sit, bend, or stoop to place your eye level at that of the patient, and repeat (reflect) what you hear, including feelings, checking to be sure you heard correctly. These indications of interest and active listening will help you focus on patients and tune into the meanings behind their words. Having someone listen to concerns, even if no problem solving takes place, may be therapeutic. Venting is the term used to describe the verbal "letting off steam" that occurs when talking about concerns or frustrations. In today's complex health care system, the risk is high that patients feel ignored or anxious on occasion. Because nurses are available to patients more than any other health care provider, they are likely to hear patients' complaints. It is important that nurses understand these complaints and frustrations as a professional, realizing that they are rarely personally directed at the nurse. Nurses may have difficulty listening for a variety of reasons. They may be intent on accomplishing a task and be frustrated by the time it takes to be a good listener. They may be planning their own next question or response and not truly hear what the patient is saying. They may be distracted by a colleague, a cell phone, or worries about another patient. Like all people, nurses have their own personal and professional problems that sometimes preoccupy them and interfere with effective listening. No message can be received if the receiver (the nurse) is not listening. In the context of care, being listened to meets the patient's emotional need to be respected and valued by the nurse. Hospitalized patients particularly may feel that their lives are out of control and that they are isolated or invisible. They may need to discuss those feelings with someone who will listen without judgment or defensiveness

Appropriateness

Appropriateness refers to the correct "fit" of a reply, that is, when it matches the message, and the size of the reply is neither too lengthy nor too brief. In day-to-day conversation among casual acquaintances passing in a hallway or in public, most people recognize the question "How are you?" as an expression of greeting in brief social interaction and not as a genuine inquiry into one's health and well-being. The individual who launches into a lengthy, detailed description of how his morning has gone has responded inappropriately to the casual question, "How are you?" The reply does not fit the circumstances, and the reply is too expansive for casual discourse. An appropriate response is, "Fine, and how are you?" or other short colloquialism. Conversely, when you go into a patient's room and ask "How are you?" your intention is to inquire about your patient's health and well-being as a professional interest, and the patient may respond accordingly; however, because this question is so pervasive in everyday discourse, the patient may simply answer, "Fine, and how are you?" You will need to ask the question more specifically if your patient responds in that manner. If a patient asks, "When is my doctor coming to see me?" just after having seen the physician, the nurse will be alert to other inappropriate messages by this patient that may signal a variety of problems. In this instance the inappropriate message does not match the context.

Developing Effective Communication Skills/Listening

Communication skills can be developed with time and practice. Becoming a better listener, learning a few basic helpful responding styles, and avoiding common causes of communication breakdowns can put you on the path to becoming a better communicator.

Efficiency

Efficiency means using simple, clear words that are timed at a pace suitable to participants. Explaining to an adult that she will have "an angioplasty" tomorrow morning may not result in successful communication. Telling her she will have "an angioplasty, a procedure in which a small balloon is threaded into an artery and inflated to open up the vessel so more blood can flow through," will more likely ensure her understanding. This message would not be an efficient one for a small child, however. Messages must be adapted to each patient's age, verbal level, and level of understanding. Oversimplification is a risk in trying to adapt one's language style and word choice to a particular patient. What may seem to be useful simplicity and efficiency may be perceived as "dumbing down" or patronizing language to the patient. One cannot tell with any certainty a patient's communication level, and to assume that a patient cannot understand may also cause problems. For instance, a nurse (the author!) once heard a physician tell a teenager with a urinary tract infection that she had "bugs in [her] bladder." The physician's attempt to make the language efficient and simple was misguided; the young woman took his words at face value and became upset to the point of almost fainting at the thought that she had insects in her body. The nurse immediately intervened, explaining to the patient that sometimes providers refer to bacteria or germs as "bugs"; she had bacteria in her bladder that had caused an infection. The patient immediately calmed down, asking, "Why didn't he just say that? I need some antibiotics." The physician made a significant misjudgment related to the patient's level of understanding. He came across as patronizing, and the patient was unnecessarily upset by his simplistic explanation. He followed up with the nurse, asking, 241"What just happened in there?" The nurse was glad to help him understand what had gone wrong. Some examples of patients who require special assistance in evaluating and responding to messages are young children; people with certain mental illnesses, neurologic deficits, or autism spectrum disorders; those with significant developmental delays; and those recovering from anesthesia or receiving pain medication. Although it may seem obvious that people with hearing loss will require special assistance in communication, those with impaired vision do not have the ability to note nonverbal cues, an important element of communication. For efficient communication to occur, nurses must recognize patients' needs and adjust messages accordingly.

Failing to Clarify

Failing to clarify the patient's unclear statements is a fifth common communication pitfall. Patient: "I've got to get out of the hospital. They have found out I'm here and may come after me." Nurse: "No one will harm you here." This nurse has responded as if the patient's meaning was clear. A clarifying response might be: Nurse: "Who are 'they,' Mrs. Johnson?" Confused patients or those with psychiatric illnesses often communicate in ways that are difficult to understand. Although it is very unlikely, sometimes patients' meanings are quite clear in the initial sentence, and their fears are based in reality. It is reassuring to patients to know that nurses are trying to understand them, even if they are not always successful. Communication is facilitated by clarification responses.

Criteria for Successful Communication

Feedback, Appropriateness, Efficiency, Flexibility

Flexibility

Flexibility is the fourth criterion for successful communication. The flexible communicator bases messages on the immediate situation rather than preconceived expectations. When a nursing student who plans to teach a patient about managing diabetes with diet enters the patient's room and finds the patient crying, the student must be flexible enough to regroup and deal with the feelings the patient is expressing. Pressing on with the teaching plan in the face of the patient's distress shows a lack of compassion, as well as inflexibility in communicating. Nurses can learn to use these four measures of successful communication to enhance their effectiveness with patients. If any of these four criteria are missing, communication can be disrupted and hamper the successful implementation of the nursing process. The following is a true story of what happens when communication breaks down and a rigid reliance on a bureaucratic system prevails. Some details are changed to protect the privacy of the patient and family. Mr. Lewis came to the local emergency department (ED) accompanied by his wife, who was a nurse. Mr. Lewis, who was very ill with cancer, was occasionally confused and had tried to retrieve a Popsicle stick from his large dog's mouth. In the process, he caught the back of his hand on an upper canine tooth, resulting in a deep gash. Mrs. Lewis had witnessed the accident and gave details to the triage nurse, including her first-person account that the dog did not bite her husband and that his long-term use of high-dose steroids had made his skin very fragile and prone to tearing. The nurse noted "dog bite" on her intake form over Mrs. Lewis' objection that the injury was clearly not a bite and that the dog was not at fault. The triage nurse did not acknowledge Mrs. Lewis' account of the accident, continued to get vital signs and complained about "getting slammed"—meaning that the ED was busy. Mr. Lewis was soon escorted to the urgent care room, where his wound was cleaned and sutured. Both the nurse practitioner and resident physician asked questions about how the "dog bite" happened, and Mrs. Lewis again protested that it was not a bite, and pointed out the lack of tooth marks, crushing or other signs of a bite. The attending physician told the couple that he had no choice but to report "the bite" to the county emergency medical services (EMS) per protocol, because the triage nurse had documented it as a "dog bite," although the couple had never said it was a bite and the wound was not consistent with a bite. The unit secretary called 911 and asked Mrs. Lewis to tell the dispatcher about the "dog that bit your husband." Mrs. Lewis explained what had happened to the dispatcher, who said that he had no discretion in the matter and that he had to report this to the local police. Within a half hour of arriving home at 12:30 a.m., Mrs. Lewis received a call from a police officer who said he was "initiating an investigation about the dog attack at this address." At that point, Mrs. Lewis burst into tears in frustration and explained one more time to the police officer that there was no attack, no bite, just an accident by her sick and confused husband. The officer said that he had no discretion in the case and had to make a report to animal control, who would have the final say about whether their beloved dog would have to be quarantined or worse. He said that he would make his report in a way that was sympathetic to the Lewises, although he could not promise what animal control would do. For over a week, the Lewises were nervous and upset and every time the phone rang or someone came to the door they feared it was animal control. Gratefully, they never heard anything else about the matter. But the triage nurse's failure to listen carefully created a cascade of bureaucratic procedure that caused avoidable pain for this couple that was already dealing with devastating illness. Consider the many ways that communication went wrong in this scenario. Identify points where you believe that this cascade of events could have been interrupted.

Becoming Nonjudgmental

Prejudices are simply what the word implies: judging a person in advance of knowing him or her, based on stereotypes and biases. Prejudices are strong and are often outside our awareness, which in turn makes acceptance of others difficult. Prejudging others as "good" or "bad," "right" or "wrong," is usually unconscious, hence the need for nurses to examine their prejudices and become aware of when prejudices are operating. Nonjudgmental acceptance means that nurses acknowledge all patients' rights to be who they are and to express their uniqueness. Acceptance conveys neither approval nor disapproval of patients and their personal beliefs, habits, expressions of feelings, or lifestyles. Therapeutic use of self begins with the ability to convey acceptance to patients and requires self-awareness and nonjudgmental attitudes on the part of nurses. Ongoing examination of attitudes toward others is both a lifelong process and an essential part of self-awareness, maturation, and personal growth.

(NP Relationship) Developing Self Awareness

Self-awareness is basic to effective interpersonal relationships and is especially important in the nurse-patient relationship. Few people, however, recognize their own emotions, prejudices, and biases and how they are perceived by others. With practice, however, most people can become self-aware, thereby increasing their effectiveness in both professional and personal relationships. Nurses must get their own emotional needs met outside of the nurse-patient relationship. When nurses have strong unmet needs for acceptance, approval, friendship, or even love, they run the risk of allowing these needs to enter into their relationships with patients at the cost of professionalism. Boundaries get blurred, and relationships become social, not professional. Worse, patients can bear the burden of their nurses' emotional needs. This is a particular risk in settings where the nurse takes care of a patient and family over a long period of time, such as in home health or hospice/palliative care settings, or in long-term care facilities. Patients come to know their nurses well, and details of nurses' lives are sometimes shared as part of conversation over time. Although it is not necessarily a boundary issue for a patient to learn certain details of nurses' lives, it is always a problem when the nurse comes to depend on patients for his or her own emotional support. Baca (2011) listed five ways in which self-disclosure becomes problematic: (1) if the nurse's problems or needs are disclosed;(2) if disclosure by the nurse becomes a common, rather than rare, event during interactions with a patient; (3) when the disclosure is unrelated to the patient's problems or experiences; (4) if it takes more than a very short time during an interaction; and (5) the nurse discloses personal information even if it is clear that the patient is confused by the interaction. Becoming aware of one's needs and making conscious efforts to have those needs met in one's private life keep relationships with patients professional and therapeutic for the patient. When the nurse-patient relationship crosses professional boundaries, role confusion can result, risking harm to both patient and nurse

Social VS Professional Relationships

Social Relationships* • Evolve spontaneously • Not time-limited • Not necessarily goal-directed; broad purpose is pleasure, companionship, sharing • Centered on meeting both parties' needs • Problem solving is rarely/occasionally a focus • May or may not include nonjudgmental acceptance • Outcome is pleasure for both parties Professional Relationships* • Evolve through recognized phases; interactions are planned and purposeful • Limited in time with termination date often predetermined • Goal-directed; systematic exploration of identified problem areas • Centered on meeting patient's needs; do not address nurse's needs • Problem solving is a primary focus • Includes nonjudgmental acceptance • Outcome is improved health status of patient

(NP RELATIONSHIP) The Working Phase

The 2nd phase of the nurse-patient relationship is called the working phase -In this phase, the nurse and patient address tasks outlined in the previous phase -B/c the participants in this relationship now know each other in a professional context, a sense of interpersonal comfort in the relationship may be possible Nurses should recognize that patients may be wishy washy or resisting new change -For instance, the patient may have difficulty in accepting the lifestyle changes that diabetes requires -"Two steps forward and one backward" approach to behavior change is common (It is NOT a reflection on one's skill as a nurse, nor is it an indictment of the patient's desire to manage his/her own care) Patience, self-awareness, and maturity are required of nurses during the working phase Continued building of trust, use of active listening, and other helpful communication responses facilitate the patient's expression of needs and feelings during the working phase.

Effective Communication with Other Providers/ SBAR

The Joint Commission has standardized health care communication within and across disciplines through the practice of SBAR—Situation Background Assessment Recommendation. SBAR is a structured way of relaying critical information in spoken form. It is a means of establishing a culture of quality, reliability, and patient safety because individuals—regardless of discipline—communicate with each other through a shared set of 249expectations. SBAR means that information is clear, complete, concise, and structured, and is therefore more efficient and accurate. SBAR was originally developed by the U.S. Navy for use on nuclear submarines; it was introduced into health care in the late 1990s and has been adopted in health care facilities around the world to standardize communication among care providers. In using SBAR, you filter quickly through irrelevant data so that the most relevant and important data are featured. You then present your briefing on the situation to colleagues who understand and expect the SBAR format, which gets to the problem—and hence solution—sooner. Your colleagues respond with questions to confirm or clarify what you have presented. Here is an example of a nurse in the neonatal intensive care unit (NICU) calling the neonatal nurse practitioner regarding a premature infant: Nurse: Hello, this is Paola Santos. I am the registered nurse taking care of Jeremy Benton. (Situation): Here's the situation: Jeremy's latest arterial blood gas showed a Po2 of 68, Pco2 of 64, and pH of 7.32. (Background): Jeremy is a White male born 22 hours ago at 32 weeks of gestation, weighing 1550 grams. He has been on CPAP (continuous positive airway pressure) since birth and is now at 40% O2, up from 35% 8 hours ago. In the past 2 hours, his respiratory rate has increased from 60 to 88 and his O2 saturation has decreased from 96% to 92%. (Assessment): My assessment is that Jeremy is developing respiratory failure. (Recommendation): I recommend that you or one of the neonatal fellows come see him and that I call for a respiratory therapist to be in the NICU in case Jeremy needs to be intubated.

Nurse-patient relationship- ORIENTATION PHASE

The orientation phase, or introductory phase, is the period often described as "getting to know you" in social settings. Relationships between nurses and their patients have some commonalities with other types of relationships >The chief similarity is that there must be trust between the two parties for the relationship to develop >During the orientation phase, nurse and patient assess each other >Early impressions made by the nurse are important -People have difficulty accepting help of any kind, including nursing care By the end of orientation phase, 4 things should have happened between the nurse and patient 1. the patient gains enough trust in nurse to continue relationship 2. the patient and nurse will see each other as individuals 3. the patient's perception of major problems and needs will have been identified 4. the approximate length of the relationship will have been estimated and the nurse & patient will have agreed to work together on some aspect of the identified problems

(NP RELATIONSHIP) Termination phase

The termination phase includes those activities that enable the patient and the nurse to end the relationship in a therapeutic manner. The process of terminating the nurse-patient relationship begins in the orientation phase when participants estimate the length of time it will take to accomplish the desired outcomes. This is part of the informal contract. The giving and receiving of gifts at termination has different meanings for different people. The meaning of such behavior should be explored in a sensitive manner with the patient. When a nurse has been involved with a family over a long and/or intense period of time, such as in an end-of-life setting, it is common for those families to want to give the nurse a gift as a sign of their appreciation and as a remembrance of the patient who has died. Both the agency's policy on gifts and your clinical faculty should also be consulted. Even if you are not allowed to accept a gift, you can acknowledge that you wish you could accept their gift and express your gratitude for their thoughtfulness. Because termination is often painful, participants are often tempted to continue the relationship on a social basis, and requests for screen names for social media, addresses, phone numbers, and email addresses are not uncommon. The nurse must realize that professional relationships are different from social relationships. This is an issue of professional boundaries that has been discussed earlier in this text.

Failing to see the uniqueness of the individual

This failure is caused by preconceived ideas, prejudices, and stereotypes EX: If an elder says that they have back pain, the nurse may say that it is normal because he is old. The nurse is not responding to the patient as an individual The nurse could have said: "Tell me more about your back pain" Her chances of asking more about the back pain has been significantly decreased

Avoiding common causes of communication breakdown

Unsuccessful communication can occur for many reasons. A sender may send an incomplete or confusing message. A message may not be received, or it may be misunderstood or distorted by the receiver. In-congruent messages may cause confusion in the receiver. In nursing situations, there are several common causes of communication breakdown. These include failing to see each individual as unique, failing to recognize levels of meaning, using value statements, using false reassurance, and failing to clarify unclear messages. Failing to see the uniqueness of the individual, Failing to recognize levels of meaning, Using value statements and cliches, Giving false reassurance, Failing to clarify

Giving False Reassurance

Using false reassurance is another communication pitfall. Although the nurse (and patient) may feel better temporarily, this strategy impedes communication and does not help the patient. Patient: "I'm so afraid the biopsy will show cancer." Nurse: "Don't worry. You have the best doctor in town. Besides, cancer treatment is really good these days." For a fearful patient, this type of glib reassurance does not help. The patient has stated very clearly his legitimate concern as he faces a biopsy. He may indeed have cancer. A more sensitive response would be: Nurse: "I regret that you are having to go through this. Let's talk about your concerns." Note that in the first sentence, the nurse did not offer any reassurance, but expressed human feelings of regret, which indicates concern to the patient. The nurse then gave the patient an opportunity to talk about his concerns. Note that when you say, "Let's talk about...," you are indicating that you are available to your patient for this kind of in-depth conversation. If you are in the middle of your early shift assessments, you may need to follow this up by setting a time at which the patient knows you will return to continue this conversation. These types of patient needs are common; not honoring your offer to talk to him about his fears is dehumanizing for the patient.

Using Value Statements and Cliches

Using value statements and clichés is another communication problem. Value statements indicate that the nurse has made a judgment, either positive or negative. The use of value statements indicates that the nurse is operating out of his or her own framework without considering that the patient might feel differently. The use of clichés, which are trite, stereotyped expressions, is common in social conversation but should be used carefully in professional relationships. Consider the prevalence of the cliché "Have a good day." This statement has come to have little real meaning. This common error can cut off communication by showing the patient that the nurse does not understand the patient's true feelings. This nurse has used a value statement ("how nice") and a cliché ("there's nothing as comforting as a mother's love"). She has made an assumption that the patient welcomes a visit from her mother and has failed to verify what the patient's actual wishes are. In fact, the patient and her mother may have a difficult relationship, and the patient may dread the impending visit. By assuming otherwise, the nurse has contributed to communication breakdown. This patient probably will not attempt to discuss her relationship with her mother any further with this nurse. A more helpful response would be: Nurse: "How are you feeling about her visit?" This allows the patient to express her feelings about her mother's visit, whether positive or negative. The nurse has conveyed a genuine interest in the patient's true feelings and has avoided a "yes" or "no" answer by asking the patient a "how" question. (DONT ASSUME THAT PATIENTS WILL HAVE THE SAME VIEWPOINTS AS YOU. EVERYONE IS DIFFERENT. YOU MAY LOVE A VISIT FROM YOUR MOM, BUT THEY MAY HAVE A ROUGH RELATIONSHIP)

Feedback

When a receiver relays to a sender the effect of the sender's message, feedback has occurred. It is also a criterion for successful communication. In making the social appointment mentioned earlier, if the receiver of the message had said, "Let's make sure I understand correctly—12:30 on Tuesday at the Looking Glass Café for coffee," that feedback could have led to successful communication. In a nurse-patient interaction, a nurse can give feedback to a patient by saying, "If I understand you correctly, you are saying that you have pain in your lower abdomen every time you stand up." The patient can then either agree or correct what the nurse has said: "No, the pain is there only when I get up in the morning." Effective nurses do not assume that they fully understand what their patients are telling them until they confirm their understanding with the patient.

Failing to Recognize the Levels of Meanings

When nurses recognize only the overt level of meaning, communication breakdown can occur. Patients often give verbal cues to meanings that lie under the surface content of their verbalization EX: When a patient says "it's getting awfully warm in here" the nurse may take it literally and open up a window. A figurative tool could have been used instead