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CPD

Prepare for revalidation:


read this CPD article and
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CONTINUING
PROFESSIONAL
DEVELOPMENT

Page 60

Communication
skills multiple
choice questionnaire

Page 61

Jackie Pecks reflective


account on blood
glucose monitoring

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Guidelines on
how to write a
reflective account

Effective communication
skills in nursing practice
NS772 Bramhall E (2014) Effective communication skills in nursing practice.
Nursing Standard. 29, 14, 53-59. Date of submission: July 18 2014; date of acceptance: September 1 2014.

Aim and intended learning outcomes

Abstract
This article highlights the importance of effective communication skills
for nurses. It focuses on core communication skills, their definitions and
the positive outcomes that result when applied to practice. Effective
communication is central to the provision of compassionate, high-quality
nursing care. The article aims to refresh and develop existing knowledge
and understanding of effective communication skills. Nurses reading
this article will be encouraged to develop a more conscious style of
communicating with patients and carers, with the aim of improving
health outcomes and patient satisfaction.

Author
Elaine Bramhall
Managing director, consultant and trainer, Effective Communication
Matters, Manchester, England.
Correspondence: elaine@ecmatters.co.uk

Keywords
Active listening, communication skills, communication skills training,
compassionate care, effective communication, empathy, interpersonal
skills, nursing care, patient cues, patient safety

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The aim of this article is to increase readers


awareness and understanding of the role of
effective communication in compassionate
nursing care. The article can be used to
help readers develop a more conscious style
of communication, while enhancing their
confidence and ability to notice and respond
to patient cues. After reading this article
and completing the time out activities
you should be able to:
Outline the role of effective communication in
the provision of compassionate nursing care.
Discuss barriers to effective communication.
Describe the core communication skills
required in healthcare settings.
Integrate effective communication skills into
clinical practice.
Identify individual learning requirements
and recognise the need for support and/or
additional communication skills training.

Introduction
Communication can be defined as a process
during which information is shared through
the exchange of verbal and non-verbal
messages (Brooks and Heath 1985), and where
people create a relationship by interacting with
each other (Groogan 1999). Communication
is integral to the nurse-patient relationship and
is one of the six fundamental values of nursing
identified in the governments strategy to deliver
high-quality, compassionate care for patients
(Department of Health (DH) 2012). The policy
document Compassion in Practice states that
communication is central to successful caring
relationships and to effective team working

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CPD communication skills

1 Reflect on one
or two of your recent
interactions or
consultations with
patients where there
were communication
challenges. List the
challenges and emotions
involved, and write
down how you managed
these challenges. Reflect
on how you think the
other person felt at the
end of the consultation.
How did you feel?

(DH 2012). The Nursing and Midwifery


Council (2008) highlights the importance of
communication in its code of conduct, stating
that nurses must meet peoples language and
communication needs and share with people,
in a way they can understand, the information
they want or need to know about their health.
Effective communication helps vulnerable
patients to cope with and make better decisions
about their care and treatment (Donnelly
and Neville 2008). However, maintaining
effective communication in busy healthcare
environments where patients are vulnerable
and staff are frequently stressed requires
advanced interpersonal skills, as well as an
awareness of self and others.
A growing body of evidence demonstrates
that it is possible to improve and develop
effective communication skills with training
(Maguire et al 1996, Fallowfield et al 2002,
Wilkinson et al 2008, Connolly et al 2014).
However, in recent years there has been a
surge in complaints about care and significant
failings in communication and attitudes of
staff (Francis 2010, DH 2013a, 2013b, Royal
College of Nursing 2013). The need to provide
compassionate care is emphasised, but it is
difficult to clarify exactly what it is and how it
can be demonstrated in practice.
One definition of compassion is a deep
awareness of the suffering of another coupled
with the wish to relieve it (The Free Dictionary
2014). The Oxford English Dictionary (2014)
refers to the Latin origins of compassion,
compati, meaning suffer with. Peters (2006)
defines compassion as a deep feeling of
connectedness with the experience of human
suffering that requires personal knowing of
the suffering of others and results in caring
that comforts the sufferer. Compassionate care
is also defined as a relational activity that is
concerned with the way in which we relate to
other human beings when they are vulnerable
(Dewar et al 2011). The varied definitions
and understanding of what compassion is
highlights the challenges of demonstrating this
complex connection with another person in
nursing practice. If nurses had a deep awareness
of the suffering of every individual they cared
for, they could easily become overwhelmed and
find it almost impossible to function within a
professional role.

Compassionate nursing care


Empathy is perhaps a more realistic way of
showing we appreciate and care about the

experiences of patients as they cope with


difficult diagnoses, treatments, symptoms of
ill health and life-limiting illness. Empathy
verbalised by one person to another can
offer support and comfort at times of
vulnerability, anxiety and distress. Empathy
can be described as the ability to set aside
your own thoughts and feelings. This may
sound easy, but in practice nurses often have
an overpowering desire to offer a solution,
information or reassurance to patients and
relatives. The desire to help or alleviate distress
can dominate the thoughts and feelings of
any healthcare professional. The act of setting
aside personal thoughts and feelings enables
active listening to take place. In addition,
empathy means being willing to try to perceive
the world as it is for the other person. Being
willing to view the world of someone who
is experiencing a high level of distress takes
courage and bravery. Finally, empathy is
conveyed by expressing appreciation of the
other persons situation and feelings (Mearns
and Thorne 2007).
Complete time out activity 1

Communication skills training


A report from the Royal College of Physicians
(2014) on end of life care in hospitals in
England found that the majority of discussions
with families and friends took place less
than two days before death. This finding
may indicate some degree of reluctance
to engage in these sensitive discussions
earlier in the patients illness, not only by
nursing staff but also by all members of the
multiprofessional team across health and
social care, hospital and community settings.
The report recommends that training in
communication skills should be mandatory
for all staff involved in caring for dying people.
If healthcare professionals felt more confident
and competent to engage in these sensitive
discussions, more discussions would take place
at a time when people who are dying and those
close to them are better able to prepare and
adjust to the situation.
This is not a new recommendation.
Improving Supportive and Palliative Care
for Adults with Cancer (National Institute
for Health and Care Excellence (NICE)
2004) described a four-level model for
providing psychological support to patients.
The guidance stated that psychological distress
is common and these signs of distress are
not readily recognised, with the result that

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people fail to receive the support they require.


All healthcare professionals, regardless
of grade, role or specialty, were noted as
having a role in identifying and responding
to the distress of patients and their relatives
(NICE 2004). The core responsibility to be
able to recognise distress and respond in
a helpful and supportive way continues to
be highlighted in the literature. However,
healthcare professionals are failing in this
core responsibility to recognise and respond
to the needs of patients in distress (Francis
2013). These failings may in part be the
result of inadequate formal, structured or
consistent communication skills training in
pre and post-registration nursing courses.
Nurses learn much about communication
in clinical practice from peers, senior staff
and others, who may themselves have
received little or no communication skills
training. This informal approach can be
effective for some, but it may offer little
constancy or opportunity for feedback
and development.
Promoting effective communication in
health care is demanding, complex and
challenging because of the nature of the
work environment, which is often stressful
and pressurised, providing little time for
communication. If nurses are to meet these
challenges in the future they need to be
supported by high-quality, evidence-based
training. Nurses should receive regular
communication skills training if they are
to feel confident and competent in their role.
The benefits for patients, carers and healthcare
professionals are clear good communication
influences patients emotional health, symptom
resolution, function and physiological
measures such as blood pressure, and it
decreases reported pain and drug use (Stewart
1995). Most nurses should be able to remember
a patient who had reduced pain as a result of
feeling less anxious and frightened. Fear has
the potential to increase pain, and in the labour
ward it can impede the birthing progress (Otley
2011). Healthcare professionals themselves
experience benefit if they feel confident about
managing communication situations such
as breaking bad news, handling difficult
questions and responding helpfully to strong
emotions. Ramirez et al (1996) and Taylor
et al (2005) found that healthcare professionals
experience adverse psychological effects if they
have not had sufficient training in effective
communication skills to match the demands
of their role.

The availability and quality of


communication skills training is variable,
but some workshops provide evidence that
attendance and participation can have a
positive effect on clinical practice. Two such
workshops are Connected National Advanced
Communication Skills Training, previously
part of the National Cancer Action Team
Programme (The Royal Marsden 2014),
and the foundation-level half-day SAGE
& THYME course (Connolly et al 2010,
2014). Evidence-based communication skills
training workshops have similar core elements.
These include theory and an evidence base;
the participants decide the content of the
workshop and receive supporting handouts and
references. A presentation and/or demonstration
is given of effective communication skills in
practice and participants have the opportunity
to practise skills and receive feedback in a
structured format. The insight they gain
leads to a greater awareness of the way people
communicate with others, and their confidence
and competence increases.
Complete time out activity 2

Barriers to effective communication


The following tasks are aimed at raising
awareness of the barriers to effective
communication and developing a
common language and understanding of
communication skills (Box 1). This knowledge
has the potential to improve effectiveness
and focus the consultation on the needs of
the patient. By having a conscious awareness
of the potential barriers to effective

2 Working with
a colleague, discuss
and list the barriers to
effective communication.
One person could
consider the barriers
from the healthcare
professionals point of
view and one from the
patient and/or carers
point of view.

BOX 1
Barriers to effective communication
Patient and carer barriers:
Environment noise, lack of privacy, no control over who is present or not
present (staff or relatives).
Fear and anxiety related to being judged, being weak, or breaking
down and crying.
Other barriers difficulty explaining feelings (no emotional language to
explain feelings), being strong for someone else, or communication cues
being blocked by healthcare professionals.
Healthcare professional barriers:
Environment high workload, lack of time, lack of support, staff conflict,
lack of privacy or lack of referral pathway.
Fear and anxiety related to making the patient more distressed by talking
and/or asking difficult questions.
Other barriers not having the skills or strategies to cope with difficult
reactions, questions and/or emotions. Thinking it is not my role, and the
patient is bound to be upset.
(Wilkinson 1991, Booth et al 1996, Heaven and Maguire 1998, Maguire 1999)

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CPD communication skills


communication, it is possible to manage and
minimise the effect of these barriers in the
clinical environment.
Complete time out activity 3

Effective communication skills


It is essential that nurses have skills that
keep the focus of communication on the
patient, that demonstrate active listening
and assist with information giving (Box 2).
Examples of communication skills that are
integral to nursing are provided in Box 3.
It is important that these skills are developed
in pre-registration training and further
developed during preceptorship, clinical
supervision and mentorship throughout a
nursing career to promote confidence and
competence in this area.

Cues
Cues can be anything you see or hear when
you are interacting with another. Cues are
sometimes obvious, for example, crying,
or subtle, for example, if a patient looks away

every time treatment or results are talked


about. While cues assist any interaction to
be patient-centred, there are other benefits.
Zimmermann et al (2003) reported using
facilitative questions linked to cues to increase
the probability of more cues. The following
is an example of an interaction in which a
facilitative question linked to a cue (selected
cues are written in bold) is used:
Patient: I thought, after the surgery, I would
bounce back, but that hasnt happened.
Nurse: Bounce back?
Nurse uses sensitive reflection to pick up
the cue bounce back and waits for the
patient to say more.
Patient: well, I suppose, I hoped I would
be like I was before I got ill I know its daft
really I need to be patient with myself.
Fletcher (2006) explored the effect of
facilitating the first patient cue, which
appears to be important. If this is missed,
patient cues can drop off as the consultation
progresses, whereas open questions
linked to a cue are notably more likely to
lead to further disclosures than unlinked
open questions.

BOX 2
Effective communication skills

3 Make a list of all the


effective communication
skills you can think of
and categorise these
into skills that:
Assist in keeping
the focus on the
patient and/or carer.
Demonstrate
listening.
Assist with
information giving.
It may help you to think
about an interaction
you had recently or the
challenges you reflected
on in time out activity 1.

Skills that assist in keeping the focus on the patient and/or carer:
Looking and listening for cues.
Asking open questions. For example: How are you?
Asking open directive questions. For example: How are you since I last saw you?
Asking open questions about feelings.
Exploring cues. For example: You said you are not with it, can you tell me more about that?
Using pauses and silence.
Using minimal prompts.
Screening. For example: asking the question Is there something else? before continuing with
the discussion.
Clarifying. For example: asking the question You said you are not with it, from what you say, it sounds
like it is hard to concentrate?
Skills that demonstrate listening:
Reflecting.
Acknowledging.
Summarising.
Empathising.
Making educated guesses.
Paraphrasing.
Checking.
Skills that assist with information giving:
Checking what information the person knows already.
Giving small amounts of information at a time, using clear terms and avoiding jargon.
Avoiding detail unless it is requested do not assume people want to know.
Checking understanding using an open question. For example: Ive gone through some difficult
information, what sense have you made of it?
Pausing and waiting for a response to what you have said before moving on.
Checking, with sensitivity, the effect of the information you have given on the patient or carer.
For example: There has been a lot of information to take in today, how are you feeling?

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Patient: well, I suppose, I hoped I would


be like I was before I got ill I know its daft
really I need to be patient with myself.
Nurse: So you hoped you would be like you
were before you were ill, and you are finding
it hard to be patient with yourself as you
recover how are you feeling about that?
The nurse uses reflection of what the
patient has said to show it has been heard,
and acknowledgement to pick up the cue
relating to being patient, then a pause
and tentative open directive question to
find out more. By recognising and acting
on cues, the nurse is able to gain insight
about the effect of the illness on the patient
in this example.
Patient: Well, not very happy. Im not a patient
person, or one that sits about. I dont get looked
after, I do the looking after... I feel like everyone
is managing without me now, that Im not
really needed anymore.

There are few healthcare professionals


who do not feel they work under considerable
time pressure, and nurses experience it
daily. Counterintuitively, recognising
and responding to cues improves time
management. In studies that explored
cue-based consultations specifically,
consultations were consistently shorter
by 10-12% (Levinson et al 2000, Butow
et al 2002). If the consultation is led by
the patient and/or carer, the healthcare
professionals conversation can be tailored
to elements that have been identified
as important for the patient, omitting
non-relevant detail, and therefore less
time is needed.
Complete time out activities 4 and 5
Various cues can be ascertained from the
quotes in time out activity 4. However,
the quotes cannot also portray whether the

BOX 3
Definitions and examples of core communication skills
Skills to keep the consultation patient-focused:
Empathising
Saying something to show you appreciate (not understand or sympathise) how the other person seems to
be feeling. For example: Everything has happened so fast, no wonder you are finding it difficult to take in.
Making educated guesses
Seeing or hearing something (cues) that gives you a hint about how the person is feeling. For example:
You are telling me you know what is going to happen, but you look a little confused.
Looking and listening for cues
Cues are hints and can be words, gestures or body language. Noticing verbal and non-verbal cues is
important to understanding the patients needs.
Psychological focus
Recognising and responding to emotions, feelings and concerns. Patients appreciate healthcare
professionals asking about their feelings.
Using pauses and silence
Pauses and silence provide a slower pace and will help the person to engage in the conversation and give
them time to think what they want to say.
Using minimal prompts
Small, encouraging words and gestures, for example, nodding or saying go on.
Negotiating
Negotiating and asking permission. For example: Would it be okay to talk about what is worrying you?
Active listening: acknowledging
Showing a response to what you are noticing or hearing. For example: I can see you are very
upset about this.
Active listening: summarising
A clear way to prove you have heard all the cues, concerns or questions. For example: So what you told
me you are concerned about is the treatment, your husband and how long you may need to be off work.
Reflecting
Reflecting is a helpful way to pick up a cue. Reflection can also function like a question, but is easier for the
person to respond to. Reflect back to the patient or relative their own words, or use your own words
to check that you understand. For example: You have been thinking, what will happen [pause].

4 Identify cues in
the three quotes from
patients and carers
in Box 4, and explain
how you noticed these
cues. Discuss which
cue you noticed first,
which are physical
and symptom cues,
and which may lead
you to psychological
concerns or a deeper
understanding
of feelings.
5 Look at the
photograph in Figure1.
What non-verbal cues
can you identify?
Describe what could be
going on for this person.
How many ideas can
you generate

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CPD communication skills

6 Reflect on the skills


discussed, and identify
one or two you intend
to use consciously in
practice as a result of
working through these
time out activities.
Think about how these
skills will affect the
interactions you have
with patients and
carers. After several
patient and carer
interactions, reflect on
your communication
skills and check if you
identified accurately the
cues and the insights
to be gained from
these using effective
communication skills.

individuals concerned made eye contact or


averted their eyes while speaking, whether
the individuals speech was loud, a whisper,
slow or fast, and other non-verbal cues
are not known.
In quote (A): Hello again, Im really feeling
much better and not sure that I need to be here
taking up your time, I hardly notice the pain
now, picking up the three cues in bold would
enable the nurse to gain more insight into
how this person is feeling and coping with the
current situation. Once the nurse has used skills
such as reflection to recognise and explore the
cues that may indicate the patient is attempting
to minimise the symptoms or worry, the nurse
could then ask is there something else on

BOX 4
Patient and carer quotes
A. Hello again, Im really feeling much better and
not sure that I need to be here taking up your
time, I hardly notice the pain now.
B. Im not sleeping well at all, I keep going over
whats happened, I cant take it in, the pain is a bit
worse but Im sure that its me thinking about it
all the time. My husband keeps telling me to relax
and not think about it.
C. I am so angry, I should have been here last
week but the appointment card didnt arrive until
the day after I was due to be here. More time
wasted before I get this thing sorted and I can
get back to normal.

your mind? to ensure there is the opportunity


to express additional thoughts, feelings
or concerns before moving on with the
discussion. The final part of the conversation
can explore any physical symptoms and
future appointments.
In quote (B): Im not sleeping well at all,
I keep going over whats happened, I cant take
it in, the pain is a bit worse but Im sure that its
me thinking about it all the time. My husband
keeps telling me to relax and not think about
it, the listener hears about not sleeping and
pain, but the more significant cues for the
nurse to recognise and respond to are those
highlighted. Using effective communication
skills to show you have heard that this person
is trying to assimilate and adjust to the news
or situation has the potential to reduce anxiety
and improve coping.
In quote (C): I am so angry, I should have
been here last week but the appointment
card didnt arrive until the day after I was
due to be here. More time wasted before
I get this thing sorted and I can get back to
normal, the important cues relate to the
angry emotion, time and the future, which
this person hopes will be a time when he
or she will have regained health. Anger can
often mask other difficult feelings such as
fear. These cues provide insight into how an
individual is experiencing what is happening
to him or her and also how the individual is

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adjusting and coping. It is only by noticing,


acknowledging and exploring cues like these
that we can gain insight into the experience of
the person and consequently discover how to
support him or her.
The cues in the photograph in Figure 1 relate
to body language. The mans seated position,
looking down, his clasped hands and his gaze or

FIGURE 1
ISTOCK

Interpret the patients body language

Maguire P (1999) Improving


communication with cancer
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Person-Centred Counselling
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Care Excellence (2004) Improving
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Adults with Cancer. The Manual.
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Nursing and Midwifery Council
(2008) The Code: Standards
of Conduct, Performance and

focus can be interpreted by nurses to gain more


insight into how this patient is feeling. While a
nurse may come up with a particular or several
interpretations of what he may be feeling,
the nurse would need to ask the patient to check
what he is thinking or feeling. The nurse could
communicate effectively with the patient by
using open questions and empathising.
Complete time out activity 6

Conclusion
Effective communication is a core skill for all
healthcare professionals and nursing staff in
particular, since nurses spend more time with
patients and relatives than any other healthcare
professional. Developing rapport is integral
to promoting good patient care. Supportive
relationships with patients and carers grow
from contact with warm, genuine and caring
healthcare professionals. When nurses
communicate effectively with interest, listen
actively and demonstrate compassion, patients
may be more likely to report their experiences
as positive, even at times of distress and ill
health. Nurses have an important role in the
care of patients and their loved ones in a
variety of healthcare settings. Therefore, every
point of contact can be an opportunity to
improve patient care and relationships using
effective communication NS
Complete time out activities 7 and 8

Ethics for Nurses and Midwives.


NMC, London.

Royal College of Nursing (2013)


The Keogh Review and Special
Measures. RCN, London.

Otley H (2011) Fear of childbirth:


understanding the causes, impact
and treatment. British Journal of
Midwifery. 19, 4, 215-220.

Royal College of Physicians (2014)


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